Public Bodies (Joint Working) (Scotland) Bill: Stage 1
The next item of business is a debate on motion S4M-08389, in the name of Alex Neil, on the Public Bodies (Joint Working) (Scotland) Bill. I advise members that time for the debate is extremely tight. I ask members to keep to their time limits, which will allow us to call all the members who are to speak.
15:12
I am pleased to open the stage 1 debate on the Public Bodies (Joint Working) (Scotland) Bill. I thank Duncan McNeil and the Health and Sport Committee for their scrutiny of the bill and for preparing their stage 1 report, which contains interesting and welcome recommendations. I also thank the Local Government and Regeneration Committee, the Finance Committee and the Delegated Powers and Law Reform Committee for their consideration of the bill and for contributing to the Health and Sport Committee’s scrutiny of the bill.
I am grateful to partner organisations across the national health service, local government and the third and independent sectors and to the broad range of stakeholder working groups that have helped the Scottish Government to develop the policy that is reflected in the bill, and I thank the organisations and individuals who provided oral and written evidence at stage 1. I am sure that the Parliament will wish to join me in welcoming those contributions. By definition, integrating health and social care requires a good team effort, and that is exactly what the work by a wide range of people and organisations represents.
I am pleased that the Health and Sport Committee welcomed the bill in its stage 1 report and recommended that the Parliament should approve the bill’s general principles. The committee asked a number of questions on specific issues and asked for further clarification on a range of points. I am grateful for the committee’s careful scrutiny, to which I have responded in my reply to the stage 1 report.
I will begin this debate by capturing once again the essence of what this legislation is about, why it is needed as a matter of urgency and why the principles that underpin it command widespread support.
The 2011 census showed us that, for the first time, Scotland’s population included more people aged over 65 than people aged under 15. We all know that that statistic represents an extraordinary achievement on the part of our health and social care services, which have helped to enable so many people to live longer, healthier lives in Scotland.
However, I need remind no one of the challenges that an ageing population brings as we consider how best we should plan and deliver services in the future. In particular, as more people live longer with multiple conditions and complex needs, we must make sure that the health and social care support on which their wellbeing relies works seamlessly, effectively and efficiently.
That is why we are integrating health and social care: to improve outcomes for the growing numbers of people who need both 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 and in the right place.
Too often, people are admitted to hospital or to a care home when care provision and support in the community would result in better outcomes for them. Too often, the system is not configured to provide the right care in the right place at the right time.
On that point, does the cabinet secretary agree that adaptations to housing provided by registered social landlords and community transport are just as important to the integration of health and social care?
Absolutely. It is very important that vital services such as housing and transport are actively involved in partnerships and that they feed into the design and commissioning of the services that we are talking about.
Too often, people’s independence and wellbeing are diminished too early or to too great an extent by an overreliance on institutional care.
We all accept that it is our responsibility as a Parliament to tackle these challenges, not least because the costs and consequences are not limited to the individuals involved. The consequences of our failure in Scotland to use different types of care and support to best effect undermine our entire health and social care system and are shared by everyone as public sector resources are spent on activities that do not deliver maximum possible benefit.
The solution to many of these challenges is strong, effective leadership—from clinicians and care professionals, from people working in the national health service, local government and the third and independent sectors and, by no means least, from parties and Parliament itself, which is why this legislation is necessary and important.
This Government is committed to establishing a public service landscape in which different public bodies are required to work together and with their partners in the third and independent sectors to remove unhelpful barriers and use their pooled resources for the greater benefit of patients, service users, carers and families. That is fundamental to the ethos and ambition of this bill.
I will now spell out some context for the bill’s provisions. As I have stated—and as the stage 1 report by the Health and Sport Committee reiterates—there is a clear need for legislation to provide the framework for driving forward change, because not enough progress has been made under the current permissive legislation.
The purpose of this bill is exactly that: to establish that framework for integrating health and social care and to improve the quality and consistency of services by focusing on improving outcomes for service users, carers and their families.
The bill will foster an environment that encourages constructive culture change by requiring health boards and local authorities to establish integrated partnership arrangements and to work more closely together day to day and via medium and short-term joint strategic planning arrangements.
Evidence shows us that effective integration depends particularly on four key features. First, local systems must plan together for shared populations of need; in other words, health and social care with their third and independent sector partners must plan for people with complex needs together, not separately and in isolation from one another. Secondly, resources must be pooled to deliver population-based plans, which is why integrated budgets will be so important. Thirdly, clinicians and other professionals must be closely involved in and lead the design and planning of local services. Fourthly, both local and national leadership must be strong, effective and consistent. The bill is built directly on those four features of well-integrated systems.
With regard to overarching arrangements for integration, the bill provides for local flexibility and leadership to determine which approach to integration is most appropriate to local circumstances. Two models are provided: delegation between partners—or, in other words, lead agency arrangements—and delegation to a body corporate. It will be up to each area to decide which is appropriate for them.
Having set up the integrated partnership arrangement, health boards and local authorities will then be required to delegate adult health and social care functions and budgets to the integrated partnership. By bringing together integrated governance, integrated strategic planning and integrated budgets, we will create the environment not only for improving outcomes but for greater financial accountability by reducing the opportunities and indeed incentives for cost shunting between organisations. I intend to lodge at stage 2 an amendment that will set out on the face of the bill that only adult social care functions—and therefore budgets—must be included in the integrated arrangement. Regulations will set out the types of adult healthcare—and therefore budgets—for integration, including adult primary and community healthcare and, importantly, aspects of acute hospital care that offer the best opportunities for service redesign in favour of prevention and anticipatory care in the community.
The bill requires each integration authority to put in place a strategic commissioning plan for the integrated services. Strategic planning lies at the heart of this process of reform and the bill is clear on the broad extent of consultation required to ensure strategic planning is robust and effective. A key feature of strategic planning arrangements is the bill’s requirement on the integration authority to establish locality planning arrangements, which will provide a forum for local clinical and professional leadership of service planning. Where the body corporate model is used, a chief officer must be appointed by the integration authority to ensure integrated oversight of strategic planning, budget management and service delivery. To facilitate such changes, community health partnerships will be removed from statute and national outcomes for health and wellbeing will be established via secondary legislation after consultation. Integration authorities will be required to publish a performance report to provide accountability and transparency for delivery against the national outcomes and any further outcomes agreed upon locally.
The bill does not sit in isolation but fits within a wider agenda of public service reform that is currently taking place in Scotland. Reforms in other areas, including those in the Social Care (Self-directed Support) (Scotland) Act 2013 and the Children and Young People (Scotland) Bill and our planned changes to community planning, all serve to complement the work of this bill, which in turn will reinforce that wider programme of reform for the benefit of our population. Through the creation of an integrated health and social care budget and a single set of joint outcomes, integration creates a positive policy environment for health boards to play an integral part in self-directed support policy and practice, and it is vital that we take full advantage of this opportunity.
Should local authorities and health boards decide to include children’s health and social care in their integrated arrangement services, the planning requirements of the bill will feed into the development of the plans that will be required under the Children and Young People (Scotland) Bill, which the Parliament is considering.
Like other public sector bodies, integration authorities will be expected to play a strong and effective role in supporting the work of community planning to achieve better outcomes for communities on shared priorities.
The bill deals with a number of important and complex issues, and this debate provides an important opportunity for the Parliament to consider, in some depth, the bill and the challenges to which it responds. I think that there is wide agreement in the Parliament and beyond on the aims of integration and the broad principles that underpin the approach. As Bob Doris, the deputy convener of the Health and Sport Committee, put it when the committee’s stage 1 report was published:
“whilst this legislation is not a panacea, it will provide a focus for cementing and reinforcing progress that has already been made”.
I agree with that, and I look forward to working with members of all parties as we take this bill through Parliament.
I move,
That the Parliament agrees to the general principles of the Public Bodies (Joint Working) (Scotland) Bill.
15:26
As convener of the Health and Sport Committee, I am grateful for the opportunity to speak in the debate.
I express my thanks and those of committee members to everyone who gave written evidence and who came along to our evidence sessions. I also thank the clerks and the team from the Scottish Parliament information centre for all their help during the process. Members of the committee undertook fact-finding visits to West Lothian and the Highlands, to see integration in action, and we appreciated the welcome that we received. I am also grateful to Lothian Centre for Inclusive Living, which hosted an event for service users and carers representing a wide range of disabled people’s organisations. Finally, I thank the cabinet secretary for his engagement with the committee and for his written responses to our report.
The bill will bring about big changes in how health and social care services are structured and managed. It will require a change in working practices among front-line staff, who must identify new ways of working across teams and departments. The committee has considered the area before. Two years ago, our inquiry into the regulation of care for older people highlighted the increasing shift to the provision of care in a person’s home rather than in a care home setting. In anticipation of the integration process, we called for a review of the national care standards, which would embed principles of independent living in the framework for the delivery of care services. We would welcome progress on that.
The bill reflects the shift in emphasis from acute care to community-based care. The Royal College of General Practitioners recognises the need for integration in responding to the growing older population. However, there remains a good deal of concern that general practitioners might not have adequate resources to enable them fully to participate in the design and planning of the new joint-working arrangements. The cabinet secretary is currently engaged in discussions on a renewed GP contract, and I ask him to report back to the committee in due course on the role that the contract will play in encouraging GPs to immerse themselves in the integration process.
I note the Scottish Government’s intention to introduce legislation to support carers through integration, but I would like more detail on that in the bill.
The bill has been drafted in the spirit of the Christie commission in that it seeks to tackle what Christie referred to as the
“unduly cluttered and fragmented … public service landscape”.
All that comes against a backdrop of an older population and the increasing demand on our public services to deliver more with less. In a healthcare setting, that marries with the objective of reducing bed blocking.
Christie also suggested that
“changes need to be driven by how we can achieve more positive outcomes”.
That is a theme to which I shall return.
Our report highlighted a number of issues on which we seek clarification from the Government on the effect of the legislation. Andrew Eccles of the Glasgow school of social work suggested a need for
“More subtle and complex engagement with some of the issues”.—[Official Report, Health and Sport Committee, 10 September 2013; c 4193.]
The themes of strong leadership and cultural change came up repeatedly in evidence to the committee. There is a clear need for committed engagement among all involved in the processes. Health boards and local authorities are required to identify the structures that best suit their circumstances. Most areas have opted for the body corporate; so far, only the Highland region has adopted the lead agency model.
The vast majority of evidence has been supportive of both approaches. However, further clarity is required on how the body corporate model will operate. How will the health boards, local authorities and the new joint boards work together in practice? In particular, there appear to be concerns about a transfer of funding from acute budgets to social services. Concern has also been recorded among recipients of social care services about charging for care services when national health services are free at the point of use.
The committee has heard that around half of the total health board budgets will be under the scope of integrated plans, but there is concern about the potential for cost creep in obtaining social care services. It is important that users of the services receive assurance that they are not going to be hit with additional charges.
The bill contains significant powers for Scottish ministers. In evidence to the committee, the cabinet secretary noted his intention to lodge amendments at stage 2 that would seek to mitigate the fear—held by the Convention of Scottish Local Authorities and others—that too much power was being given to ministers. That is a helpful and constructive offer, and I look forward to those amendments.
I will now move on to what I consider to be the most important aspect of the bill. The legislation seeks not only to encourage health and care providers to work together more closely, but to improve the outcomes available to patients and service users. It is those outcomes that are crucial.
The legislation is to be commended for closing the gap between the provision of health and social care. It is paramount that the bill makes it easier for patients and their carers to access the services that they need. For that reason, our report highlighted the need for a
“continuous commitment to improving these individual outcomes.”
I look forward to seeing more detail at stage 2 on how that important aim will be achieved.
Although the bill rightly focuses on the provision of services, we should never forget the important role played by the third sector and independent providers. We heard repeated pleas from providers and their service users for assurance that they would be represented in the new integrated board structures. We accept that that is by no means a straightforward issue and that the Government has set out good reasons why that might not be possible. However, I call on the cabinet secretary to give due consideration to how the involvement of the third and independent sectors can be strengthened in the bill.
The process of integration is already well under way, and the committee agrees that we are heading in the right direction. However, the Parliament has a duty to ensure that the bill delivers for all those individuals and organisations that contributed to our report, for all the staff who are affected by the changes and, most important, for the patients and carers whose quality of life depends on high-quality health and care services. We will ensure that its implementation receives appropriate scrutiny.
On that basis, the Health and Sport Committee recommends that the general principles of the Public Bodies (Joint Working) (Scotland) Bill be approved.
As we are tight for time, speeches in the open debate will be restricted to five minutes. I call Neil Findlay, who has up to nine minutes.
15:35
We will support the bill at decision time, as we agree with its broad principles.
As a West Lothian councillor for nine years from 2003, I saw how cultural change, co-operation and political vision from the Labour group on the council in 2003 advanced integration without any need for legislation. However, the issue of social care in Scotland is one of the scandals of our time, which has been swept under the carpet and kept as far away as possible from prying eyes.
We sit in Parliament today pretending that all is reasonably well and that, with the bill, everything will be okay. Well, it will not, and I think that we all know that. Since the summer, I have met dozens of pressure groups, health professionals, trade unions and local authorities who have all, when asked directly, said that the social care system is in crisis. Yesterday, The Herald invited 30 stakeholders to a round-table session to discuss that and other issues. Not one person at that event mentioned the bill or believed that it would make the changes that are needed, and all of them said that the system is in crisis. Let me explain why I agree with their analysis.
At present, councils are bearing the brunt of Government cuts, which is having a direct impact on the front-line services that they provide. That is nowhere more evident than in social care. Contracts that were awarded a few years ago at, say, £14 an hour are now being won at £12 an hour as contractors try to secure work in the face of council cuts that have been passed on from the Scottish Government. That may sound like a good thing, but the consequence is that, the day after they win the contract, their staff are told that they might have to work two more hours a week for the same money—and they are now in the fifth or sixth year of a pay freeze. That results in a high turnover of staff as people leave to get a better-paid job, maybe in a supermarket, while those who are left behind are demoralised and de-skilled, as training is often cut back to save money.
Many staff members are on the minimum wage. Some have to pay for their own uniforms and use their own mobile phones, and do not get paid for travelling between clients. Those people often work for less than the minimum wage. The result of all that is that, as one care worker told me, people now work in care only because they cannot find another job and many stay only until they find another job. We simply cannot continue like that.
How we treat staff has a direct impact on the quality of the care that is provided to our elderly, our disabled and our most vulnerable people. I ask the cabinet secretary to reflect on this. In the circumstances that I have described, what quality of service does he expect to be delivered? Does he really believe that, in the words of today’s white paper, Scotland has “world-leading ... social care”? If he does, he is the only person in Scotland who believes that.
At the moment, many providers operate in 15-minute time slots. When those were introduced, if a person needed an hour of care, four 15-minute time slots were provided for them. Now, it seems that one 15-minute slot has become the norm, irrespective of the care that is required. In The Times today, Age Scotland highlights the fact that care visits are now down to seven minutes. Is that a world-class social care service? I think not. What level or quality of care can be provided under such a system? I repeat: we cannot continue like that.
A few weeks ago at my surgery, I spoke to a young woman of 18 who had just left school. She wanted to work in the care sector, so she got a job with a private provider. After being given four days’ training in an office, she shadowed a fellow worker for one and a half days and was then sent out with her own client list. On day 1, she was given 30—I stress 30—visits to do. On her first visit, she was verbally abused by a client who suffered from a mental health disorder. She was quite scared. The second client whom she visited was a male in his 70s who had a catheter in and she did not have a clue what to do; and so things went on throughout her day.
I thank the member for the points that he raises—we have all heard about similar issues—but I cannot help thinking that the Care Inspectorate is responsible for standards of care and for inspecting care-at-home standards. Does he think that it is doing enough, because there is nothing in the bill that will change what it does? Is the Care Inspectorate doing what it was set up to do?
Mary Scanlon has hit on a very good point. I think that care at home is extremely difficult to assess. It is easier to assess care in a care home—the inspectors turn up at the home and they inspect the care that is provided there. Care at home is much more difficult to assess. The fact that the provider that I am talking about got a clean bill of health from the inspectorate did not prevent the person who spoke to me, who worked for that provider, from having the experience that I am describing.
That experience went on throughout the young woman’s day, which lasted from 7.30 in the morning until 10 at night. She was, of course, paid for only the eight hours that she was supposed to work. The princely sum that she was paid was £5.03 an hour. Is that the value that we place on the care of the elderly? I say to the minister that this is a scandal and that, no matter how deeply he puts his head in the sand, it will not be wished away.
The bill is very limited and it is woefully inadequate in addressing the care crisis—not the care crisis that is coming, but the one that is here now.
I am glad that Mr Findlay has started to talk about the bill that is before us. Does he not see that there are opportunities in the bill, such as the opportunity to disaggregate the acute budget for older people and to invest some of that in social care? Surely that is an opportunity. I understand some of the issues that he raises, but surely he should be engaging with the opportunities that exist to improve services rather than just lamenting the poorer practices.
I think that we should all be addressing such issues, because they are the fundamental problems with the care system as we know it. Let us not pretend that they are not there.
The bill is inadequate in addressing the care crisis that is here. We will support it, but we need to have a much bigger national debate about how we as a society value our elderly and most vulnerable people. We need to look at the support that is available for those who provide unpaid care and those who simply act as good friends and neighbours. We need cultural as well as legislative integration of health and social care that looks at pharmacies, general practitioners, families and communities, and we need to state clearly whether we are prepared to invest to create a service that is based on dignity, care and respect rather than one that is based on a race to the bottom, because one thing is certain—we cannot allow the current situation to continue.
At stage 2, issues of governance, staffing, shared services, budgets, service user involvement, scrutiny and the powers of ministers will be considered, and I am sure that the bill will be amended. It needs to be improved and we will contribute to that process. However, the bill should have been about addressing some of the issues that I have raised. It should have been about putting people at the centre, pursuing a rights-based agenda that was focused on high-quality care, and having a skilled and motivated workforce.
Alex Neil rose—
The member is in his final minute.
However, the bill is about none of that. Councils are heroically trying to deliver services in the face of unsustainable pressures and I salute them for their efforts, but a failure to address the real issues is—in my view—a dereliction of the cabinet secretary’s duty and of the Parliament’s.
I call Nanette Milne, who has up to six minutes.
15:44
I thank the cabinet secretary for giving us the Government’s response to the stage 1 report last Friday, in good time for today’s debate. However, I am disappointed that we are holding the stage 1 debate on this particular day, because although the bill will be hugely important to the delivery of health and social care to a large and growing number of people in Scotland, sadly it has been totally eclipsed by the launch of the referendum white paper.
I am also disappointed that the bill’s title does not include its main purpose, which is to integrate adult health and social care so as to improve the wellbeing of recipients of that care. The title focuses instead on the public bodies that organise the care, which I think gets things the wrong way round. I know that there were compelling reasons for having that title, but I do not think that it sends out the right message to patients, service users, their families or their carers. Those issues aside, I am happy with the bill’s general purport, and the Conservative group will support the motion on the bill’s general principles at decision time.
In recent years, there have been many initiatives intent on achieving greater integration of health and social care, and excellent results have been achieved in some parts of Scotland. However, concerns remain that joint work between partners to bridge the gap between primary and secondary healthcare, and between health and social care, has not been as effective as it could be and is, at best, patchy across the country. Because the integration agenda has not been compulsory and barriers still exist in terms of structures, professional territories, governance and financial management, the Scottish Government has concluded—rightly, I think—that legislation is required if the balance of care is to be pushed from institutional care to community provision of services, with resources following people’s needs.
The proposed legislation should set the framework for change, but it will be successful only if cultures and attitudes change as well, which will depend on strong leadership at the local level that is committed to improving outcomes for individuals and to true integration that is capable of not only delivering those outcomes, but doing so with more efficient use of the available resources.
As we know, the bill requires each health board and local authority to develop an integration plan setting out proposals for establishing an integration authority that can be set up under either the body corporate model, with a joint board and its own chief officer, or the lead agency model, in which local authority and health board partners can delegate to each other agreed functions, with a joint monitoring committee accountable to both bodies that will scrutinise the effectiveness of the integrated arrangements. Concerns were raised with the committee about governance arrangements, particularly under the body corporate model, so I hope that the on-going work of the Scottish Government and its partners in the national health service and local government will lead to greater clarity around that important issue.
I was fortunate enough to visit both NHS Highland and NHS West Lothian to hear about their experiences of working as integrated adult health and social care services under the different models. Although both would accept that there is still much work to be done on the road to full integration, I was really struck by the enthusiasm of the staff in both areas and their commitment to deliver person-centred care by developing a service with a clear focus on securing the best possible outcomes for people.
My party is generally not in favour of a centralising agenda, but I agree with Carers Scotland’s statement in its evidence that the provision that councils and health boards will be jointly accountable for the local delivery of national outcomes set by ministers after consultation has
“the potential to achieve consistency across Scotland in the delivery of holistic health and social care services.”
The provision should also help to reinforce the message that health, wellbeing and care are not the sole responsibilities of any single agency.
The potential to extend integration beyond adult health and social care was raised as an issue, with COSLA wanting to restrict the proposed integration arrangements and others arguing that it was essential that they include housing services, for instance. I look forward to seeing the Government’s promised amendments at stage 2, but I welcome its clarification that the bill should permit local flexibility beyond adult health and social care.
Clearly, in a six-minute speech I cannot cover all aspects of the bill; I will just note that there are significant concerns over the fact that human rights, quality standards and the need to involve rather than just consult patients, users and carers are not expressed in the bill. I have no doubt that there will be some interesting discussions on those matters when amendments are lodged at stage 2. The lack of involvement of non-statutory partners—those in the third sector, for example—with the statutory local authority and NHS partners at the strategic planning stage is another controversial issue that was raised with the committee.
There are concerns about other issues, such as the potential for cost creep, which Duncan McNeil mentioned, the need for partners to be able to share information electronically, and the reallocation of budgets between acute and primary care. Those are all important issues on which there needs to be further discussion.
In the final moments of my speech, I will focus on locality planning and GP involvement. Both are essential elements if services are to be redesigned in a way that engages individuals and local communities in delivering the best possible outcomes for patients and other service users. I saw at first hand the success of local healthcare co-operatives, which were located in a few general practices, and the failure of community health partnerships, which were far too big and toothless as health board sub-committees.
Now we have the opportunity to truly engage again with GPs, who are pivotal in the delivery of care in the community. I welcome the cabinet secretary’s statement that GPs will be embedded in the process as key stakeholders in shaping the redesign of services. I appreciate that current discussions on GP engagement in the planning and development of integrated health and social care arrangements are confidential within contract negotiations, but I am pleased that they are happening and I look forward hopefully to a positive outcome in due course.
I have had time just to scratch the surface of the bill, but I am happy to support its general principles while accepting that a number of amendments will be lodged as it progresses through the next stages of the parliamentary process.
We move on to the open debate. I call Bob Doris, to be followed by Malcolm Chisholm. Speeches should be of up to five minutes, please.
15:50
I note that Nanette Milne’s thoughtful speech did the job of stage 1 scrutiny very well. I associate myself with Duncan McNeil’s words and the thanks that he gave to everyone who has been involved in scrutinising the bill, those who gave evidence on it and the Government and its civil service team. A lot of positive work has been done on the bill.
I begin by making it clear that I wish that the Parliament did not need to pass the Public Bodies (Joint Working) (Scotland) Bill. The integration of health and social care has been an aspiration for many years, but a reality far too rarely. The bill will set up an overarching framework to deliver integration and, as a last resort, compel health boards and local authorities to get on with the job of integration where that is not happening.
I will go on to talk about structures shortly, but first I will say a bit more about what the bill hopes to achieve. We have already heard a great deal about the demographic challenges that Scotland will face with an ageing population. The objective is to have a unified health and social care strategy for our older population that suits the needs of older people and ensures that the person is put before the pound sign—in other words, that cost shunting between health boards and local authorities becomes a thing of the past. That means having a single budget for the health and social care of older people.
For too long, there has been a suspicion that there is a tension between speedy discharge and delayed discharge from our hospitals. The longer a patient is in hospital, the greater the cost to the NHS, and the earlier an older person is returned into the community, the greater the cost to local authorities. In what way is the patient, rather than the pound sign, at the centre of that? I do not think that the matter is necessarily a high enough priority at present. If we have a single budget, put people before pounds and have a truly integrated health and social care system, we can end that cost shunting once and for all.
We need a disaggregation of acute budgets. I am delighted that the Scottish Government shared with us some estimates of what proportion of acute budgets may be disaggregated and put towards combined health and social care, but there are still no real projections of what sections of local authority budgets will be put towards that. Will it just be whatever budget lines local authorities identify from their own social care budgets, or do we need to be a bit more sophisticated about it?
I know that we are not going as far as housing at the moment, but an argument could be made that there is a direct link to housing adaptations and policy. If we can get older people in an ageing population back into their houses and they are happy and safe there, they will be content, and sometimes that will be cheaper than having them in hospitals or residential homes. We have to think in a more sophisticated way about joint budgets for health and social care, and we need more clarity about the expectations on local authorities.
As I said, this is not just about saving money. It is about getting older people out of hospital sooner, preventing them from going into hospital in the first place and having them live at home happily for longer. That is not just cheaper but better in relation to outcomes. We have to look at the outcomes that the bill seeks to deliver rather than just structures, but of course we have to look at structures, too.
I have a question relating to my constant theme of care at home. Does the member recognise that, when we are looking at the quality of care, it would be helpful to ensure that all home carers are given the training and support that they need and that they are required to register with the Scottish Social Services Council much earlier than 2019?
The 2019 target was jointly agreed by the Parliament and it makes us world leaders in the registration of care-at-home employees. However, it is a vexed issue and the Government has already said that if registration could be accelerated in a safe and structured way, there is no reason why we could not do that.
I have only 30 seconds left, and there is so much more that I wanted to say. On structures, if it ever comes down to a vote between health boards and local authorities, we will have lost the case for positive and constructive health and social care integration. Whether or not they have voting rights, we have to make sure that the third and independent sectors, allied health professionals, GPs and the like are involved in drawing up the strategic plans. Assurances need to be given that they will have proper and suitable engagement with any strategic board.
The exciting part for me is localised strategic planning, in which local communities and older people are not just told what the priorities are for their care in their local area, because they also get to decide those. Some information on how that would work would be welcome.
15:55
I was lucky enough to be on the Health and Sport Committee temporarily and so was able to read much of the written evidence as well as hearing all the oral evidence. I was particularly struck during the first session of oral evidence when we heard from Professor Alison Petch, who is probably the leading Scottish academic on community care. She said:
“The bill per se will not make any of what is proposed happen”
and
“legislation is not really what drives day-to-day delivery.”
She was not the only person who gave evidence who said that the issues were culture change, leadership, bringing teams together on the ground, and so on. She also said:
“the most important aspect of the bill is that it states the integration principles”.—[Official Report, Health and Sport Committee, 10 September 2013; c 4193, 4204, 4196.]
She and several other witnesses said that they would like to see that section of the bill strengthened, so I hope that we will look at it at stage 2.
Many members will have received an interesting paper from the Royal College of Nursing and others yesterday about this important aspect of the bill. I was struck by the RCN’s wish to see two principles, among many others, in the bill. One was about protecting and enhancing the safety and welfare of service users, which is pretty crucial, and the other was about enabling service users to participate in decisions about their need for services and the provision of those services to them. That is also important and it connects with the recent debate that we had on person-centred care. My conclusion from the evidence of Alison Petch and others is that we need the bill, or some amended version of it, and that it is a necessary but not sufficient condition for the delivery of more integrated care.
That said, we have to make sure that the bill will help, that it is clear and that it does not get in the way. Clarity is an issue because, at several points in the committee’s report, we say that we want more information. One particular aspect that I want to mention is the surprise that I felt when we received some very late evidence from the Government—it came in after all the evidence sessions, including the Government’s—about the extent of health board budgets that were to be delegated to the integration authority. I will read it very quickly:
“we anticipate that approximately half of the total Health Board budgets ... will be included within the scope of the integrated strategic plan. This would represent approximately 75% of total expenditure on unplanned bed days for people aged 75+”.
That is a crucial piece of evidence that we ought to have been able to interrogate. I have been thinking about it since we received it. How would it work in practice? Those unplanned bed days in my area would mean the Edinburgh royal infirmary, the Western general hospital and St John’s hospital at Howden in Neil Findlay’s constituency. That sounds as if the integration authority will have money that it will presumably then have to pay to the acute sector in a kind of commissioning relationship. That seems to be going back towards the bureaucracy of the internal market that we have got away from. I might be overstating that, but that is what it sounds like. It seems to me that one of the dangers of the bill is that we will increase horizontal integration, but reduce and damage vertical integration. That needs to be explored at stage 2 and further on.
The other issue is that although we can reduce income to Edinburgh royal infirmary and the Western general hospital, that will not mean that their costs will be reduced. That is a practical problem as well. Some of these issues need to be thought through, particularly for some of the large health boards such as NHS Lothian and NHS Greater Glasgow and Clyde.
That uncertainty is connected to other uncertainty about the relationship of the integration body to the parent bodies. Peter Gabbitas of the City of Edinburgh Council and the health board—he already has a joint appointment—gave powerful evidence to the committee about that. At stage 2 we need to look in detail at the wording of the bill in that respect. For example, section 21 says that the chief officer
“is in all respects as if the person who delegated the function”,
which gives the impression that the chief officer is fairly autonomous. All that wording needs to be looked at and if the Government intends something else, it or we will have to amend the bill at stage 2.
The locality arrangements and clinical involvement are crucial. CHPs were meant to be local but often turned out to be otherwise, to my disappointment. They were meant to be the places where primary and secondary care clinicians engaged with each other but often that did not happen. The role of GPs is crucial to the new bodies, as are, of course, service users and the third sector. I would like to see a bit more in the bill on all that and I would like it to be included in negotiations on the GP contract.
I have 10 seconds left. Let us look at good practice, wherever it is to be found. I apologise to the cabinet secretary, as this is the second debate in a row in which I am referring him to a good example in England. “Integrating health and social care in Torbay: Improving care for Mrs Smith” is an excellent publication by the King’s Fund about how integration has worked successfully in Torbay in Devon and realised the objectives that we want: fewer emergency admissions and more care in the community.
16:01
I am delighted to be speaking in a debate on the general principles of a bill that will introduce a substantial and wide-ranging reform of the way in which we deliver adult health and social care. The cabinet secretary reminded us in his opening speech why the bill is so necessary. As a nation, we have larger numbers of people who are living longer than ever before. That is good news, but it means that we need to re-examine how we deliver and manage care in Scotland for our older people.
The integration of health and social care services is needed to improve outcomes for individuals, particularly adults with multiple long-term conditions and complex support needs, and to improve the experiences of both those who use such services and those who provide them. As we know, key to delivering that vision is the principle of person-centred healthcare, whereby services are integrated around the needs of the individual.
I want to highlight the representations that the committee received on the need to ensure that the housing sector’s contribution to improved health and social care outcomes is recognised in the bill, and that the new integration authorities involve their strategic housing partners in joint commissioning to achieve person-centred quality care at home.
Ultimately, our aim should be that everyone, no matter the complexity of their requirements, has an equal chance of a good life. We know that homes that are responsive to a patient’s needs—particularly if the patient has dementia, a learning difficulty or autism—are needed to achieve that aim, as they make a significant difference to how care and support are delivered and the outcomes that they have.
Another key issue that was raised with the committee was the need for the full involvement of the third sector. Issues were also raised at both the strategic partnership and local levels surrounding the involvement of a range of other key stakeholders, including our allied health professionals, service users, carers and disabled people and their representative organisations, all of whom have a wealth of collective experience, expertise and professionalism. They are huge assets in helping to achieve a person-centred and needs-led approach to the delivery of locally based quality health and social care services.
Another key voice is that of our GPs. The evidence that the British Medical Association and the Royal College of General Practitioners submitted to the committee was helpful, as it allowed us to examine possible barriers to fully and successfully engaging GPs in the planning of local services. An excellent example of integration that is already working—and being driven by GPs—is Kirkcudbright community hospital and its adjoining GP practice, which has developed strong working relationships with local social services staff.
That is only one example. At the other end of the spectrum, the GPs at the deep end group’s case in favour of having GP surgeries in our most deprived areas functioning as natural hubs for integrated care to tackle deep-seated health inequalities requires us to recognise that, in many of those communities, services may be the least integrated.
That great variation in local experience reinforces the case for the bill and highlights how important integration at the locality level will be, how important the widest involvement of key stakeholders—including GPs and our local professionals—and partners at that level will be, and how important it is to scale up the capacity of the third sector to ensure that those who work closest to individuals and communities can participate and engage fully in service design and service delivery. Fully involving our GPs, the third sector, local professionals, carers groups and disabled people at the locality level will make a positive difference to the delivery of integration. The localities will be where many of the key decisions concerning service users will be made.
In Dumfries and Galloway, the local authority and the NHS board are already clear that the way to implement integration is to focus on building up the service model at locality level first. Our region has a natural advantage, in that it has four well-established areas corresponding to the old district councils—a natural pre-existing delivery model. The NHS and the council have capitalised on that by commencing integration from the point closest to the service user through planning local integration in those four areas, rather than starting at the furthest away point with the top-level governance model. Of course, both those structures need to be right, but in considering the top-level arrangements we must not lose sight of the fundamental importance of integration in the localities, where the services will actually be delivered and the real difference made.
I will close by saying that I fully support the general principles of the bill. I look forward to considering the amendments during stage 2, when I hope that we can work together to produce an act that will be regarded as a fundamental reform of the way in which we care for Scotland’s people.
16:06
I believe that all members in the chamber today will offer broad support for the general principles of the bill, and I certainly want to express my enthusiasm for its direction of travel towards greater integration between health and social care. However, like others, I must admit to feeling slightly worried about the bill’s ability to deliver on that agenda and to feeling downright anxious about whether some aspects of the legislation will work at all.
I recognise and acknowledge the good intentions behind the Public Bodies (Joint Working) (Scotland) Bill. In fact, some of the language in the proposals looked rather familiar to me from previous parliamentary sessions. I remember speaking about what was then called the joint futures agenda not long after being elected in 1999. For those who may not remember that, the joint futures group was set up by the first Scottish Executive—more than 14 years ago now—with the specific aim of trying to improve joint working between social care and healthcare and to secure better outcomes for patients and service users.
The various recommendations of that group read like the bill’s policy memorandum. They focused on joint working, the rebalancing of care between community care and acute care, how to improve the financial and management frameworks of the different agencies involved and how to establish best practice. They also examined some of the difficulties around charging. Here we are, more than 10 years on, still wrestling with precisely the same thorny issues.
The reason that I mention joint futures is not to sound jaundiced or cynical or to suggest that integrated working cannot be achieved, but quite the reverse. If this was important in 1999, it is even more important in 2013, with the rapid pace of demographic change, the ever-increasing pressures on our budgets and the need to move to a preventative care agenda. I mention the work that has gone on before simply to highlight what a difficult agenda this is to achieve.
As the Health and Sport Committee reveals in its report, the legislation itself is perhaps less important than achieving cultural change—getting health professionals, social workers, the voluntary sector and the myriad of people who are involved in care to work in partnership, rather than just within their own professional disciplines, funding structures or special areas of interest.
There are practical difficulties with the bill, too. I was drawn almost immediately to the issue of governance. Having just read the Auditor General’s report on police reform, I suspect that no member can be unaware of how legislative confusion over roles and responsibilities can hamper the creation of a new organisation. It is strikingly obvious that, if there is not clarity about the relationship between the new joint boards proposed in the bill and their parent bodies—the relevant NHS board and local authorities—that is a recipe for conflict.
As for budgets, all of us will be familiar from casework, if not from our own experience, that services tend to follow the money. One difficulty here is that there are so many competing budgetary agendas. There is an expectation that the bill will save money or at least deliver efficiencies to meet rising demand. Alongside meeting rising demand, there is a clear drive to focus on community and social care rather than on acute care, but there is a rather less specific commitment to reallocate those acute budgets. In theory, yes, reducing unplanned admissions will free up resources, but we also know that in practice the demand on our hospitals is such that those resources will immediately become reallocated—any beds that become free are immediately filled by other patients. That is before we even get into the fact that, in social work, the health service, local authorities, NHS boards, housing or the voluntary sector, there will be competing budgetary needs and not simply collaborative or consensual agreement on spending priorities. I am afraid that there is no shortage of people or organisations that think that they can spend someone else’s budget better.
Most important of all, it is vital that the bill succeeds not because of organisational simplicity or budgetary accountability, but simply to make life better for patients. The committee’s report contains a particularly informative section about the difficulty of integrating the free healthcare that is available in the NHS with social care that is subject to charges and various eligibility criteria. We know from the on-going legal cases on NHS continuing care what a minefield that can be and how much anxiety it produces. Those with chronic and long-term disabling conditions or progressive neurological conditions such as Parkinson’s are particularly anxious about where we will head in the area. Before the bill has even cleared stage 1, we know that people the length and breadth of the country are struggling with 15-minute care visits. Our health and care services are under huge pressure to maintain quality and standards and they sometimes buckle under it.
As the RCN and others have made clear, quality and safety of care are unfortunately not at the heart of the bill—or not yet. The briefing for the debate from Macmillan Cancer Support contained an excellent line, which states:
“We believe that this debate must focus on how services will work for the cancer patient, not on how it will work for the service provider.”
That applies to patients in general and I entirely agree with it. The bill is well intentioned and I hope that it can deliver.
16:11
I am pleased to speak in the debate as a member of the Health and Sport Committee. Scotland’s people are living longer and healthier lives, and all the evidence that has been gathered has brought about the realisation that it is better for people of all ages to recover and be treated in their home where appropriate. It is therefore imperative that all the relevant agencies are involved in the good work of ensuring that the recovery process works to a high degree and maintaining a high standard of health and social care for the individual. Those agencies should be not so much connected but intertwined to effect the best results.
Although we can point to some good examples of integration working and working well, for the best part, I do not think that it is an exaggeration to say that the norm in past attempts has been failure. In the evidence that was presented to the committee, we did not find a single authoritative voice suggesting that integration between the sectors would be a bad thing. On the contrary, the opposite is the case—all the evidence said that joint working would be to the benefit of everybody, both provider and receiver. It is hard to disagree that, as we have a universal goal with a high score value at the end, legislation needs to be introduced to bring about that goal.
Most of those who have questions on the lack of success so far have put that down to leadership. I must confess to a little scepticism about that view. To me, from the outside looking in, the issue is more about budget protection in each sector than anything else. If I am wrong, and the commentators who think that the lack of good leadership is the main reason are right, legislation clearly will not solve that, as it does not provide or manufacture such leadership. Having said that, I am confident that legislation will be the stimulus that will make the difference. I am more than confident that those who work in the health and social care professions and in the third sector have the required leadership—that is apparent day in, day out—and are more than capable of making the bill a success.
In many debates in the Parliament, it has been acknowledged that the wellbeing of the patient is paramount and that the patient and their family are the first and most crucial aspect. From when someone is admitted to hospital with an illness to when they are released to recover fully at home, the patient’s needs are our top priority. We know that most people desire to stay in their home, albeit with vital care support and assistance when they have conditions or are infirm. It is also crucial that we provide an integrated service that gets it right first time for the individual and that recovery takes place with fewer relapses. Relapses are costly in terms of money and the impact on someone’s already fragile health. They may also add to the cost of care.
Getting it right will allow the savings that are made to be deployed back into health and social care services to make the joint sectors even more beneficial, and so the progress will go on, moving forward at all times.
I must offer some caution to temper my optimism. With the UK Government’s cuts agenda continuing to have an acute impact on Scotland’s finances, we might be expected to do the same—or even more—with less money. I hope that I am wrong in that regard and that the hard work that is being carried out by all sides will be rewarded and recognised by any savings being reinvested back into the sector to ensure that our people are kept healthy.
Scotland has an ageing population, and the future challenges that we face will be huge and complex. I hope that the bill will go some way towards ensuring that we are ready to face those challenges and rise to meet them.
I am pleased to commend the bill to the Parliament and support its progression from stage 1.
16:16
The bill has been a long time in the making. The integration of health and social care is overdue and it is an idea whose time has certainly come. It was a key component of the Scottish Liberal Democrat manifesto for the last election, and we have long called for the delivery of common sense by having health boards, local authorities and the third sector work more closely together to provide more joined-up care and better outcomes for patients.
The pressures and challenges that the NHS faces have undoubtedly made the proposals necessary. For example, the incidence of emergency admissions has increased significantly in the past few years alone, with the largest increase among the over-75 age group.
Although I am supportive of the integration of health and social care and support the bill in principle, I share some of the reservations of many people in the public and third sectors—I will touch on those shortly—and expect further engagement from the Government to enhance the bill as it progresses.
One of my concerns, which was well articulated by Glasgow City Council and others in their evidence to the committee, is about disconnects in care provision. The failure in patient outcomes occurs not only because health and social care are not integrated, but because of the disconnect between acute and primary care. Although that is noted in the bill’s policy memorandum, some people believe that the proposals will address only one of the disconnects and will leave the other unchecked. The submission from Glasgow City Council highlighted the point that
“integration works best when GPs and other stakeholders are engaged effectively.”
The cabinet secretary was right to say in his response to the committee’s report that structural change will not in itself lead to greater partnership working, but that a cultural change is also required. I welcome his commitment that GP engagement will form part of the contract discussions, but he will have to provide more detail on the Government’s plans, irrespective of continuing negotiations.
The Scottish Government must be realistic. Demands on GPs may be about to increase significantly at a time when the proportion of the NHS budget that is given to general practice has fallen. The cabinet secretary must still explain how he plans to put a square peg in a round hole, regardless of integration joint boards agreeing integrated budgets, because the capacity and resources might simply not be available, although the desire exists.
I note COSLA’s understandable concerns regarding the degree of latitude that the bill appears to offer the cabinet secretary to widen its scope beyond adult social care and to bring any local government function within its parameters. I give him the benefit of the doubt and characterise that as an unintended erosion of local democracy and creep towards centralisation. To his credit, he appears to have realised that there is a real issue with the bill. I welcomed his commitment to the Health and Sport Committee that he would work with COSLA on amendments at stage 2 to rectify that.
That said, the air of centralised power cannot be overlooked. The electorate look to their health boards to provide their health services, and they elect their local councillors to manage their social care services. They are the people whom the electorate will, rightly, hold accountable. However, the integration plan that is designed by the two bodies cannot simply be agreed between them; it must also be signed off by Scottish ministers. The cabinet secretary will be well aware that many people have described the plans as being too prescriptive and too detailed. I suppose that they have a point.
In addition to integration plans having to be signed off, the joint integration boards have been instructed by the Scottish Government to whom their joint accountable officer will report. The Government will also tell them what their responsibilities will be. Can we not at least trust the joint integration boards to determine what is most appropriate for them locally, because they are best placed to do that? It would be interesting to find out whether the cabinet secretary agrees that it is perhaps not entirely necessary that ministers personally determine the job criteria and the line managers of newly created positions. Perhaps Michael Matheson could reflect on that in his summing-up speech.
It is not a perfect bill—far from it. There are still issues to be ironed out regarding democratic accountability, the extent of the third sector’s role and so on. However, the principle is sound, which is why the Liberal Democrats will support the bill at stage 1.
16:21
As a member of the Health and Sport Committee, I am pleased to speak in the debate because the committee has spent some time working on the bill and has considered a total of 81 submissions that were received after the call for evidence, and has considered oral evidence that was given by various sources during committee meetings. Further to that, the committee visited projects in Inverness and West Lothian to gain first-hand experience of joint working on the front line.
I was able to take part in the West Lothian visit, and I was impressed with how people there are taking the bill on board, and with what they are doing to implement changes that should improve the service for local users. I hope that others will follow West Lothian’s example.
It is welcome news that the people of Scotland are living longer and healthier lives. Life expectancy in Scotland has increased and is expected to increase by two thirds in the next 20 years—I am sure that many of us are happy about that. Because of that, we need to change how care is delivered now rather than wait for that to become a problem further down the line. l am therefore happy with the Government’s proposals as set out in the bill
I am pleased to note that the Cabinet Secretary for Health and Wellbeing has welcomed the support of the committee for the principles of integrating health and social care with the aim of improving outcomes for service users, and I know that he is committed to doing that.
The committee notes that there is a need for legislation to provide change and to improve outcomes for people who use health and social care services because not enough progress has been made under the current system.
At the moment, Scotland is experiencing problems that integration could help to address. Those include unscheduled emergency admissions to acute care, delayed discharges from acute care to community settings, delays in accessing required support, and lack of communication between services. There are too many occasions in which the hospital and the local social work department are not on the same page; when I was a councillor in North Lanarkshire I had to intervene on a number of occasions to resolve situations in which a patient was ready to come out of hospital but could not go home because support had not yet been supplied. On those occasions, I had to contact the social work department and the hospital in order to ensure that the patient’s needs were being met. If such problems could be solved, it would be good news for all patients, especially those who are in the last months of their lives, because delays in those patients’ being discharged often results in their becoming too sick to move back to their homes and communities, where they would rather be.
Under the bill, health boards and local authorities will be required to create integrated plans for their areas. As has been said, two models will be available: the body corporate model, in which a health board and a local authority will delegate functions to a joint board that is headed by a chief officer; and the lead agency model, in which local authorities and health boards will delegate functions to each other under the oversight of a joint monitoring committee. Allowing each area to choose which of the two options best suits it will ensure that people in those areas’ communities receive the best care, tailored to their needs. I suggest that all partners, plus GPs and local authorities, must work together to make local arrangements.
The point has been made that the Health and Sport Committee had representations from many organisations. However, as I have said, given the number of organisations, how many people will need to get round the table and will the table be big enough?
The bill will allow ministers to set out national health outcomes, and health boards and local authorities will be held accountable by the Scottish ministers and the public for delivering the targets. Councils and health boards should see that the bill is meant to solve and resolve the problems that are not being dealt with under present arrangements.
It has been said that the bill will not guarantee a successful outcome, but I fully support the bill’s intentions and its aim of providing better outcomes for patients and service users while delivering better value, in order to meet the challenges of the ageing population. I will support the bill.
16:26
I welcome the opportunity to speak about the bill. We can all agree that the bill’s aim is to create a system of high-quality care that is seamless and effective.
In my many years as a Labour Party councillor on Glasgow City Council, and now as a member of the Scottish Parliament, constituents have regularly come to me as they have slipped through the cracks in the system. Such cracks are caused by a lack of joined-up thinking and practice from social care providers and health boards up and down the country. That situation must end.
The bill does not go far enough to provide integrated health and social care. Many council departments up and down Scotland have merged and renamed themselves as health and social care, but apart from rebranding, little has been done to integrate the different cultures and decision-making structures.
A person who was cared for by a mental health team came to me for support when his case was closed by a doctor who said that his personality disorder was untreatable. That diagnosis completely ignored the possibilities that social workers in that person’s team could offer him. That complete lack of joined-up thinking led to a vulnerable person feeling as if he had been abandoned by the system.
Mr Malik is making excellent points about cultural challenges. In Glasgow, our health and care partnerships did not work. Section 12(1) of the bill will give ministers the power to intervene to compel integration. Does he agree with my hope that that power will never have to be used, because local authorities and health boards will finally get on with it and do integration properly?
My friend makes a fine point, which I will go on to address. I described a complete lack of joined-up thinking, which leads to vulnerable people feeling abandoned.
The bill does not properly deal with the major differences in eligibility between the health system and the social care system. Healthcare provision is a universal service that is free at the point of delivery, whereas social care provision is subject to eligibility criteria and charging. We need to ensure that the bill sets out clear and transparent decision-making criteria for eligibility in which service users and their carers are involved, so that services are provided effectively.
On joined-up thinking and working, Glasgow City Council had a structure; it had a committee, with area or regional committees that dealt with doctors, healthcare workers and others to provide services, but it was done away with. I am not sure whether the bill will redress that.
Quite frankly, I say that our doctors need all the support they can get, because they are working under a lot of pressure. I have gathered over the past two years that our doctors seem to be doing more and more in terms of service provision. They are also doing a lot of work in communities, which is welcome.
Clarity about services is the most important element of the bill. If people continually fall through the cracks, we are missing the point. There are far too many agencies trying to grapple with providing services to individuals. If one of those agencies lets down the client, patient or individual, the whole structure fails. We must try to ensure that that does not happen.
I call on the cabinet secretary to lodge an amendment to the bill that will secure the fundamental right to services, so that we force all the partners to work together to ensure that service provision is appropriate.
16:31
I welcome the opportunity to speak in this important debate, and I welcome the committee’s stage 1 report.
At roughly £4.5 billion per annum according to the 2010-11 figures, health and social care spending on people aged 65 and over constitutes nearly a third of the health and wellbeing portfolio budget. Investment in those areas is not only significant but absolutely essential. It is important to ensure that we fund and design an integrated service that will be sustainable.
The consensus surrounding the bill is positive. It should come as no surprise, given that the bill reflects the current international trend towards integration of health and social care.
I was delighted to learn that the group that is overseeing Fife’s adult health and social care integration—it is called communicating health and social care integration in Fife—which comprises staff from NHS Fife and Fife Council, was last week shortlisted to be in the final three, out of 130, in the health and social care integration category of The Herald’s society awards 2013. That accolade was dedicated to the council and its NHS Fife colleagues, partners, service users and patients who have helped to support the group’s work. It demonstrates that successful progress is already being made on the ground.
It is fair to say that we need to fund healthcare and social care as efficiently as possible owing to the current pressure on public finances, but we need also to work towards having a care sector that offers a career option and which has motivated staff who are working towards providing a first-rate service. We need to strive to improve the standard of care that some patients are receiving as we plan for the inevitable demographic changes of the future.
Scotland is not alone in moving towards a joined-up approach to delivering those areas of care. For the past 40 years there has been a movement in that direction all around the world. There are no direct parallels with Scotland, but we can and should always learn from international examples.
Nearer to home, England has introduced the Health and Social Care Act 2012. Although the principle is the same, I understand that integration is proving to be difficult to implement, according to some professionals who cite the fragmenting effect of introducing private enterprise into the NHS as an obstacle to success.
In Wales in 2007, a primary, secondary and social care strategy, called chronic conditions management demonstrators, was introduced for people with multiple chronic illnesses, which has resulted in considerable reductions in bed days resulting from emergencies. Indeed, there were falls of 27 per cent, 26 per cent and 16.5 per cent in successive years.
To see the advantages of a local approach, which the bill provides for, we need look no further than Sweden.
In the committee report is a recommendation in paragraphs 43 to 45 regarding the justification for the bill. Some witnesses who gave evidence to the committee suggested that steps could have been taken towards more joined-up care service delivery using existing legislation and guidelines. Some pointed out—rightly, in my view—that legislation alone will not bring about the changes that we want to see. I listened to what Malcolm Chisholm said on that point earlier and agree with it.
I have spoken before about the transformational effect of legislation and said that the introduction of legislation can lead to attitudinal changes across the country. Individuals and organisations not only become obliged to observe a set of guidelines; many do so proactively before they are required to do so in order to remain ahead of the curve. I therefore believe that the committee was right to describe the bill as
“the momentum needed to make the widely desired progress a reality”.
I note that, with regard to the provisions in the bill that relate to the two possible options for delivery of integrated services—the body corporate model and the lead agency model—the cabinet secretary has undertaken to provide more information on the roles and duties that will be involved in those arrangements. I welcome that, and the consensus among relevant organisations and the Government on the basic model behind the proposals, which is that local government and health boards should be jointly accountable. That is also very positive, but it is absolutely clear that we cannot have a system in which health boards and local government are locked in budgetary disputes with each other. Such disputes serve no one in the long term, and ultimately the biggest losers are the patients, who are liable to experience delays and confusing information about their care, as experience has shown.
The case for co-operation has been strongly made, and the bill’s provisions that allow a high degree of freedom in choosing the model that is best suited to an area will, I hope, mean that more health boards and local authorities will be able to take forward adapted plans of their own to meet national standards with tailored means to a unified end.
To conclude, I commend the committee on its thorough report and look forward to monitoring the bill’s progress as it passes through Parliament.
We now turn to the closing speeches. I remind all members who have participated in the debate that they should be in the chamber for the closing speeches.
16:36
I, too, commend the Health and Sport Committee for its excellent work in scrutinising the bill and bringing forward its stage 1 report.
I am very pleased to be back to speak in this debate on health and the Public Bodies (Joint Working) (Scotland) Bill. I am even more pleased that I will speak in such a positive way. After hearing about all the problems, I can honestly talk about what is happening in Highland, which is an undoubted success, although I appreciate that there are still challenges.
In last week’s debate on the Children and Young People (Scotland) Bill, Highland Council was commended throughout the chamber for its work on getting it right for every child. I agree that that model is working in Highland and commend Highland Council for its plan to recruit five more health visitors.
There was a time not so long ago when health visiting seemed to be withering on the vine. Some health visitors expressed the view that they did not want to become social workers. The lead agency model in Highland allows Highland Council to focus on the needs of and priorities for children and young people, and to adopt not only an integrated model of delivery but, more important, an integrated model of care and support that covers all aspects of a child’s needs.
There is still a way to go—I would like to see more holistic support for troubled families—but I acknowledge that the care model that Highland Council has adopted is good and that tremendous progress has been made from what happened in the past, which in my opinion was a recipe for passing the buck.
The lead agency for adult care—NHS Highland—has also brought about significant improvements. Again, I accept that there are challenges ahead, but I acknowledge the many submissions on the bill that state that cultural change is difficult.
In the past, when local constituents came to my surgeries to ask whether I could help to get their elderly parent out of Raigmore hospital to be cared for at home or in a care home, I had to phone social workers. On many occasions, the social work ring-fenced budget had run out, and people had to wait until the end of the financial year, which could have been several months. As far as the council was concerned, the person was being cared for, albeit at a higher price to the public purse, in hospital. That led to high figures for delayed discharges—otherwise known as bedblocking—which of course impacted on hospital admissions.
Now I can email the chairman of NHS Highland—I did so twice last week—who can arrange for the appropriate care package to be delivered at home or in a care home, in a seamless manner. It is in NHS Highland’s interests to free up beds and ensure that every patient receives appropriate care.
In the past, Highland Council paid up to 80 per cent more per person per week if someone was cared for in a council-run residential care home rather than a home in the independent or voluntary sector. Now that NHS Highland is in charge of the budget, questions need to be asked about why council care homes receive so much more funding, given that all care homes must achieve the same quality standards, which are set out by the Care Inspectorate. I accept that there is a challenge in that regard.
Earlier this year, care-at-home services in Highland received a very poor inspection report—I was thinking about that when Neil Findlay was speaking. The report was not a disaster but presented an opportunity for NHS Highland to bring in more support and training for care workers, to enable them to provide the level and quality of care that we expect them to provide. The lead agency model brings carers into the whole healthcare system, where they can get the maximum support.
I spent many years as a member of the Parliament’s health committees. In particular, I was a member of the Health and Community Care Committee when it scrutinised the bill that became the Community Care and Health (Scotland) Act 2002. I can confirm that, even then, all but one witness said that a single agency should deliver care of the elderly, although there was no consensus about who should do that. We talked about the NHS, social work and GPs, and there was talk of pooled budgets and aligned budgets. At the time, the cultural differences between the NHS and social work were even more significant than they are now. I think that the situation has improved considerably in recent years.
I appreciate that there is no single definition of integrated care. However, I have talked about Highland because good practice should not be ignored. I agree with the Multiple Sclerosis Society, which said in its written submission to the Health and Sport Committee that the bill should not focus
“too heavily on structural change ... at the expense of the primary focus on improving outcomes for people.”
That is my point. The Highland model focuses on the person and not on where they are, what the budget is or constant arguments between NHS Highland and the Highland Council. Highland’s focus is on the person, as is my focus and, I am sure, that of the Health and Sport Committee.
What has happened in Highland has not required legislation, but it is disappointing that progress has been so slow in other parts of Scotland. I welcome the bill; we will support it at stage 1.
16:42
I think that there is unanimous support in the Parliament for the general principles of the bill. We need an integrated health and social care service that has no barriers and which appears seamless to service users and their carers. However, I am not sure that the bill alone will achieve that—it needs to go further. Moreover, I am not convinced that it is possible to legislate for the type of leadership and cultural change that Duncan McNeil and Malcolm Chisholm talked about, which is crucial to making the step change on how we deliver care.
Mary Scanlon talked about Highland, which has adopted the lead agency model. No other area appears to be taking that model forward. It is clear that the model’s success—or partial success, because Highland admits that it is a work in progress, which has a long way to go—and indeed the fact that integration has happened at all, has been the result of strong leadership at NHS and council levels. People have been committed to change, and there has been cultural change in the staffing structure. Most of all, there has been trust. The people involved have said that it will be difficult to replicate the lead agency approach elsewhere unless there is trust.
It is not possible to legislate for trust and cultural change. The bill addresses the mechanisms and bureaucracy, but we must be clear that that alone will not work. We will need to consider how we nurture the culture and leadership in organisations.
I ask that Ms Grant moves her microphone a wee bit closer because I can hear the private conversation taking place in front of me somewhat better than I can hear her.
I hope this is better, Presiding Officer.
The bill deals mainly with the bureaucracy, but even that does not seem to be done very well. The legislation will allow a board to be set up with an accountable officer, but staffing and resources appear to remain with the parent bodies. What budget will be required by the new body if it does not have responsibility for paying staff or if capital resources remain in the ownership of the parent authority? How can that new body direct their use? That is not at all clear.
The cabinet secretary said in his opening speech that integrated budgets are essential to success, but in committee he said that—as the Government has said in previous budgets—healthcare money would remain ring fenced and protected and that local government money would remain part of the local government settlement. It is therefore difficult to see how the budgets can be integrated if organisations must account separately for the money and show that it is spent in their own organisation and under their existing responsibilities. We must look at how that will work.
Malcolm Chisholm mentioned health board budgets. Half of their budgets will go into the new body. That might work in some instances, but what about acute centres of excellence? They may take patients from all over the country, but what part of their budget is ring fenced for that national service and what part will go to local service delivery? Those matters are not at all clear.
Neither is it clear what thought has gone into the impact of people working together with different terms and conditions on salaries, pay bands, pensions and policies, including disciplinary and grievance policies. How will those work when people work together? Who would take out a grievance? What policy will they use if they are working with somebody employed by a different agency? That issue needs to be considered, including by the governing bodies and the trade unions.
We need to make progress on those issues because, as Ken Macintosh mentioned, if the budgets, the powers and governance are not sorted out, we will end up in lengthy wrangling. I can see that happening if the cabinet secretary does not consider those important issues.
Let me be clear that service users and their carers need to be at the centre of the legislation. They are concerned about where they fit in, how they will be involved, whether co-production is at the heart of the bill, whether services are provided for them rather than their being allowed to design their own services, and how they will be represented.
The point was made that the voluntary sector interface also represents service providers and that quite often service users feel drowned out by the providers’ voices. We need to make the distinction between service users and providers, and we must ensure that the individual is very much at the centre of what we provide in order to help them to live their lives and to enable them to live how we would wish to live.
For example, should an individual wish to move, their care package should be portable and move with them. They should also know what that care package would cost in other areas. That is important and as Ken Macintosh said—Macmillan Cancer Support research made the same point—the service user must be at the centre.
Putting the service user at the centre also means that we must look at quality and safety. The RCN, among many other organisations, asked for that issue to be covered in the bill. We need minimum standards of care—people need to access the same level of care, regardless of where they live, and they need to know what to expect.
It is not possible to have quality without reasonable conditions for staff. Neil Findlay mentioned working conditions. Many people who deliver front-line care do not even get the minimum wage, training or time to do their job. They are frustrated and distressed by the stress that the job causes if they cannot do it properly. We therefore need to ensure that quality is covered in the bill.
Furthermore, some of the principles on integration need to be moved up the bill and emphasised, so that everyone is clear about the culture change that is needed as well as the different structures that are to be put in place.
There are many more issues that we need to consider. For instance, we need joint inspection that is independent, rigorous and available to workers, staff and service users. Whistleblowers also need to be protected in those conditions.
I have come to the end of my time, but I very much hope that the Government will listen and will strengthen the bill. It could be a good bill if those concerns are listened to and taken into consideration.
16:50
This has been a good debate on the stage 1 report, with a number of important speeches.
What has struck me most in the debate is that the change that the bill will introduce through the integration of health and social care will be one of the largest changes to take place in the health and social care system in almost a generation. It is unusual that a piece of legislation that will result in such a significant change has such cross-party support. That is a reflection of the fact that, as the committee’s report recognises, there is a broad consensus around the issue and the need for it to be addressed.
In his opening speech, the cabinet secretary set out some of the key drivers behind the need to take integration forward, such as the demographic challenge that we face. In themselves, however, those are not the only reasons for integration.
Ken Macintosh highlighted the history of the debate. He talked about the joint futures agenda back in 1999 and the fact that the document for taking forward joint futures echoed many of the opportunities that the bill creates for partnership working, joint budgets and joint commissioning of services. However, the policy predates joint futures. The whole integration agenda started in the 1980s and continued into the 1990s. The debate has been around for some time and has presented some real challenges.
I have no doubt that, when Malcolm Chisholm was a health minister, he tried to pursue the agenda and was successful in some areas and unsuccessful in others. That demonstrates the challenge in ensuring that integration takes place on a systematic and consistent basis across the country, which is why the bill is extremely important.
The bill will not resolve all the difficult issues that we face in our health and social care system at present, but it will ensure that we focus on some of the challenges much more effectively so that, in health and social work, our local authorities and health boards will work much more closely in partnership.
Neil Findlay referred to the route that West Lothian Council pursued in 2003. That is an interesting illustration, as the joint futures agenda goes back to 1999. There was a four-year period before West Lothian Council was able to take forward the agenda, but it is now the most advanced area in the country in this matter, which we should recognise. When colleagues in other parts of the country ask me what integration is going to look like, I tell them to look at what is happening in West Lothian and the way in which the council has been able to lead the agenda.
Will the minister give way?
I will just finish this point.
The experience of the 1990s, joint futures and what has happened in West Lothian teaches us that, if we do not provide the legislative framework to drive integration forward, it will not happen on a consistent basis. The bill builds on the good practice in areas where joint working is taking place, ensuring that it happens consistently and right across the country.
I welcome the minister’s acknowledgement of the excellent work that is being done by that Labour council. I am sure that it will be a shining example for other councils to follow.
Sure, and I know that my SNP colleagues did exactly the same in driving forward that agenda when they were in charge of West Lothian Council. I could, of course, identify other councils that are not doing as well, but I will not get into that, because I think that it is a question of ensuring that we create the right legislative framework to drive forward the agenda in a much more effective way.
Bob Doris pointed out that the integration of health and social care has been an aspiration for several decades, and the bill will make that happen in a way that has never previously been done. In doing so, it will enable us to integrate the services that people receive much more effectively.
What Mary Scanlon said about the experience in Highland was a good illustration of the benefits that come from the greater integration of services. Taking forward that agenda has put an end to the lack of planning and the cost shunting that can go on between different agencies. The experience of the approach that has been taken in Highland bodes well for the benefits that can be achieved through integration.
Some members raised concerns about the potential for services that have been provided by health moving into social care and being charged for. When we consider such issues, we should be careful to remember that the moving of more services into the community is not a new development. The late 1980s and the 1990s saw the closure of long-stay hospital beds for people with a mental illness and for those with learning disabilities. Most of those patients moved into the community and received social care packages to support them there. Many of them continue to live in the community with the help of such support. Therefore, the process that we are talking about is not new—it has taken place previously.
It is also worth bearing in mind that the bill is not about taking a service that is provided in hospital, such as physiotherapy, and giving responsibility for it to a social care partnership, which must then decide whether to charge for it. Instead, the bill is about ensuring that there is joint commissioning of health and social care services, that those services are jointly planned and integrated, and that people work together collectively to look at the best way of doing that.
We need to consider how we can best configure social care services at a local level to meet the demand on the healthcare system, and how we can better configure them to reduce the demand that exists in some areas. Rather than taking something that health does and putting it into the social care setting, we must ensure that services are configured and planned much more effectively.
A number of members, including Duncan McNeil and Hanzala Malik, highlighted the importance of general practitioners in taking forward the integration agenda. Primary care is key to the success of greater provision of healthcare in a community setting and to ensuring that social care provision is properly aligned with that.
The work that we are doing with the British Medical Association on issues such as the GP contract gives us an opportunity to do some of those things in a way that has never been done. Although those negotiations are confidential, I am strongly of the view that we are all singing from the same hymn sheet—GPs, social work, the Government, the independent sector and the third sector all want to see more effective integration. We need to find a way that allows us to deliver that for patients on a daily basis. We are taking forward our work with the BMA to assist us in achieving that.
Neil Findlay highlighted concerns about the quality of the inspection process for those people who receive care at home. I recognise some of the challenges of conducting inspection in a home setting. That is why the cabinet secretary has already commissioned the Care Inspectorate to do work on how we can improve the inspection process and ensure that it is much more rigorous when it comes to the quality of care that is provided at home.
I point out that inspections are not a bad thing. Inspection is a good part of the system that can help to drive up standards and lead to improvement. As Mary Scanlon said, care-at-home services in Highland did not receive a fantastic report, but that report has created a platform for improving those services. That is what we need to do much more systematically right across the country. The work that the cabinet secretary has asked the Care Inspectorate to undertake is exactly about doing that and ensuring that we have a more robust and clear inspection regime for care at home.
I believe that the bill has not only cross-party support in the Parliament but public support, because people want to see services working in co-ordination and planning their delivery much more effectively in their communities. The bill will help us to make significant changes in how we can deliver in our communities right across Scotland.
I call on members to support the cabinet secretary’s motion at decision time.