The first item of public business for us is consideration of two reports: primarily the Accounts Commission and Audit Scotland report entitled “Delayed discharges: A symptom of the challenges facing health and social care”, along with a briefing note, which is also a joint production by the Accounts Commission and Audit Scotland, entitled “Community health and social care: Performance 2025”.
I am very pleased that we are joined this morning by Caroline Lamb, who is director general for health and social care and chief executive of NHS Scotland, and Derek Grieve, who is director of health and social care performance and delivery for the Scottish Government.
We have some questions to put to you on the report and the briefing note, but before we get to those questions I invite the director general to give an opening statement.
Thank you, convener. I welcome Audit Scotland’s report on delayed discharge and the briefing note on community health and social care performance. My team and I have carefully reviewed the reports and the recommendations that have been made.
The Scottish Government shares the view that, despite the hard work that we have undertaken with the Convention of Scottish Local Authorities, health boards, and health and social care partnerships, more must be done to ensure that people receive the care that they need, in the right place and at the right time. We agree with Audit Scotland that delayed discharges have a detrimental impact, most importantly on the people who are affected by those delays, but also on the wider health system. We also agree that delays are a symptom of the many challenges that the health and social care system faces.
As the committee will be aware, the delivery of social care support is the statutory responsibility of local government, and we have been working with COSLA and local systems through the collaborative response and assurance group to explore the challenges in that area; to ensure that there is common understanding of the impact; and to look at good practice and improvement.
The recommendations in the delayed discharge report are complex, in particular those around performance, cost modelling and evaluation. Addressing them will require careful, whole-system thinking, especially given the different approaches to the integration of service delivery across Scotland and the different systems and processes in play across the country. Ministers have asked the collaborative response and assurance group, which they co-chair with COSLA, to consider all those recommendations and to develop a partnership approach to addressing them.
Alongside that work, local systems continue to work hard to share best practice, to reduce delays and to deliver on the commitments in the “NHS Scotland Operational Improvement Plan”. Despite the challenges that the report sets out, some areas have delivered improvements through a whole-system approach.
The community health and social care performance briefing reinforces the need for stronger, more consistent performance information as an essential foundation to improving outcomes across health, community health and social care. Once again, we agree with that, and we will continue to work with partners across the system, building on the work that we have already taken forward, to provide the whole-system pressure dashboard. That work recognises how important it is that every part of the system can see how their performance compares with that of others in order to identify areas for improvement. It also enables different services to see their performance as part of the whole system, helping to drive shared accountability and a common understanding of risk.
We will be very happy to answer the committee’s questions.
Thank you very much indeed. I begin by asking you whether you accept in full the key messages, findings and recommendations of these reports.
Yes, we accept the key messages and the recommendations. We also accept that some of those recommendations will be complex to implement, given that they require a whole-system approach. That is why ministers have taken the approach of asking the collaborative response and assurance group—I will call it CRAG from now on, if that is okay—to work to ensure that a whole-system approach is taken to implementing those recommendations.
As I mentioned at the start, you are the chief executive of NHS Scotland, so you must be concerned—must you not?—when you see figures such as
“11.7 per cent of hospital beds being unnecessarily occupied”
by people because of delayed discharge. That is 720,000 days that are lost because of delayed discharge, and two thirds of those delays involve people over the age of 75. What is your response to that?
First of all, yes—I am very concerned by those figures. I am concerned because of the impact that delayed discharge has on individuals; we know how bad it is for people to be in hospital in an acute bed, in particular when they are there for longer than they need to be. We know that that leads to deconditioning, and that the longer people spend in hospital, the more care and support they are likely to need when they get home. I am concerned, from the perspective of those individuals, about wanting to ensure that they can get back into a homely environment as soon as possible.
However, there is also no doubt that the levels of our hospital beds that are occupied by people who do not have a clinical need to be in them has an impact on how the whole system operates. That is why we have focused not only on a whole-system approach, bringing all the partners to the table through CRAG to examine where things are working well and how systems can learn from each other, but on things we can do within the national health service. For example, we look at what we can do within the NHS to ensure that people are not admitted to our hospitals unless they absolutely need to be and that, if they are admitted, their stay is as short as possible. We aim to do everything that we can, working with partners, to ensure that, from the moment someone arrives in hospital, we are planning for the time when they can be discharged.
It is important to remember that 97 per cent of discharges happen without delay, but also to acknowledge the impact that delayed discharge has on those people who are delayed, as individuals, and on the way in which the whole system works.
You have mentioned a whole-system approach a couple of times. In the report, exhibit 3 sets out the areas where there are contributory factors to this systematic failure. It talks about “financial pressures” but also makes the observation—it is the Accounts Commission and Audit Scotland making this observation—that “governance is complicated”, and that, while we have “an ageing population”, there
“is a lack of planning for the future housing needs of an ageing population”.
The report also highlights something that we have discussed repeatedly over the past few years, which is our workforce shortages, not just in the national health service but in social care in particular. Could you explain to us how you are addressing each of those challenge areas that are identified in the report?
I am happy to do that. If we take the first area, which is the financial challenge, there is absolutely no doubt that there is a financial challenge across both health and social care services, and that we need to redesign systems and make sure that we are working, and using every penny that is provided to us from the public purse, as effectively as possible.
In our “Health & Social Care Service Renewal Framework 2025-2035” and “Scotland’s Population Health Framework 2025-2035” documents, which were both published in June last year, we very much set out the progress that we need to make around moving the focus of our systems towards prevention and early intervention, which is when those interventions are cheaper, and—in the service renewal framework in particular—needing to look at how we work differently across the system. That means looking at delivering more activity in primary care and in the community—again, away from the most expensive sectors, such as acute hospitals—along with a focus on digital and on how boards work better together on a collaborative basis. The committee will be aware that we have recently published ministerial directions around subnational planning. All of that is about tackling the financial pressures, in particular—understandably—from a health perspective.
With regard to governance, we accept that organisations play many different roles. The national health service has its role to play; local government still has statutory responsibility and has a role to play; and there are the integration authorities that seek to join those areas up. In addition, Audit Scotland referred to the important role of the third sector and the independent sector—that is important, too.
That is complex, and those relationships work best when they work really well locally. Certainly, from my perspective as chief executive of the NHS, having our chief officers sitting at the executive tables in our NHS boards and, therefore, being part of understanding the totality of system pressures and their contribution towards meeting those, and where they can make a larger contribution, has been key to that.
We have an ageing population—that is not going to change. It is important, therefore, for us to look at how we can deal with the demands of that ageing population in the way that is most appropriate to it and which helps the functioning of the system. I would point to areas such as frailty units at the front door and the success that some of those initiatives are having in reducing the length of stay. Our primary objective is to prevent that elderly population from needing to be admitted to hospital in the first place, but, where they are admitted, we are trying to ensure that they can get home as early as possible.
With regard to the workforce, there are challenges around international recruitment in particular. We were making good progress on international recruitment; that has obviously been made more difficult by decisions at a United Kingdom Government level. That said, the most recent Scottish Social Services Council workforce report, which looked at the workforce as at 2024, shows an increase of around 6.36 per cent, I think, in the care home and care-at-home workforce from 2015, and a smaller increase—but still an increase—of 1.4 per cent between 2023 and 2024.
We have more recent statistics available to us on the NHS workforce. The latest quarterly report, as at December, shows a small increase in that workforce now. There will continue to be pressures and we need to focus on not only how we continue to attract and retain people in our workforce, but how we look to design our services and look to use digital so that we are focusing our workforce on the jobs that only people can do.
I think that your final point was on housing. We absolutely recognise that pressure, and the committee will be aware of the moves that the Scottish Government is currently making to try to address some of the housing issues. That includes in remote and island communities, where it is particularly difficult to attract and retain staff because of the challenges that they have in accessing housing.
Sorry—it has been a bit of a canter through all that. I am happy to pick up on any of it in a bit more detail.
No—I recognise that it was a wide-ranging question, and well done for remembering all of those different headings that I put to you.
I have just a couple of other questions that I want to raise with you. I suppose that one of my overall points is that we have integration authorities and integration joint boards, and you are the director general of health and social care, but we are still having all these issues with delayed discharge. That is about whether we have a joined-up social care and health system, is it not? Does this report not suggest that that is not working? The integration is not working, and the plan that we have had for the past 10 years has not delivered what it was supposed to deliver.
I think that the report acknowledges that delayed discharges are a symptom of the pressures across the system. We have just run through a number of those pressures, which are multifaceted. I do not think, therefore, that it is fair to say that integration is not working. I think that integration has actually delivered a lot of improvements on the ground. Whether those are enough to address the challenges that we face is another question, but I think that it is still really important that we focus on what is right for the person in the middle of it all, and that is done better by looking across systems than by focusing on a single siloed system.
Okay. I have just one particular area that I want to ask you about, which is mentioned in the report: the whole issue of power of attorney. That gets us almost into a legal area, does it not? It is about whether people have access to established power-of-attorney arrangements with their relatives or with whoever. That is seen to be one of the reasons why we have delayed discharge: because those arrangements are not in place. Could you shed a bit more light on that and perhaps explain what the Government is doing to tackle it? That seems to be one of the driving forces behind delayed discharge and people getting caught up in the system.
09:45
That is absolutely the case with regard to the issues relating to adults with incapacity, which is how they are described in the system. Those are people who do not have the capacity to make their own decisions and for whom there is no power of attorney in place. You are absolutely right that that creates a difficult position, because local authorities then have to apply for guardianship arrangements in order to enable those decisions to be made on behalf of people. That is a complex legal process, and there are some different approaches to it and different appetites for risk around that across the country.
First, as a Government, we have recognised that we have to promote the need for people to have power of attorney in place—all of us, across the whole population—to ensure that we are prepared to deal with the eventualities that arrive in life. We have done some publicity campaigns around that; our current approach is to try to identify the impact of those, and also to identify barriers to people being able to put a power of attorney in place, particularly when it is seen as just an additional expense on top of everything else that people are dealing with.
We also need to look at the legislative route. The relevant legislation is the Adults with Incapacity (Scotland) Act 2000; the Government has been out to consultation on that and published the results of that consultation. We are now working on what the policy response would be, bearing in mind that there are some quite complex interplays with the European convention on human rights. We need to ensure that we are protecting the rights and dignity of the individual at the same time as recognising that, for most people who fall into this category, hospital is absolutely the wrong place for them to be, and we need to find a way in which we can address that.
With regard to numbers, this group of people is significant as a proportion of those who are delayed, and they tend to be delayed the longest.
I will add something here if I can, convener.
Caroline Lamb is exactly right: the Scottish Government has a role in promoting the importance of power of attorney, but it would be fair to say that it is not just the Scottish Government’s job. We know that the social care workforce, and also the social worker workforce, play an important role in this space because they are often the interface between the family and patients, in particular before someone reaches crisis point.
As Caroline alluded to, having families go through some of the process when there is a wider crisis in play and somebody is in hospital is really challenging, so the ability to have power of attorney in place and to support those difficult conversations with families is important. However, as Caroline rightly said, having power of attorney when one does not need it is probably the place where we want us all to be.
As a very quick question, are people eligible for legal aid to help them to pay for that? The documents for establishment of power of attorney are not inexpensive, are they?
No, that is right—they are not inexpensive. I will confirm this to you, convener, but my understanding is that people are eligible for that, although whether the Scottish Legal Aid Board is able to wholly meet the demand in that area is another challenge.
It might be a Scottish Government issue as well, of course.
Yes.
Okay. Colin Beattie has some questions for you.
I am looking at what needs to happen with regard to delayed discharge. The Auditor General told the committee that the delayed discharge reflects a wider long-standing failure to shift the balance of care from hospitals to community settings. Since I have been on the committee, that has been the headline. Nothing has changed, and I have been sitting here for 15 years.
Malcolm Bell from the Accounts Commission told the committee:
“IJB reserves are being continually depleted, often to shore up day-to-day work”—[Official Report, Public Audit Committee, 21 January 2026; c 29.]
instead of doing what they should be doing, which is transforming the whole-service offering. Witnesses were clear that progress depends on clear leadership, stronger governance and firm accountability at both national and local levels, but none of that seems to have happened.
I say again: this is a repeat. The issue comes up every time that a report comes before the committee, but there is no movement. Why?
It is fair to say that a lot of us recognise that our strategic intent has, for some time, as I said in answer to the convener’s question, been to move the activity in our systems away from our acute hospitals and towards the community—towards social care and community services.
When we published the service renewal framework in June, we were clear that, although that was not a new approach, we needed to look at the concrete actions that are required to ensure that we can implement that approach. One of the first concrete actions that we have taken in that regard concerns the additional funding that is being made available to general practice in the draft budget for 2026-27, which will enable us to increase the capacity in general practice and to place an enhanced focus on the preventative role that general practice can play.
It is also important that we are able to look at the spend in its totality across both the acute sector and primary and community care. One of the most successful areas where we have seen that progress is being made, not only in reducing delayed discharges but in all the other measures that contribute towards that, such as reducing admissions and length of stay and accelerating the processes for discharge, has been NHS Lothian. That progress was achieved by some of the funding that was made available by the Scottish Government being directed by the health board towards the social care partnership. That has achieved results, so it is clear that we are starting to understand the interventions that make a difference and to see some progress, but I absolutely accept that that has not been as fast as we would want it to be.
There is only a finite pot of money, so part of what we need to do is ensure that our acute sector is functioning as productively as it can, in order that we are able to identify ways in which we can provide more support to community and social care.
Derek, do you want to come in?
I will add a couple of points.
The Audit Scotland report outlines that the operational improvement plan gives strong signals that we are seeking to shift the balance of care. That comes with additional funding, but it is being used as a means to leverage existing funding rather than being the only funding available.
Caroline Lamb gave some examples earlier, such as the development of frailty units, having hospital-at-home programmes in place and looking at a wider range of community-based interventions in order to shift the balance elsewhere from the acute system. If I can give the committee a little bit of hope in this space, I will highlight another example in addition to the example of NHS Lothian, which Caroline outlined. We have taken this to CRAG as an exemplar. We know that in NHS Forth Valley there has been an explicit decision taken to reinvest a quantum of funding from the acute services and redirect it into community care services.
We are now seeing practical examples of systems doing exactly what we are looking for, which is shifting the balance of care.
I am pleased to hear that. I understand that, from the beginning, the concept was that there would not necessarily be additional funds going into the IJBs—rather, there would be a movement of funds from secondary to primary care. That was a sticking point, of course, because nobody wants to lose any part of their budget, and it never really happened.
You have described a situation where it has happened, but it is certainly not happening in general. How are you going to stimulate progress on that and push people to actually deliver what was originally intended? It seems almost a moot point after 20 years.
We stimulate that progress partly through sharing good practice, such as Derek Grieve described in NHS Forth Valley. There is good practice to be shared from NHS Lothian, too.
The approach through the whole-system pressure dashboard has been to give all those people who are involved in different elements of the system an overview of what is happening as a whole, so that they see their responsibility in relation to the overall performance of the system. Everybody who is working in these systems wants to do the best thing for people, and that requires having a system that is working at its optimum.
Another shift has been around leadership. Leadership is important with regard to not only focusing on the acute sector but seeing how primary care, community care and social care impact on the acute sector. In that context, I note that a significant number of our recent appointments to chief executive posts in NHS boards have experience of working in social care, some as chief officers.
We have been developing a leadership cadre who absolutely understand the interdependencies and are interested in doing the best thing for the population and ensuring that the health board is doing its bit by doing whatever it can to keep people out of hospital in the first place. That can be through hospital at home or frailty units, or even through the work of the Scottish Ambulance Service, which is now conveying only around 50 per cent of its call-outs to hospital.
There is a whole healthcare system approach in order to ensure that people stay out of hospital and then, through work in multidisciplinary teams, to ensure that people are being discharged. There is an increasing recognition that—as Derek Grieve said—where there is money to be spent, it is better directed at the areas that can provide support to those more expensive aspects of the system. It is increasingly recognised that that is what we need to do with the money as a whole, rather than being able to do it only when additional bits of money are being made available.
You touched on leadership, which is obviously mentioned in the Auditor General’s report. There are concerns about the quality of leadership and the governance and accountability. Those themes come forward again and again, but we do not seem to see any movement on them—certainly nothing that would give us confidence. How are you going to strengthen leadership, both nationally and locally, as well as the important areas of governance and accountability?
I think that we are making progress in all of that. We have brought the whole system together to work together, starting with CRAG, which is co-chaired by ministers and Councillor Kelly, who represents COSLA. We are working with all our local systems to ensure that they have the data to understand how they are performing relative to others and, therefore, to identify the areas where they can improve. It is also about enabling them within their own systems, through our systems and the health board working closely with the IJB and health and social care partnerships. All of that is critical to each system starting to appreciate where its focus needs to be in order to improve the performance across the whole system, and to understand which areas it needs to prioritise.
Sometimes that is complex with regard to governance and people being prepared to give things up in order to achieve a better outcome for the whole. However, we are seeing areas where it has happened. Derek Grieve pointed to the example of NHS Forth Valley, where money has been shifted from the acute sector into social and community care, and we have seen a similar approach in NHS Lothian. Our health boards are certainly moving to a position where the thing to do in response to pressures is not simply to try to open more acute beds, but to look carefully at what they can do to support their social care, community care and primary care sectors. That is absolutely understood across the system.
There is more for us to do, and it remains work in progress. However, I believe that, in the face of all the pressures around demographics and around funding, the work that we are doing, although it is not yet enabling us to see a big reduction in delayed discharge, is enabling us to see a stable position, which might not otherwise have been the case.
We have had 20 years—in my case, 15 years—of reassurances from you and your predecessors. Why should we believe that it is going to work this time? You paint a very rosy picture, but the report does not paint quite such a rosy picture. How can we get the reassurance that things are actually happening and we are moving in the correct direction?
10:00
I am not sure that I would describe what I am painting as a rosy picture; there are very significant challenges across the piece. However, I think that we have set out conditions that make it possible for systems to start to change. I have already referenced the money to support enhanced capacity in primary care, and that is accompanied by data reporting requirements. I know that the quality of the data that we have on primary care has been an issue of interest to the committee, and we will be able to assess that.
I would also point to the actions that we have set out in the population health framework, and probably even more to those in the service renewal framework regarding how we will work differently across our NHS boards. We are introducing the concept of the west subnational and east subnational regions, and we are looking at all the opportunities to work differently and more collaboratively not just in and between boards, but, just as important, with partners in social care, too.
We have talked about money, but what is actually needed? IJBs need sustainable financial security to take forward what they are supposed to be delivering, and clearly that is very patchy. What can be done to ensure that that financial stability—that funding—is in place, so that they can deliver timely discharge services?
First of all, as a Government, we need to do our best to make as much money as we can available within quite a constrained financial envelope. The local government settlement is at a record level this year, and it will be up to local government to make decisions about how it chooses to deploy that money and what it prioritises. As I have said, and as the committee will be well aware, social care is the statutory responsibility of local government, and I am sure that the committee will want to speak to COSLA about its role and the role of local government in managing delays, too.
We are spending a very significant amount of money and we need to focus not just on trying to quantify what more money we might need, in the knowledge that that funding is not readily available, but on making use of the money in absolutely the best possible way. That will involve ensuring that we are not reworking or duplicating things. In that context, I would point to all our work on getting it right for everyone, which focuses on the person and what they need and ensures that the multidisciplinary teams that need to do so can come together, share information about that person and make decisions on the best support that can be provided to them without all of that needing to be repeated multiple times across the system.
There are also opportunities for us to use digital in a different way, not only to support people but to free up time and capacity in our staff teams, so that they can focus more on the face-to-face work that absolutely needs to be done with people. There are some great examples of that, such as our virtual wards and the use of virtual monitoring to keep people out of hospital and in an environment that provides better value for money.
I do not think there is any silver bullet here; if there were, we probably would have found it by now. We need to look at the multiple opportunities that we have across the system to make small gains and to bring everything together.
Derek, do you want to add anything?
I am sure that the committee will be aware of this, but, as the Audit Scotland report has identified, there is, as well as the real human cost, a financial cost to high levels of delayed discharge. That money could be used elsewhere in a different way, and we are focusing on trying to support those local systems and those with the authority to make such decisions to shift the investment from, say, acute hospital care, which is probably the most expensive care that is provided, to an alternative and—more important—more appropriate form of care, which will often involve community-based care.
Is it correct, then—this is my interpretation of what you are saying to me—that you have moved away from the original concept of transferring resources from the secondary to the primary sector and are now looking to find other funds to go into the IJBs?
The IJBs have always been funded partly by health boards and partly by local government.
We are still considering where the opportunities are in our secondary care sector. As Derek Grieve pointed out, if we can reduce delayed discharges, we have a huge opportunity in our secondary care sector to free up resource, beds and staff time that is unnecessarily spent looking after people who do not need that level of care.
That is only one example of the work that we are doing. We are also using the service renewal framework to consider ways in which we can increase productivity and to identify ways in which we can shift resource from the secondary care sector into primary and community care. The process is not about winners and losers; it is about providing resource to the areas where it makes the most difference to people and where it can result in the best outcomes for people.
It is also much more difficult to identify resource to release while under a lot of pressure. We have been trying to seed initiatives such as the frailty units, hospital at home and virtual wards, and some of the money has gone into social care, to demonstrate the difference that that can make to the systems.
Ultimately, we can provide some of the enablers, but we rely on individual systems to identify where the opportunities are. It is about trying to shift our focus away from the secondary acute sector and putting more focus on primary, community and social care, and on prevention.
In response to one of Colin Beattie’s questions, you said that the answer is not more acute beds, but what about when health boards such as NHS Forth Valley close wards? It closed ward A11 of the Forth Valley royal hospital and has reduced the bed capacity. Do you have to sanction that, or is that a decision for the health board to take on its own? Do you have a general view about the contraction of capacity? Looking at the report, the lack of available beds is clearly highlighted as an issue.
The closing of the ward in Forth Valley royal hospital is exactly the kind of thing that I meant in the example that I gave.
There was a ward with a high level of delayed discharge and that was equating to the high proportion of delayed discharge, so NHS Forth Valley took the decision to close that ward. It transferred the resources and staff from the ward and reinvested them in community activity. That is an exemplar rather than something to frown upon. The care is delivered in a different way, and people are being supported in a different way rather than being required to stay in hospital when they do not need to be there.
I am afraid that the families whose relatives were in that ward would not see that as an exemplar. I will not go into any more detail, but let me assure you that that is not how they saw it—and, frankly, it is not how the staff at the hospital saw it either.
I completely agree with what the convener has just said.
I will now go back to the issue of power of attorney, which the convener explored earlier. It is important for people to have that in place. I was reflecting on experiences that I have had, and there are cases where people’s health goes downhill very quickly, so there is not time to put a power of attorney in place. Do you think, therefore, that maybe we need to put in place a system that deals with such situations so that families can act quickly?
The ideal would be for all of us to put in place a power of attorney at the point at which we assume that it will be a long time before we need it. I accept the convener’s point about the associated expense, but the ideal is that we all do it when we are fully able to. You are right that people’s health can decline incredibly quickly, so it would be good to get to a point at which people are more focused on thinking about the what-ifs and making those arrangements.
We also need a better solution to deal with the situation when people are unable to make a power of attorney so that their dignity can be maintained and the power of guardianship, or whatever it is called in the future, can be put in place in a way that means that they can be accommodated in the place that is right for them.
The Audit Scotland report highlights the work that East Ayrshire health and social care partnership has been doing with Alzheimer Scotland to identify people who are coming to the point at which they might no longer have capacity. There are things that we can do to encourage people who are not close to that point yet, but we can also target those people who still have some capacity but might not have it for very much longer. It is important that we also look at those folk.
We have received a letter from Carers Scotland. I do not know whether you have seen it.
No.
You have not, so I will quote from it, if that is okay. The letter came last month and it refers to a Carers Scotland report called “State of Caring”, which was published in November 2025 and which found that
“just 34% of unpaid carers said they were involved in decisions about discharge and what care and treatment was needed. Only 13% had been asked about their ability and willingness to provide care, down from 19% in 2024 and just 12% felt they had been provided with sufficient support on discharge to protect their health and wellbeing and that of the person they care for.”
If those figures are to be believed, and I have no reason to disbelieve them, they are pretty shocking, are they not?
Yes. The Carers (Scotland) Act 2016 provides that carers should be involved in the arrangements for discharging the person they care for. That is hugely important to the carer’s understanding of what some of the requirements might be and to their confidence that they can manage them.
Those statistics are extremely disappointing. We have been working to provide more educational resources for staff across health and social care to ensure that they understand the requirement to involve carers. There are some good examples, but carer link workers being put in place in some systems specifically to support carers is probably not consistent across the piece. Carers do a valuable job and it is important that local systems are able to provide them with support so that they continue to perform that role for their loved ones.
I will quote another bit of this very good letter. It says:
“This poor involvement and lack of support for unpaid carers risks unplanned readmission of individuals, poorer outcomes and increases the cost of caring to carers’ own health. Carers are already experiencing high levels of poor health, with 30% living with poor physical health and 36% with poor mental health.
A lack of involvement in decisions around care … has long term consequences.”
The letter goes on to talk about the 2016 act, which you have referred to, saying that Carers Scotland welcomes the call in the report—its report, not the Auditor General’s report—for
“integration authorities with their partner NHS boards and councils to ensure they fully implement their duties and responsibilities for including unpaid carers as set out in the Carers (Scotland) Act 2016.”
Given the figures that I have just quoted, it appears that the duties in the act are not being met—why not?
10:15
Part of the reason why the duties are not being consistently met is the complexity of some of our discharge arrangements. That is why having carer link workers has made such a positive impact, and that is certainly an initiative that we would look to spread elsewhere.
There is something about that general awareness of the educational materials and making sure that health and social care staff across the piece understand that requirement. There is also something about how we make it as easy as possible for staff to ensure that carers are being involved and engaged. That is why the link model is appropriate.
I also note the comments about the pressure on carers. The move towards having short breaks for carers is important in addressing some of that pressure.
It seems to me that we have an act that was brought in 10 years ago but the requirements in that act are not being fulfilled. You accept that they should be fulfilled, but we really need to do better, do we not?
Yes.
You agree—okay. How are we going to do better? If we come back here in a year’s time, will the figures be better?
As I said already, the example of having carer link workers in local systems has demonstrated that that is a route through which we can do this better. We would want to look at encouraging other areas to take up that approach.
The term “rosy picture” was used earlier, and you said that it is not quite a rosy picture, which it is not, is it? The figures in the Auditor General’s report—there is a graph, which is exhibit 1—shows that there was, as you would expect, a huge dip in delayed discharges during Covid, then it rocketed, and now it is basically a straight line. It is stubbornly high and is not coming down. There is the occasional blip, but, in essence, it is high. It is probably higher than it has ever been, and we do not seem to be getting any improvement. Why is that, given that we have known about the issue for years?
The Audit Scotland report usefully identifies the pressures that are out there around money, workforce and other issues. A huge amount of work is going on across the system, which is overseen by CRAG. There is regular reporting through that group, so we know which partnership areas are doing better than the Scottish national average, and we know which are struggling against the Scottish national average. We know which partnerships are improving and which are not, so we will have conversations with those partnerships about the challenges that they are dealing with that are impacting on their performance.
A huge amount of work is going on across the piece, and as I have already described, I do not think that there is only one measure that we can take here that would change things. It is about making many small gains in the system, and the delayed discharge is the symptom, if you like. That is the headline figure that we see, but behind that, the things that we need to focus on are preventing people from being admitted to hospital in the first place and, once they are admitted, making sure that their stay in the acute sector is as short as possible. If they are then moved on to any step-down facility, we also need to make sure that that stay is also as short as possible, and that they are being discharged.
Initiatives such as discharge to assess have demonstrated real success in that when somebody is assessed for their care needs in their familiar home environment, they are generally assessed as needing less care and support than they would be if they were assessed in an unfamiliar environment in a hospital. All of those factors are really important in ensuring that we are able to maximise the contribution of our workforce and the money that we have to tackle this.
I would absolutely accept that the level of delayed discharges is higher than we would want it to be. We have seen dips—we have seen it coming down. We would regard it as having been stubborn, certainly since we came out of the pandemic. We could also have continued to see an increase. The position is stable, but not as stable as we would want it to be. We would like it to be stable at a much lower level.
The Audit Scotland report usefully highlights some of the wider challenges, not least the fiscal challenge. On the demographic challenge, the report clearly illustrates that the proportion of people who are over 65 has been increasing significantly—it is now more than 20 per cent. Caroline Lamb is absolutely right: the level of delayed discharges is stubbornly static at too high a level, but that is almost despite an increase in the demands that are being placed on the system.
There is a knock-on impact on ambulance waiting times, for example. There are people in hospital who do not need to be there. Ambulances turn up, bring people to accident and emergency, and there is nowhere for those people to go. There is a whole-system impact.
Mr Greive mentioned costs, but, according to the report,
“There has been no published information on the costs of delayed discharges since 2019/20.”
Why not? If we managed to do it then, why have we not managed to do it since?
The straightforward answer to that question is that Public Health Scotland believes that there is not sufficient rigour around the financial data that it has available to it to assess the cost. It is complex assessing the cost, because costs will vary depending on exactly where somebody is being accommodated. Also, I think that the Audit Scotland report quotes the gross cost, so you would have to offset the cost of care packages, care homes or whatever accommodation is provided.
I think that we would all agree that that is a metric that we would like to see. We have our own internal assessment of what the cost to the healthcare system is, but we would like to be in a position in which that information could be published.
Will you do that?
We will work with Public Health Scotland to do that, yes.
The Auditor General had to resort to coming up with figures of his own. In paragraph 26, he tells us that it is cheaper to have someone in a care home than in hospital. If that is the case, why are we not properly funding care places in order partly to fix the problem?
The Auditor General’s figures are not out of line with the figures that we would use for our internal assessment. You are right: we need to work with Public Health Scotland to get to the point of publishing those figures.
Your question takes us back to the tension throughout the system, which is how we release resource from one bit of the system to invest in another bit. That is really difficult when the bit of the system from which we need to release money is running as hot and under as much pressure as it is at the moment. As we said, the initiatives that we are taking are around trying to demonstrate what is possible—what is possible by reducing admissions and the length of stay. However, without significant additional resources to invest, it is hard to create that headroom. We need to continue to demonstrate what can be achieved, but we also need to implement the reforms that we set out in the service renewal framework, which are about the things that we need to look at across our hospital sector.
Okay.
I have one last question. I have noticed that there are a number of working groups and strategies around. You have mentioned the collaborative response and assurance group, or CRAG. There is also the national care service advisory board, whose remit is
“to provide advice and suggest where improvements could be made”,
and the health and social care delayed discharge and hospital occupancy action plan—I am not sure how that is coming along. We also have the rapid peer response and support team, which provides
“targeted support to IAs struggling with persistent delayed discharge pressures”.
How effective do you think all these committees and plans are?
I will talk about just some of those things—I will try not to go through all of them.
We have talked quite a lot about the role of CRAG already. It is chaired at a very senior level by ministers and by Councillor Kelly, and, essentially, it looks at the data across all systems on, I think, a fortnightly basis at the moment.
The difference with the NCS advisory board is that the board includes people with lived experience. It has established a number of priorities, and its focus is on providing advice, particularly through that lived experience lens. That is really important, because one of the things that we have to tackle in accelerating discharge processes is the perception that hospital is the best place for somebody to be. Sometimes, people still have it in their heads that if they are in hospital, that is the best place for them to be, even though all the evidence demonstrates that a hospital is, in fact, not the best place. That is one of the challenges that we face in thinking about the moves that we need to make.
The delayed discharge and hospital occupancy action plan set out three key areas of activity, one of which focused on data. I think that we have largely addressed that through the whole-system pressure dashboard, which has now moved on. The plan also set out the things that we would expect every system to have in place, and a lot of that work has now been picked up by the discharge without delay collaborative, which is focusing on that small number of measures that I keep referring to—that is, reducing admissions, reducing length of stay, and improving discharge processes.
I have slightly run out of steam. Have I missed anything, Derek?
Before you go on, I want to go back to one point. You gave a fairly clear commitment that you would be working with Public Health Scotland to produce total cost data, and the recommendation was that that should be done within the next 12 months. Will you meet that timetable?
We would just need to confirm that. As the statistics authority, Public Health Scotland needs to be assured that it can access data of the appropriate quality to do that work, but I am very happy to come back to the committee on that point.
Okay—that is fine. I invite Joe FitzPatrick to put some questions to you.
I want to cover some areas in which I think some really good practice is happening across Scotland. You have talked about some of this already, but I want to give you the opportunity to say a little bit more about how things are working in practice and how we are measuring the effects.
The first area that I want to focus on is the work that we are doing to prevent people going to hospital in the first place; after all, if they are not in hospital, they are not going to cause delayed discharge. You touched on the frailty teams and hospital at home—two areas on which there is a real focus and that are, in fact, being expanded. How are you doing with getting more beds at home? I have had personal experience of the hospital-at-home system, and I have to say that, until you have been there, you cannot appreciate how amazing it is in preventing somebody having to go into hospital in the first place. How are you getting on with those things?
I will ask Derek Grieve to come in with some detail, but it is important that we recognise the differences here. Hospital at home, as a development, is at the high end. Essentially, it provides acute clinical services, including the equipment, the staff and whatever else is needed, in people’s homes. We also have the virtual bed service, which is much more about the virtual monitoring that I mentioned and does not involve as much face-to-face contact or people going into homes. However, people are still being monitored to ensure that, if there is a deterioration in their condition, things can be triggered. Those two areas, along with the frailty teams, have been key focuses for us through the operational performance improvement plan.
Derek Grieve will give you some more detail.
10:30
I will start by talking about the hospital at home programme. As you are aware, there is a commitment in the operational improvement plan to have up to 2,000 beds by December. We are working with Public Health Scotland on the collection of exact data and there are some challenges with that, but we know that every system is now in the process of developing hospital at home pathways where those do not exist and expanding them where they do. That work includes recruiting new staff.
Two things are happening with hospital at home: the overall volume is increasing and so is the range of specialities. The older people pathway is well developed, and you may have had some experience of that. We are now expanding into paediatrics and other specialties, which has the potential to be a real game changer.
There have been some challenges with the programme because it requires a different model, but, as you alluded to, there is really strong evidence of highly effective patient outcomes from hospital at home. Those outcomes happen for all the reasons that we have spoken about. There is less deconditioning and less risk of infection. There is a quicker response and there are the wider social benefits that come from being at home, surrounded by friends and family.
We are tracking progress, and, although we do not have any published data, we have management information that gives us strong confidence that we are on target.
Regarding frailty units, there is a commitment in the operational improvement plan, and every A and E unit now has access to frailty services. All boards are working towards an enhanced frailty service, and we are highly confident that every mainland board will have access to such a service by the end of March. Caroline Lamb alluded to the really strong evidence of impact. There are reduced hospital admission rates for frail patients and reduced lengths of stay for those who are admitted. For all the reasons that we have indicated, that delivers better patient outcomes.
The next area that I will ask about is delayed discharge and the variations in that across the country. There is some really good practice, and I highlight NHS Tayside, in my local area, where elected members get regular briefings and have been told off for calling it “delayed discharge” when we should turn that idea on its head and talk about “planned” discharge without delay. We can see all three integrated authorities in Tayside doing better than those in other parts of the country because of that ethos and way of working. There are variations within Tayside: there has been an amazing improvement in Angus; Dundee consistently does well, and Perth is not as good but is still better than the national average.
How do we ensure consistency when good practice appears to be happening in some areas, including those that you mentioned? How can that be picked up by integration authorities and NHS boards across the country?
You are right to highlight Tayside, and it is no accident that Tayside also has the best performing A and E in the country as a result of all those factors.
Taking good practice and spreading it gives us both an opportunity and a challenge. We must accept that there can be quite different conditions in different areas and that the systems and processes that they dock into can also be quite different. It is not as straightforward as lifting a bit of good practice and dropping it in a different area. That said, there is a lot of learning to take from the areas that are doing really well, and one way that we try to do that is through CRAG and by having a regular show and tell of where systems are shifting and making a difference.
The discharge without delay collaborative is important because it brings clinicians and multidisciplinary teams together to focus on the areas that we know make a difference, such as avoiding admissions, reducing length of stay and having really good discharge processes. I think that that has been operating for about a year.
It has been slightly longer.
Right. That collaborative approach, which has been used in dealing with other challenges in health and social care, is an opportunity for people to come together, share experience and translate that into their local environment and conditions.
That is exactly right. The collaborative is engaging with the vast majority of partnerships, and the issue is a regular topic of discussion at CRAG. As Caroline Lamb said, there are ingredients that have a really strong evidence base, but the work needs to be tailored to local circumstances. Importantly, local systems, clinicians and teams on the front line need to feel that they can shape and own the work in a way that operates in their individual context, because each system will be slightly different from others.
Are we managing to resource that collaboration work? Time is one of the most challenging issues, so is there funding to ensure that there is time to collaborate?
You are right that time is one of the most challenging things. That is very much for local partnerships to look at, but we have some real champions of that approach across the system who are inspirational in what they bring to it.
Thank you.
Finally, I turn to the deputy convener, Jamie Greene, who has some questions for you.
They are hot off the press, I should add.
Oh, gosh.
Good morning. I want to take a step back. I have listened carefully to the lines of questioning and I thank you for your answers thus far. In fairness, the report identifies that a lot of work is going on across the country to tackle the problem. However, we must be realistic and honest with ourselves about the scale of the challenge.
My main problem is that we do not really seem to be budging on the issue at all. Back in 2015, there were 550,000 delayed discharge days. The then health secretary, Shona Robison, said:
“I want, over the course of this year, to eradicate delayed discharge out of the system”.
She said that on 25 February 2015, which will be 11 years ago next week. What has happened since then? The year after that, the figure rose to 660,000 delayed discharge days. Last year, there were 720,000. The figure is going up and up and up. There is eradication and there is multiplication. Do we know what the figure will be this year?
I absolutely recognise that this is one of the most wicked problems across not just our system but health systems across the United Kingdom. Every health system across the UK is challenged by the number of people who are in our hospitals when that is not the best place for them to be. We would all like the number to come down substantially.
Our understanding of what is impacting on the numbers has improved. As we have discussed already, we recognise that there is a particular set of issues around adults with incapacity, which means that they form quite a large chunk of our delays. Unfortunately for those individuals, they tend to be the people who are delayed the longest. We referred earlier to the fact that a huge amount of work is going on. I said in my opening statement that an enormous amount of work is going on across systems, but that is not yet delivering the impact that we need to make a step change.
We are retaining a bumpy but stubbornly high level. It is higher than we want, but we are not seeing that multiplication factor. In fact, since about 2021, the figure has remained relatively stable, albeit at a much higher position than we would like. That is a factor of all the work that has gone into the issue, but it is set against the challenges around demographics, workforce and financial resource to support that workforce.
I am not saying that I think that the level that we are at is a good level to be at—it absolutely is not. It not only impacts the people who are delayed but has an impact on the way in which the system operates. We need to continue to do all the things that we are doing. As I have already said in this session, if there was a silver bullet, we would have found it by now. We need to look at multiple factors across the system and harness the creativity and innovation of the people in the system to understand what we can do to make a difference and focus on those factors. I suspect that we will need to continue to work hard to maintain our position at the same time as looking at our options in digital, what we are learning from virtual wards, hospital at home and the frailty units, and how we can scale up that sort of activity to start to see a reduction.
Forgive me, but that sounds a bit like you are saying that it is not getting any worse but it is not getting any better, so that is fine. I am not talking about a blip. The report is not about one year out of the ordinary but a pattern that has been repeated over the decades since a promise was made to eradicate delayed discharge. I question whether it is possible to eradicate delayed discharge at all. It has been sitting at around 3 per cent of all discharges and consistently affecting around 18,000 people, year on year, for the past 10 years. Is that just the base level that we have to accept now?
I would hate to think that it is the base level that we have to accept. We need to find ways of getting those figures down. Some of that will involve looking at how we manage adults with incapacity and making sure that they are not being delayed in the place that is least suited to their needs, and work that involves legislation is being done around that.
I agree with your analysis that it will be impossible to eradicate delayed discharge completely, because things will always happen that mean that arrangements are not quite ready or people will have complex packages that take a bit longer to put in place. We need to eradicate long delays and do everything that we can to make sure that our processes work as effectively as they can to get people out of hospital. Part of that will also be about the broader understanding that hospital might not be the best place for people to be.
During the most recent session that we had with the Auditor General, we talked about dealing with this long-term stubborn issue, which Mr Beattie picked up on earlier. In the week or so since that session, I have tried to do some analysis of Audit Scotland’s previous reports. The 2005 report was called “Moving on? An overview of delayed discharges in Scotland” and there was a report in 2016 called “Changing models of health and social care”.
There have been repeated Audit Scotland reports over the years. One of things that has never really been clear from all those reports is what lessons were learned. I feel like I have a bit of déjà vu. If I could go back to the audit committee of 10 years ago, I would probably find that it was having the same conversation and getting similar answers from the director general for health at the time. I feel as though we are going round in circles. There is a lot of jargon and rhetoric, but the statistics prove that virtually no progress has been made since those reports came out. My biggest fear is that, during the next parliamentary session, we will be having exactly the same conversation in two, three, four or five years’ time. Fill me with some confidence that the next public audit committee and whoever sits on it will not need to have this conversation again.
I would like to think that they will not need to have this conversation again, but we do face some challenging issues. It is not just about the Scottish Government and local systems, because local government still has a statutory responsibility for social care, and it would be interesting to hear what COSLA would say to the committee in response to some of these questions. It is about our working together and recognising the critical importance of social care to the health and social care system and to enabling people to live good and productive lives and enjoy being with their families and in their communities.
10:45
More work can be done to set out where the priorities lie in social care and where they sit in respect of other parts of the service. I have already spoken about the work that we have kicked off under the service renewal framework to look at how we can be more efficient in the acute sector. We have done that with the intention of shifting resources that we never managed to shift in the past. However, it is incumbent on every bit of this system to ensure that we are as effective and efficient as we possibly can be, because the demographics will not change. At the moment, we are running very fast just to keep up with those demographics, so we need collectively to find ways in which we can make an absolute step change.
Digital and technology will be part of that change. Back in 2005, there was not the ability to carry out the remote monitoring and have the virtual wards that we have since set up. We did not have the investment in paramedics and peer-to-peer contact that has enabled the Ambulance Service to convey only around 50 per cent of calls. We also did not have a focus on flow navigation centres, which again involves peer-to-peer contact and enables people to stay further away from hospitals. We also did not have the same focus on multidisciplinary teams, particularly in the case of frail elderly people. Over the past few months, I have been in a number of the frailty units, and the thing that has struck me is the importance of hospital staff getting an understanding from community staff of an individual’s baseline—what we would normally expect of their abilities—and what that means for when they are ready to be discharged home rather than being kept in hospital. It is a multifaceted problem, which everybody needs to come together to resolve.
I do not doubt that there is the will, desire and good intention to come together to fix the problem. However, although it is not for me to put words in the mouth of COSLA, I am pretty sure that if you asked it whether social care is adequately funded, the answer would be a big fat no. We know that because that is what it said in the briefing document that it sent us a couple of weeks ago, after the budget. If the answer to the question, “Is social care properly funded?” is no, you will never resolve the issue of bed blocking, will you?
Every bit of the public sector could make an argument about funding adequacy or otherwise, and we work within a constrained financial envelope. I would turn that question around to ask whether we are confident that we use all our money in the best way possible across the totality of the services that we offer. Even the likely costs around delayed discharges demonstrate that there are opportunities to shift resource and activity out of the acute sector towards funding support in social care and primary care.
I am sure that there are opportunities to find efficiencies and enable different ways of working across all our public services, and the public service reform strategy sets out that ambition and requirement, along with our collective responsibility to ensure that money that is spent on behalf of the public purse is used in the best way possible. There are opportunities, and we need to be careful that we focus not only on the adequacy of funding or otherwise, but on how well we use existing funding, which is quite considerable.
Let me rephrase my question: who is not spending their money wisely? Which bit of the system is not as productive as it could be?
In every bit of the system, you can identify opportunities for people to work differently together in a way that provides better—
Can you give me an example?
One example is the work that we are doing across NHS Scotland to develop single approaches to business systems that provide us with better intelligence and information and take manual labour out of some of those processes.
Another example is the subnational arrangements, in which we are looking at a single plan for orthopaedics across Scotland and how we best use capacity across Scotland to manage demand. There are examples out there. We need to focus on how we deliver against those and implement some of those plans.
You are director general for health and social care, so I appreciate that you are not in charge of local government or its budget. However, I presume that you have some influence over the working of integration joint boards, the role that they play in delivering social care and how that links into the wider health and social care budget, which is essentially a unified budget. What would you like to happen? I appreciate that it is difficult to give an analysis when you are the person in charge, but you must know why people are stuck in hospital. You must know the main reasons why you cannot get people out of hospital beds and into another setting. There must be analysis of the main reasons for that. You will know what the sticking points are. What are they, and how will you go about fixing them?
Part of the reason for people getting stuck in hospital beds—for the longest delays that we see—are issues around adults with incapacity. It will require legislation to fix some of those, but if we started to see improvements, that could bring down not just the absolute number of people delayed but the cost in total bed days to the system, because so many of our long delays fall into that category.
A lot of our other delays can be relatively short term, but, looking at the demographics and the increasing elderly population, we also need to continue to focus on the things that will prevent people from needing to go into hospital in the first place. At the moment, our focus is very much on additional investment in general practice to do that preventative work. Our focus is also on the initiatives that we talked about—the frailty units, hospital at home and virtual beds are all important in shifting the balance and are all about caring for people in the community, rather than in the acute base. We need to continue to make progress in all of those areas, while looking at the things that we can do through digital and technology to improve our overall efficiency.
That is helpful.
On the issue of adults with incapacity, are those people who are medically fit to leave hospital, but do not have the capacity to look after themselves once discharged? If they were sent home, they would not be able to look after themselves, therefore they are safer in hospital.
The issue there is people who are in hospital at the moment who, because they have Alzheimer’s or learning difficulties—whatever it is—do not have the capacity to make a decision either to go back home, potentially with care packages, or go into another form of care that would be more suitable for them. Unless there is already a power of attorney in place that enables their families to make that decision, there is quite a complex legal process, in which local authorities have to get guardianship orders.
And all the while, those people are stuck.
Yes.
That is clearly an issue. That is a cohort of people who are stuck for quite a long time—sometimes months. We have heard some horrible anecdotes.
Yes.
That is one area in which there could be improvement.
We have talked a bit about data. Mr Simpson talked about the £440 million mentioned in the report. That was just one year. I presume that that was a primitive calculation based on the number of bed days and the cost per day per bed, which I think is around £618. It is a very simple way of looking at it. There must be a better way of measuring the cost. Do you have a number?
The Auditor General is sitting behind me, so I am not sure that I would describe that as a simple calculation. What I have said to the committee is that we make our own internal assessment and it is pretty much in line with that assessment. The Auditor General has drawn on the same data that we have in order to produce that. I have accepted that we need to work with Public Health Scotland on getting that information to a quality standard at which it can be published and made available. That would be really helpful for the whole system.
How many staff hours are lost to managing patients who are medically fit to leave hospital but are still having to be cared for in a hospital environment?
I do not have that figure. Boards will be able to give you, at any one time, the numbers for beds and wards, but we just need to be careful about assuming that, if those beds were not being occupied by people who did not have a clinical need to be in them, we would not need to staff them any longer. After all, there are other pressures to deal with. There are, for example, the pressures that come through the front door in A and E, with people needing to be admitted, and one of the challenges that we face with ambulance drop-offs and the long waits in our A and E departments is not having beds available. Therefore, the first call on those beds would be to improve flow through A and E.
There are also occasions when there are limitations on the number of beds, particularly when the hospitals are very busy, and that has an impact on planned care, too. Therefore, I do not think that our first move would be not to staff those beds; instead, we would look at how we might be able to use them differently to improve performance across the whole system.
I am not suggesting that you do not staff those beds. My point is that the beds are being occupied by people who do not need to be in them.
Is there any analysis of how many clinical or non-clinical hours are taken up with looking after those patients? After all, once someone has gone out the hospital door, they are someone else’s problem—the duty of care lies with someone else—and that member of clinical staff will be automatically and immediately freed up to look after someone else either in that bed or otherwise. Has that piece of work, or analysis, ever been done?
I will come back to the committee on that, but I am not aware of anything. There has been work done on cost, which obviously will include a staffing element. We can look at whether that previous work contains that sort of breakdown of the staffing element.
Finally, has the Scottish Government or the NHS done any holistic analysis of increased mortality rates as a result of delayed discharge, or indeed, additional harm caused to patients as a result of delayed discharge? If not, why not?
My statements about hospital not being the best place for people to be in draw on evidence from research not just from the NHS but from a number of different sources. I can come back to the committee with details of some of the research reports indicating the impact on people who are delayed.
Statistical data would be helpful. Thank you.
Picking up on that final question, one of the striking things in the briefing on community health and social care performance is exhibit 4 at the end, which talks about the impact of inequalities and the importance of reducing them. It points out clearly the huge gap in life expectancy, both male and female, between the most deprived and least deprived areas in Scotland, and it talks about the relationship between deprivation and the frequency in the use of day beds, premature mortality in areas of dense population and—this takes us back to the letter that Mr Simpson read out—the higher rates of unpaid care in some of the most deprived communities.
There are some fundamental social and economic structural issues out there, are there not? I acknowledge that it is perhaps not your sole responsibility to challenge and remedy them, but do you, in your position, take a view on those things? What is the Government doing to try to address the huge inequalities that exist?
I am acutely aware that the drivers of poor health or good health are, as I think that Michael Marmot would argue, 80 per cent influenced by factors that have nothing to do with what the health and social care system is doing. The population health framework very much takes a cross-sector, cross-society approach to tackling some of those issues.
As for what the Government is doing, the single thing that I would probably point to as being the most important is the child poverty action plan. As we know, poverty and other adverse events in early childhood are things that have the longest-lasting impact on your life chances, your educational and health prospects, and whether you are involved with the justice system—all of that. Therefore, we are talking about root cause prevention and tackling some of the things that result in some of our children being so very disadvantaged and, as a result, more likely to experience health inequalities throughout their lives.
11:00
Thank you. Before we finish, Graham Simpson has a quick follow-up question.
It is not quite a follow-up, convener.
Ms Lamb, last time that you were in front of the committee, you had been criticised for not visiting hospitals, and I asked you about that. However, you have told us today that, in the past few months, you have visited a number of frailty units. Now that you have been out and about and seen at first hand the problems on the ground, has that new approach of getting out of the office been useful to you in your job?
Thank you for that question. Getting out and about has always been a key element of my job and something that I enjoy more than anything else that I do in that job, because it is inspirational to talk to staff. Seeing what is going on in the frailty units gives a flavour to some of the things that I read. It is the same for everything; I have also been in several hospitals to look at what they are doing to improve productivity and planned care.
You asked me that question before and I thought that you might ask again. In my record of being out and about, there was a step change in the number of my engagements that were out of the office, as you put it, between July 2024 and July 2025. I am on record as saying to the committee that that was partly due to the fact that, during that period, I gave evidence four times to the UK Covid inquiry. Anybody who has been involved in that will appreciate just how time intensive the preparation is.
However, the reason why I was wondering whether you would ask me the question is because it also gives me the opportunity to put on record another factor that influenced what I was doing during that time. In June 2024, my father became very unwell and it became clear that he and my mother, by whom he was supported but who had Alzheimer’s, would no longer be able to carry on living independently in Yorkshire. In July 2024, therefore, we moved them up to Edinburgh to be close to me, because my brother lives in France. Unfortunately, my father died in early September of that year, and my mother passed away in June 2025. During that period, I took the decision that I needed to spend as much time as possible visiting my parents in the evening. That was one of the things that impacted on my ability to get out and about. I probably would have found it hard to talk about that the last time that we met, but I am grateful to have the opportunity now to put that on the record.
I am glad that you felt able to share that. You do not have to share such very personal things, but you have put it on the record. You spoke very well about your experience of visiting the frailty units and you have told us how useful that has been. We will leave the personal stuff, but at least you have had the chance to put it on the record.
Thank you very much for that. I appreciate it.
Thank you for that and for the evidence that you have given us this morning. Caroline Lamb and Derek Grieve, I thank you very much indeed for your time. I do not know about your diary, director general, but the committee has you booked to come back and see us in a couple of weeks’ time, in our final meeting of the parliamentary session. We look forward to that. If you want to follow up anything in writing, following this morning’s session, please do that. We would welcome anything that you wished to share with us.
I now suspend the meeting for a changeover in witnesses.
11:04
Meeting suspended.
11:09
On resuming—