Public Audit and Post-legislative Scrutiny Committee

Meeting date: Thursday, November 29, 2018

Official Report 773KB pdf

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Section 23 Report

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“Health and social care integration: Update on progress”

Item 3 is consideration of a section 23 report on health and social care integration. I welcome our witnesses for this agenda item: Caroline Gardner is Auditor General for Scotland, Claire Sweeney is audit director for performance and best value, and Leigh Johnston is senior manager for performance and best value; they are all from Audit Scotland.

I invite the Auditor General to make a brief opening statement.

Today’s joint report focuses on health and social care integration and provides an update on progress. It looks at what impact the integration of health and social care is having, and the barriers and enablers to change.

As the committee knows, health and social care services are facing increasing pressures and a very challenging financial position. Integration has the potential to bring about the service transformation that is needed to address those pressures and to bring real benefits to the people who use the services and the wider public.

We found evidence that integration can work within the current legislative framework. There is evidence that integration is enabling joined-up and collaborative working in some places, which is leading to improvements in performance, such as reductions in unplanned hospital activity and in delays in hospital discharges. However, there is much more to be done and a number of significant barriers that need to be overcome.

Integration authorities oversee almost £9 billion of health and social care spending, but longer-term, integrated financial planning is needed to deliver sustainable service reform. The publication of the “Scottish Government Medium Term Health and Social Care Financial Framework” is a welcome step, but the detail that underpins it will be important.

Importantly, the set-aside aspect of the Public Bodies (Joint Working) (Scotland) Act 2014 is not yet being implemented. That needs to be resolved urgently in order to shift the balance of care towards community-based, preventative care in future.

Strategic planning also needs to improve, focusing on how integration authorities and their partners will achieve better outcomes for people who need support and ensuring that new ways of working will be sustainable over the longer term. Integration authorities, councils and national health service boards need to establish a clear governance structure where all partners agree responsibility and accountability and put in place the right leaders.

We found some examples of small-scale changes in the balance of care, but integration authorities need to achieve wider impact. This means addressing challenges related to data and information sharing, and sharing learning from successful approaches right across Scotland. Change cannot happen without meaningful and sustained engagement right across the country with people, with staff and with politicians.

No one organisation can do this alone. The Scottish Government, the Convention of Scottish Local Authorities, councils, NHS boards and integration authorities need to work together with their staff and communities to scale up the pace of change.

Convener, we will do our best to answer the committee’s questions.

Thank you very much, Auditor General. Alex Neil will open the questioning for the committee.

Auditor General, the set-aside provisions in the 2014 act are absolutely crucial to the success of integration but, as you say in paragraphs 19 to 21 of your report, this is one part of the act that is not being implemented, despite the fact that the act has been in place now for four years and the official start date for integration is getting on for three years ago. You explain in the report why implementation has not happened, but you also said in your opening statement, quite rightly in my view, that it is now urgent. Who now needs to take what action to get it sorted?

You are absolutely right that until the unplanned hospital care element of the resources, which was meant to be managed by the integration authorities, is devolved in practice, there are real limits to the amount of change that can happen.

We identified a problem around people genuinely not knowing how much money is affected, but it goes beyond that. That is not the fundamental problem; rather, it is about people’s willingness and confidence to share that information, to think about a joined-up health and care budget in their area, and to manage it on that basis. Therefore, in part 2 of our report we have set out a number of things that we think need to happen. We are happy to talk about that in more detail.

More generally, though, I think that we have reached the stage where the Government and COSLA need to be pushing and requiring the local leaders in each part of Scotland to overcome the differences and challenges that they are facing and to put that part of the legislation into place. As you say, the legislation has been in place for four years now, and the integration authorities had to be in place by 1 April 2016, which is nearly three years ago, and we are not seeing the change that we need to see.

I have said before that if you look at the history books and at what happened when we were closing down the Victorian mental health so-called asylums—a terrible name for them—that was done over about five years with bridge funding, because both services had to be funded during the transition.

As well as dealing with the set-aside issue, has the time come to look at using some of the additional funding that we are supposed to be getting as a result of the Barnett consequentials, from the increase in health spending south of the border, to provide bridge funding or a similar type of arrangement to focus on making integration work? Even if we sort out the set-aside issue, it seems to me from reading your report that we will not make the progress that we could and should be making until we recognise that both sides—the acute side, which cannot handle a reduction in funding because of the increased demand, and the community side—need to be kept running until we make the transition.

That should be a real focus of the longer-term integrated financial planning that we are talking about. I refer the committee to page 31 of the report, where we talk about the need for that. We highlight at the bottom of page 31 that many of the changes that have been made so far have been done with the additional funding that has been available from different sources. That additional funding certainly makes it easier and it is very important.

The challenge is that we do not yet have those plans in place where people, either nationally or locally, can say, “To get from here to there, we need to spend what we currently have and, for these two years, we need an investment of this much, either to pump prime or to double run or to invest in new facilities.”

That planning is important for the integration joint boards themselves and that level of detail needs to underpin the Government’s health and social care financial framework. We need to ask exactly those questions about how the additional money could be used to make that change happen—if that is what is needed—before we start committing it to other parts of the health and social care landscape.

I presume that the emphasis has to be on the investment in the community side, in primary care, in social care, and so on.

A few months ago, I asked Paul Gray whether, instead of channelling the money to the IJBs via the health boards and the councils, the time had come for the Scottish Government to allocate budgets directly to the 31 integration boards for their core statutory functions. He said that the reason for not doing that is because of the variation across boards—some boards have taken on children’s services, for example. However, it seems to me that direct allocation could be done for the core statutory functions. If the health boards and the councils agree that additional services are to be provided by an IJB, let them argue about that, but let us at least get the core statutory functions moving.

A lot of the frustration and friction in the system is because we are channelling the money to two bodies, which then have to negotiate. Having negotiated the amount, they then have to delegate the budgets back again. Can we not simplify the whole process by directly funding the 31 IJBs?

You were asking the right person whether that funding route is possible—we are not in a position to answer that for you. The legislation sets out how IJBs work. About one third of the £9 billion comes from councils, not from Government, so that issue would need to be resolved.

Exhibit 2 shows the route by which the money comes from health boards and councils into IJBs. The spirit of the legislation is about getting the system to work as a whole. That has been the driver so far. If it is not possible to get the system to work as a whole—this report very much highlights that that is happening—Government probably needs to look with COSLA at more radical solutions. However, we have found signs that it is starting to work and my focus at this point would be on speeding that up.

We have 31 IJBs, we still have 22 health boards and we now have three regional structures in the health service, which is a total of 56 different organisations that all have overhead costs. Given the financial pressures and the need to streamline the management structure, is it not time to look at that huge overhead? Your report says that there is a question about leadership and the availability of quality management. In this small country, so many organisations are looking for leadership. Has the time come to take a fundamental look at the management structure of health and social care and the relationship between the two?

As the committee knows, I have raised concerns not only in this report, but in my recent “NHS in Scotland 2018” report, about the complexity of the management arrangements and the scope for confusion among the people involved in it. That is a matter for Parliament, because it legislated to create integration authorities as an additional layer. Our focus is on making sure that that works as well as it can, and on highlighting the pressure that it throws up.

You referred to the challenge of getting enough leaders of the right calibre. It is definitely a challenge for the integration authorities, and we have highlighted the number that either have shared posts or have high levels of staff turnover. There is no doubt that that situation makes doing the work harder.

The committee may be interested in the plans that the Government and COSLA, through its joint working group, have got for addressing some of those challenges and speeding up the limited progress that we have seen so far.

In Lanarkshire, we have recently had a situation in which one of the chief executives has been—this is my understanding; it is perhaps not the official version—encouraged to leave. There may be another huge pay-off. A lot of chief executives have left post in the three years that integration authorities have been up and running. Are you keeping an eye on what pay-offs there are? I think that a lot of public money is, again, getting wasted on massive pay-outs that are not a statutory requirement.

Yes, as part of the annual audit of all the bodies that come under my responsibility and that of the Accounts Commission—that includes IJBs and local government bodies—the auditor is required to look at the remuneration report and at significant transactions and events such as the departure of a chief officer. I report those that sit in my responsibility to this committee, as appropriate.

Mr Neil has got to the heart of three big issues: budgets, consistency and structure.

On budgets, you quite rightly said that there needs to be an increase in investment—you called it pump priming—in some of the integration authorities. How much of a challenge is the fact that, because health boards and local authorities are having to make savings, they are passing on the need to make savings to integration authorities and undermining the plan to pump prime integration?

10:15  

I will ask Leigh Johnston to answer your specific question, but I will kick off by clarifying that I said that, at the moment, we do not know what additional funding might be required, but we have identified that the significant changes that we have seen so far have often relied on that sort of funding. That is why longer-term financial planning matters. Leigh, can you talk about the financial pressures facing the bodies involved?

We have set out the savings that the integration authorities need to make and, in our recent report on the NHS, we talked about the savings that boards are having to make, too. We see changing the models of care as a way of trying to make the system more sustainable; after all, the current way of delivering health and care is not sustainable, because of financial pressures and rising demand, and some of the new methods of delivering care that are starting to emerge are ways of trying to ensure sustainability.

When you speak to individuals from local authorities and the integration authorities, you get the sense at times that they feel that health boards and local authorities are simply passing on to the IJBs some of the hard decisions or savings and cuts that they would have to make, simply because it is easier to pass the bad press on to them. How much have you seen that in your interaction with the integration authorities?

Each authority has a scheme—an integration scheme, if you like—in which it agrees how the finances will work. In other words, in setting up such a scheme, it has already agreed how the savings will be made, what proportion of contributions will be submitted and, if the authority is struggling to break even at the end of the year, how contributions in that respect will be divided up between the partners. We have outlined that in the report. There is an agreement in that respect, but tough decisions about service provision have to be made all round.

Is it fair to say that budgetary pressures on local authorities and the NHS are making it harder to achieve the integration that we all want?

Yes. I think that we say in our report that the financial pressures are making it more difficult to achieve the scale and pace of change that we want.

There seems to be inconsistency across the 31 integration authorities in that there is no agreed model for the area of responsibilities for IJBs. How much consistency do we need, and how much should we leave that to individual integration authorities and their ability to flexible?

That is a really good question. The legislation was deliberately designed to give people local flexibility. We all recognise that there can be good reasons for that—after all, Glasgow looks very different from the Highland and island health boards and councils—but our concern is that flexibility is leading not to a consistent pace of change tailored to local circumstances, but to confusion and disagreement over the arrangements. That is why we have reached the stage of saying that a stronger steer is needed from Government and that the Government and COSLA integration review reference group that is looking at this is an important vehicle for making that happen.

What should that steer look like? Should there be a framework setting out the basics of what an integration authority should be doing and a list of the options and add-ons? Can you tell us what you think a solution might be?

As far as outcomes for people are concerned, it is probably important to be clearer about which services ought to be involved in integration authorities and the outcomes that the authorities are working towards. As we highlight in the report, a very wide range of outcomes and indicators apply to them, making it hard to see what the priorities are. Beyond that, we think that there are ways of working that can improve their effectiveness, and Leigh Johnston will want to say a bit more about that.

Reflecting on our recent children and young people’s mental health report, for example, I think that we do not understand enough or have enough evidence yet about which services should and should not be delegated.

There is a minimum that the integration authorities are responsible for. In our audit on children and young people’s mental health, we tried to look at whether it was more effective for children’s services to be delegated, and whether the outcomes were better, but we could not find evidence of that. Some authorities argue that children’s services should stay in the local authority because it is closer to education, while others argue that children and young people’s mental health should sit within the IJB in order to be closer to the health services that children and young people might need. We need to understand more about that, and to understand the outcomes that are being achieved through different services being delegated.

We heard earlier about the challenges around budgets and their impact on integration, and also about the challenges around consistency, given that there are so many integration authorities working in partnership with local authorities and NHS boards. I think that those challenges are connected to the structure. Surely it is management and bureaucracy heavy in terms of value for money, given the high-salary roles in the 22 health boards, the 31 integration authorities and the 32 local authorities.

Is the integration of posts, if not alignment of the structures, an area that we should be looking at in order to reduce some of the bureaucracy costs? Is it time to look at reducing the number of bodies in order to get greater consistency and value for money and to drive the money and investment towards actual service delivery, rather than salaries and management posts?

There is a bit of a paradox here. It is easy to castigate management as being different from the provision of health and care services, but I do not think that it is. Good management is essential to the ability to plan, deliver and transform services in the way that we need.

However, I say in the report, as I have said in previous reports, not only that we now have more bodies involved in the area that we are discussing, as well as in others, but that it is not always clear to us or, more important, to the people involved what the different roles and responsibilities are. I say in the report that some people who sit on IJBs do not understand, for example, what the new regional responsibilities for workforce planning look like. We are seeing increasing responsibilities for the planning of acute care and the delivery of some specialist acute care at a regional level, but it is not clear to everyone who is involved how all of that joins up. That means that what ought to be an investment in senior managers and leaders who can work with staff and others to change things ends up being spent on negotiating and disagreeing about what they are there to do. That is the problem.

This is my final question. In the report, you make clear the importance of governance and leadership. Surely a more streamlined governance and leadership structure would help to provide stronger management and better consistency across the country. Will Audit Scotland be looking at how we can streamline our leadership and governance structures in order to deliver that?

I ask Claire Sweeney to pick up that question.

There is no doubt that, when we spoke to everybody who is involved in the system for this piece of work, something that came across strongly was that they had struggled with the accountability and governance arrangements, and in many areas they are still struggling. We have some examples in the report. In particular, Aberdeen city got support from the Good Governance Institute to help it to think through things such as risk management and how that would apply across all the bodies that are involved. It is incredibly complicated. That said, the change that they are trying to effect is complicated and it will take time.

There is also something about bringing together the two cultures of local authorities and health. People in each culture need to understand not only how the other one works in a broad sense, but some of the technical issues of things such as finances. We highlighted that as a risk in our initial report back in 2015. You will see in appendix 3 some of the issues that we identified in that report. That work is happening and there are some examples of progress, but there are still some risks, which are highlighted in the report that we are discussing today.

May I add a tiny supplementary question, convener?

Yes, if it is tiny, Mr Sarwar.

Given that we now have 31 local integration authorities, do we need 22 health boards?

That is a question for Government rather than for us. We set out in the report the difficulty of bringing those various roles and responsibilities together. There is no doubt that the environment that the IJBs are operating in is incredibly complicated, given the financial challenges. We asked questions about the clarity and understanding of that regional, national and very local model, and it is clear that it is still not fitting together very clearly and people are struggling to understand their way through it. That came through loud and clear in the work that we did for the report.

I want to develop Anas Sarwar’s interesting line of questioning, but before I do so, I will put a very blunt question to Leigh Johnston. You talked about effectiveness, but I note that, although the report contains some statistics on that, they do not seem to show any marked improvement—if I can put it that way. Might any improvements in those statistics simply be down to chance or something that the health board or the council is doing rather than something directly attributable to the new set-up? If so, are we diverting £400 million from the health budget into something that is not making any marked improvement?

There is no suggestion of causation in that respect, but as we lay out later in the report, we are starting to see improvements at local level. However, those improvements are not marked, which is why we say—and, indeed, have said several times recently to the committee with regard to the NHS—that we need better data and monitoring and more openness and transparency about the difference that is being made by and the impact of integration. We do not have a clear enough picture of that at national level, but having reviewed all the local performance reports, we think that we are starting to see improvements at local level that are directly attributable to integrated initiatives and projects and different ways of delivering services.

In response to Mr Sarwar, the panel has talked about leadership, governance and so on, and the report certainly highlights in a concerning way aspects such as the appointment of part-time chief financial officers, chief financial officers in dual roles and the inability to recruit such officers. I have to say that I was not quite convinced by the whole idea of corporate infrastructure when I looked through the report, and you also refer to the “lack of support services” with regard to, for example, human resources. That being the case, should the Scottish Government be stepping in and giving a much clearer steer on what the model needs to look like, the staff who should be involved and how things are supposed to run?

My sense is that instead of having some template for the staffing model that needs to be in place and how the support services work, Government and COSLA—after all, this is a joint initiative with local government—need to focus on being clearer about the progress that should be made and need to be willing to step in where that progress is not happening for whatever reason, be it a lack of capacity, a lack of people doing the key jobs, disagreements about set-aside budgets or the need to invest some pump-priming money to move from the current service model to a new one. We all recognise the importance of respecting local difference—there is no question but that that matters—but for a policy this big and important where progress has been as slow as it has been, it is just not feasible any more to maintain a hands-off approach or be unwilling to step in and require changes to be made if progress is not happening and people are stuck.

That leads me to ask a brief question on an issue that I am not clear in my own mind about. We as a committee have looked several times at the difficulties in recruiting at the top level. Of course, it will always be difficult to find talent and experience, but are the people who look after the IJBs the same as those who are playing a dual role with, for example, health boards?

Almost all of them come from a health board or council, but the situation varies in different parts of Scotland. Perhaps Claire Sweeney and Leigh Johnston have something to add.

Not so much. It is absolutely right to say that the dual role issue relates to the system as a whole—that is the pool that is being drawn from. However, we have tried in the report to set out clearly the different relationship ask that integration brings. For example, it requires leaders who work in a much more collaborative way. There is flexing, to a degree, in the chief officer role, what with the need to negotiate around change and to try to get consensus across a range of partners, and one could argue that that leadership style is very different from what has traditionally been the case across, say, the health system for a while now.

The message is that the system is not working, and there is consensus on the need for change. We were very interested from an audit perspective about issues to do with power and how that was being reflected in the role of chief officers. The system can work only if all parties are signed up to and engage with it. There are big implications for everybody involved, and thinking about leadership is key.

10:30  

That is really interesting. You talked earlier about the Aberdeen example, and the report seems favourably predisposed to what is happening there. What is it about Aberdeen? The report mentions cultural differences. Have leaders somehow managed to get rid of the cultural differences? Are they working around them? In any event, how will that knowledge be shared?

It is fair to say that not one area of Scotland has got all this right, which explains the range of examples in the report. The Shetland scenario planning example on page 28 is about getting to the heart of having difficult discussions. We were warned early on to be cautious about partnerships that seemed quiet and where there was not a lot of disagreement, because that suggests that things are not being tackled.

No one area has got it cracked. Aberdeen city’s model and its focus on governance are interesting. It has got support from people who are well informed on governance to facilitate that conversation about what the tricky issues are and how to resolve them locally.

We highlight in the report that the changes at senior level that have taken place since the introduction of integration bring a degree of fragility to some of the examples. We see things working well in some areas—I am very mindful about the examples of the third sector starting to make improvements—but the situation can quickly change. That has been our experience over a number of years. We see pockets of small examples of things working well that can change quickly if leaders change, the funding is not there or the pressures increase. There are lots of good examples in the report, but they tend to be small scale.

One thing that the Scottish Government and COSLA group is focusing on is training and developing leaders to do that. We have highlighted in our report the things that need to be done by leaders not just in the integration authorities but in health boards and councils. Developing that will take time.

You asked about sharing good practice, which is the other critical thing that needs a real boost now. We found examples of things working well, some of which are fragile. We need to learn from things such as the NHS’s approach to the patient safety programme, and spread that experience much more widely in a way that not only respects the fact that different places are different but makes clear what is expected of people in terms of the change that they are making.

You referred to the group that is co-chaired by COSLA and the Scottish Government, which you mention in paragraph 35 of your report. My understanding is that that is looking at how to overcome barriers to integration. Has the group produced anything substantive? When will its work be available? When can all the bodies have something substantive to look at that says how they need to change?

It is positive that the group has produced a statement that acknowledges that the pace of change is not sufficient and needs to be much quicker. We have highlighted areas that the group is working on. Claire Sweeney will be able to tell you more about the process that it is going through in order to do that.

The group will conclude its work in January 2019. We are following the group closely, and we want to keep in regular contact with it.

In essence, it has drawn together all leaders across health boards, local authorities and integration authorities to think through what the difficult questions are that we need to tackle and to see whether there is a need for more guidance and direction. It is about considering the facilitation of the training and support that the Auditor General mentioned, to make sure that the leaders are in the state that they need to be in order to tackle the agenda, as much as it is about thinking about the capacity that is around them to support them.

You have mentioned appendix 3, but, given your view that not so much progress has been made, it might not be correct to use the term “Progress” in the heading to that appendix.

I do not want to go into the specifics, but I note that the appendix contains recommendations for the Scottish Government and integration authorities. I remember Paul Gray telling us at one point that, in respect of the NHS, the buck stopped with his role. Where does the buck stop here—with the Scottish Government or with the integration authorities?

Because integration authorities—and integration joint boards—are local government bodies and have been established as such in the legislation that Parliament passed, they are formally accountable to their electorates in the same way that councils are. Government is obviously accountable for the success of the overall policy of integration and meeting the needs of people right across Scotland.

Something that we have heard a lot as we have done this work is that the accountability arrangements are not clear. Actually, that is not true—if you keep it simple and high level, they are clear—but what gets in the way is people’s agreement about their individual integration schemes and the ways in which the health boards, councils and integration authorities work together. Again, Government and COSLA really need to ensure that all of those things are clarified and that people live up to them in providing the services for which they are responsible.

When you finalised the report and did the fact checking, who did you give it to?

Most of the factual accuracy confirmation for this report came from Government itself, and where individual integration authorities were mentioned, we passed that particular section to them for their comments.

Is a particular person in the Government responsible for this?

The director general for health and social care is the accountable officer.

For the Scottish Government.

Yes.

But what about the integration authorities?

There is no single person responsible, as is the case for local government as a whole.

I will continue that theme. If you were to choose a word to describe the picture set out in appendix 4 on financial performance, it would not be “integration”. The picture across the authorities and the IJBs is really mixed. Members have raised the issue of how well they are or are not integrating. What about COSLA? Has it responded to the report? What message are we getting from that side of things?

COSLA has responded to the report, welcoming the overall findings and the push for further change. We know from its involvement in the group that it co-chairs with Government, which has issued a statement acknowledging that the pace of change needs to increase, that it is committed to push forward the policy. In some ways, the challenge that it faces mirrors the one that the Government faces. There are 32 councils, 31 integration authorities and a lot of people and services that need to change, and my view is that the priority for Government and COSLA is to get a grip on that.

When IJBs report on their performance, do they report as integration authorities or do they report separately on the performance of, say, the council components?

The IJBs produce their own reports. Leigh Johnston can say more about that.

NHS Ayrshire and Arran covers three councils. When an IJB reports, does it report on performance by authority?

Each IJB produces its own performance report, and every integration authority must report against a range of core indicators. The answer, therefore, is yes, each authority has a performance report.

Do they know what the greatest area for work is and so on? I am not picking out any particular authority, but if one was a wee bit behind the curve, would it be aware of that so that it could do something collectively to tackle that?

As I have said, the authorities are working towards core indicators along the lines of the national indicators such as admissions to hospital and delayed discharge, so they will have an idea whether they are reducing some of those numbers. However, as we say in the report, we do not have a good national picture of performance and impact in the different areas.

Perhaps I can short circuit that a bit by pointing you towards exhibit 4 in the report. It is a double-page spread that sets out the national performance framework, nine national health and wellbeing outcomes, 12 principles in the act, six national indicators and a range of local priorities, performance indicators and outcomes.

Integration authorities are reporting against those measures, which makes it difficult either to get a clear picture of an individual integration authority’s performance or to make the comparisons that I think that you are trying to get at. It is not that there is a dearth of information or data, but that there is a lack of that clear picture of where they are and where they are planning to get to.

We could have had almost the same discussion in another area, at another time in this committee.

We have heard about issues of leadership, financial planning, strategic planning, governance and sharing good practice in a number of areas. We have agreed that we need to do something about them and that the participants have agreed to deliver on those things. They agree, too. How on earth do we move forward to the next stage and get it done? Who are the leaders who must get this done? Should the Government dictate new guidelines and requirements? Should COSLA be firmer? What is the key to succeeding? How do we get any comfort that, when we are sitting here in a year’s time with the follow-up report, we will be closer to that?

I share the committee’s frustration on that matter. It is obviously a very important area of policy and there are, as you say, common features. In the report, we have tried to be as clear as we can that Government and COSLA need to build on the foundations that are in place. They are only foundations, but they provide a basis for going forward.

In exhibit 7, we have set out the features that we have identified as supporting integration. They are simple things—although that does not mean that they are easy to achieve—including collaborative leadership, integrated financial planning, a real focus on the outcomes that are to be achieved, monitoring progress and involving people in the process. It is about using the same consistent and rigorous approach that the Government uses for things such as the patient safety programme, to make sure that its efforts and the efforts across the health and social care system are pushing in the same direction.

George Foulkes, a member of this committee’s predecessor committee, used to ask, “What next?” This is a really good report and it gives everybody clear information about what the direction of travel should be but, other than waiting for your report to come next year to give us some indication that there has been slow progress, how will we assess and see whether progress is being made? How do we monitor it as we go, to make sure that the things that need to be done are being done? How does that process happen?

Claire Sweeney mentioned that the Government and COSLA group is due to report by the end of January. At that stage, the committee might want to look at the report that is produced and take evidence on it from the group, to see how it plans to address some of the barriers and deal with the things that we think would make a difference.

Good. Thank you.

Auditor General, I think that we all agree that your report shows a really messy landscape across Scotland. I remember that, at the start of the previous session of Parliament, the then health secretary said that they had to leave sufficient room in the legislation for local bodies—NHS boards and local authorities—to make their own plans. The picture looks really messy now, with areas of strength in some places. A close look at the report finds some small examples of good practice, as Claire Sweeney said, but some of that predates the legislation. I might be wrong, but I am sure that the small example from Dundee on social prescribing predates the legislation on integration. How much progress has been made since the 2014 act? We know that integration was happening on an informal basis before we voted on the bill in Parliament.

That is a question that we have considered a lot among ourselves and in the wider team: is the legislation on integration making a difference? After lots of grappling with the evidence, we have come to the conclusion that it can make a difference; in some places, on some aspects of what is needed, it is starting to unpick some of the barriers that have been getting in the way of change for a long time. However, it is not enough to say, “Let 1,000 flowers bloom” for people to magically work together at a local level and make the change that is required.

10:45  

We know that there are good reasons why it is tough. People are very focused on delivering what started off as their day jobs. In the future, integrated services will be the day job, but running hospitals, social care and primary care is where most people started, and the budgets still come through the separate organisations. It needs a real push to move away from the momentum and the inertia of the way things have been in the past to do this differently.

We are encouraged by the good practice that we have seen—not all of which is mentioned in the report—but more is needed to really move forward. It will not happen just as a natural process of rolling out. The Government and COSLA group is an important step forward but, in a sense, this is a really important opportunity that cannot be missed to take that commitment and good will and move on to release some of the pressures that we see with the separate running of the NHS and social care.

You said that the integration authorities have been in place for three years now. Is there a case to be made that, if we do not see progress at a local level, we will need to make the legislation more detailed and be more specific about how the bodies should be run?

In a sense, there would be no alternative but for Parliament to have another look at the legislation if the position does not start to change clearly in the next 18 months or so, simply because the pressures on the NHS and social care are increasing so quickly.

Okay. We have looked at the governance of several health boards in Scotland, and the financial officers clearly have a key role to play here. I note from paragraph 36 of your report that

“only half of IJBs have a full-time”

chief financial officer

“and there have been difficulties in filling those posts in some areas.”

As I understand it, some IJBs have a full-time CFO and some have a part-time CFO who does a job in either the council or the health board. Is it better practice for IJBs to have a full-time CFO, considering that they are responsible for so much money?

That speaks to the broader point about the capacity of IJBs to make a difference given the challenge that they face. We mention in the report that a number of them do not have that full-time capacity in place. We would have a question as to the ability to make progress in a significant area such as this one unless there is really good finance, HR and data support around the IAs. They are very small, so it is key that all players are supportive of the agenda. That is an example of an area that needs to be looked at.

Would it be better if each integration board had a full-time chief officer and a full-time chief financial officer?

There is certainly enough work for the integration authorities to be doing if they are to fulfil their responsibilities. We say in paragraph 37 that one challenge is that, if they do not have that capacity, they are very reliant on the information that is provided by the health board and the council. That makes it harder for them to come to an understanding of what the set-aside budget ought to be and to take on responsibility for managing it, which in turn makes it more difficult for them to avoid emergency admissions to hospital and get people out of hospital more quickly. They need to be able to make sense of the services that they are responsible for and to start to move away from the way that we have always done things towards where we want to get to.

What about the chief officers? Are they all full time?

Yes.

Your report says that we spent £3 million on chief officers’ pay in 2017-18, but there is not a lot of progress to show for it. Would that be a fair summary?

The areas that are making more progress are those that are demonstrating that they have moved forward on the issues that we identify at the start of part 2 of the report. Some are making more progress than others.

Something that came through strongly to us early on in looking at this policy area was a sense that some areas thought that this was not going to happen—that existing systems could continue and there would be a small pocket of integration at some point where the services intersected. Over the past year, we have seen a stepping up of the commitment to integration. We could argue that the areas that are not addressing the issues that we set out in part 2 and which did not think that real change was going to happen at a system-wide level are playing catch-up and are further behind.

A range of issues are captured in part 2 of the report. We are not seeing things working ideally in any one area. There are lessons to be learned, and we hope that that comes through strongly, particularly in part 2.

Exhibit 5 gives national performance against six areas, including bed days. Is it possible for the committee to have that information broken down by local authority?

We tried to include local variation where we could, so we can supply the committee with the information that we were able to get for this. The six indicators in exhibit 5 are those that the ministerial steering group uses to keep focus on whether integration is delivering.

We found it very difficult to get agreement around some of the data for exhibit 5. We can share a fuller picture with you, but we were not able to break down the information by local area for all the indicators.

Leigh Johnston is laughing. You obviously had difficulty getting local information. Why was that?

We did find it difficult. It is because of the difference in how information is collated and the methodology that is used centrally, and what the localities recognise. That reflects the difficulty of understanding, at a national level, what impact and progress there has been. There are such a number of indicators. Yes, it was challenging.

Perhaps that could be addressed in the legislation if the Parliament was minded to look at it again.

How does the council funding work? Last year, the councils put in £2.4 billion, I think, which came out of their budgets. These are constrained times for council budgets. Is that money fully funded by Government or were the councils instructed to carve out that £2.4 billion from their current budgets to put into the IJBs over the piece?

In any event, is there not a danger that councils, by virtue of having to fund this area, will have to cut services elsewhere, which perhaps have been mirrored?

There is a lot in there—

Sorry.

That is all right—I will do my best to answer your questions, and the team will keep me straight.

The intention is that councils and the NHS will, together with the integration authorities, identify how much is spent on community health services, primary health services, unplanned hospital services, and social care services—for adults in all places and for children in places where they are included in the integration scheme. They will then pool their budgets to cover that, so the money comes from their core budgets.

There has been additional funding from Government—£250 million in 2016-17, I think, and an addition in 2017-18—which went to NHS boards and then had to be passed on to the integration authorities to fund some of the services that are involved. Both the councils and the health boards are required to make efficiency savings in different ways, reflecting the overall pressure on public finances and the intention that they should be improving how they use money.

The money comes from their core budgets, with savings coming out of that, and there is additional funding. That complexity is partly why a number of integration authorities have found it difficult to agree their budgets; there are timing differences as well. In addition, as you say, if that money is coming in to the integration authority, the pressures that we recognise are affecting other council services and other parts of the NHS budget become harder to manage. All that is why this is complicated. I am sure that there is more to cover, so I will pause there and let the team come in.

It is quite complicated to get a clear picture of IJB finances. We set out on page 12 of the report that a number of the IJBs needed to call on additional resources on top of those that were initially planned from the council and the NHS board.

The 2014 act set up the IJBs specifically so that they could agree locally who would carry the risk. We have tried to explain in the report that the situation is very different in different local areas. If there is an overspend on the social work services that the IJBs direct, how that resource comes from the partner bodies when there is an issue is very different in different areas. Some of that is being worked through and, again, we have tried to set that out on page 12 of the report.

As there are no further questions from members, I thank the Auditor General and her team very much indeed for their evidence this morning.

10:54 Meeting continued in private until 11:16.