Health, Social Care and Sport Committee

Meeting date: Tuesday, October 4, 2022

Official Report 668KB pdf

---

Health and Social Care Integration

The fourth item on our agenda is an evidence session with witnesses from integration joint boards on their experiences of health and social care integration, all joining us remotely. I welcome: Stephen Brown, chief officer, Orkney integration joint board; Vicky Irons, chief officer, Dundee integration joint board; Judith Proctor, chief officer, Edinburgh integration joint board and chair, chief officer group; and Allen Stevenson, head of health and community care, chief social work officer of Inverclyde integration joint board. Good morning to you all. We will move straight to questions, led by Paul O’Kane.

Good morning. The committee is keen to understand the process of integration, looking ahead to our scrutiny of the National Care Service (Scotland) Bill and looking retrospectively at how the arrangements are currently operating.

Do you feel that, at the time of integration, planning and guidance for the implementation of integration was suitably clear, detailed and timely? What was the experience of the planning for that integration process?

Judith Proctor and I have been engaged in the evolution of the IJBs from the outset, during the passage of the Public Bodies (Joint Working) (Scotland). Act 2014 but also during the shadow years. I am currently the chief officer of Dundee IJB but I was originally the chief officer for Angus IJB through the shadow year and then through the establishment phase from 2015 onwards.

I feel that the process and the guidance were thorough. We worked closely with the civil servants who were based in the Scottish Government at the time to develop that collaboratively, so that we could implement arrangements across the system.

Most systems had a good year of working in shadow form, and that year enabled the systems to put in place many of the local agreements that had to be discussed and developed, particularly around the deployment of corporate services, as many of those were not delegated into the new integration authorities but were retained by the relevant national health service boards and the local authorities that made up the partnership.

Having said that, I think that there was still a degree of interpretation present across a number of IJBs in Scotland as to exactly what the governance and organisational arrangements should look like. In many cases, we worked through those issues as we developed the integration schemes. As they were processed through Parliament, many of us were in a position where the original integration schemes required further amendment before they were formally approved. I feel that, at the outset, there was quite a degree of guidance, and that enabled us to put in place quite robust arrangements.

Judith Proctor might like to comment further from her perspective.

10:15  

I was involved in integration from the outset. Prior to being the chief officer in Edinburgh IJB, I was the chief officer in Aberdeen City IJB and was involved in the development of the integration scheme and that integration joint board.

I agree with Vicky Irons that the process felt very thorough. We had the bill and then the 2014 act. There was development work with chief officers that enabled us to work together across the country to share good practice and understand what we were each implementing and what issues were arising as we did that. Other things that were important to us ultimately included the work that we were able to do with our shadow integration joint boards on establishing the vision, values, principles and the way that they wanted to work, as well as, in particular, that element of added value—what would be different and how we would be able implement that. We were able to set out the strategic vision that then became the strategic plan and I think set the culture and vision for the integration organisation.

That time in the shadow year also felt necessary for developing the relationships between the partners. Integration, as it was delivered and conceived in that bill, was disruptive—it was doing something very different and we needed to re-establish the relationships between councils, health boards and this new organisation. I certainly feel that the time that we had to do that prior to the go-live date was necessary time, and I think that we had a good amount of support, guidance and time to work together to work through that complexity.

That is helpful in terms of understanding the process towards integration. If we could park the pandemic—I am sorry for that unfortunate phrase, and I know it is not easy to do—I would like to get a sense of whether people feel that integration was well established. Is it absolutely there, or does it still feel very much like a work in progress? Stephen Brown or Allen Stevenson might want to give their observations on that.

I think that there was a lot of progress made at the time. As Judith Proctor and Vicky Irons described, in the early days, there was a degree of excitement around what was possible with regard to bringing community-based health and care services together. Significant strides were made but, clearly, there are also significant barriers. We talk about information systems getting in the road. We have loads of information systems across both health and care, which makes it difficult to share information. We also have different terms and conditions across health and care. There are a number of things that would lead me to describe the situation as a work in progress.

We are not able to bring in Allen Stevenson yet as we are having issues with his connection. Paul O’Kane, perhaps you could move on.

I will pull this opening segment together. I am keen to understand the learning from this process as we move towards another process. What do you know now that you wish you had known at the start of that integration process and can be used as we scrutinise the forthcoming bill?

I can see Vicky Irons nodding along with you, so we will go to her first. Lesson learned, Vicky Irons: if you nod along, I will come to you first.

From my perspective—this might give away the length of time I have been working in these types of roles—this is probably the third set of reforms that I have lived through in similar jobs across health and social care. There is certainly a cycle to the learning. I was involved in the predecessor organisations that came before IJBs including the local healthcare co-operatives and the community health partnerships. With each of those changes, as my colleagues have outlined, we have seen significant gains regarding the operational integration of our health and social care services and some quite phenomenal work in the way that our teams have operated closely together. However, each system has struggled with each reorganisation to fully understand how governance works, to fully embrace the integration of health and social care and to enable us to develop further.

For me, there is a need to understand which components of the current health and social care integration legislation have thrived and which other aspects have just been inherited from the surrounding infrastructure and environment that supports that organisationally. It is in those areas that we need to do quite a lot of work to ensure that we do not necessarily pass those on through the next series of reforms.

We also need to understand that we seem to be very good at reviewing organisations such as the IJBs to see whether they are working and succeeding and then replacing them with a new style of organisation, but we fail to really understand and review the organisational arrangements and the characteristics of the other aspects of the public sector to see if there is any change required there. It is clear from the report that was done years ago under the ministerial group around health and social care integration and then from the subsequent Derek Feeley review that health and social care integration has worked phenomenally well in areas where there has been a will to make it work. However, it has not necessarily thrived in other areas where there has not been that level of support and development. We need to concentrate our efforts on those things rather than expecting another significant organisational change to fix them. I think that the issues are much more about the culture and the will to make things succeed rather than about significant organisational change.

I agree with a lot of what Vicky Irons has said. This is a huge cultural change and one of the lessons that I would take into any consideration about where we go next is the test of whether it truly integrates the operational delivery and receipt of health and social care where people and communities need to experience it. I think that, too often, we think about structural change at a high level without really testing through what it will mean for real transformation and change at the front line, where people are working at that interface with people’s lives. It is important to think about that.

As Stephen Brown said earlier, many of the things that we were not able to implement over these seven or eight years could not be implemented because we remained part of two separate organisations with two separate systems around everything, and that mitigated against that joint and integrated working at the front line. The fact that many areas were able to establish that as well as they have done was despite the arrangements rather than because of them. I think that there is definitely a need to ensure that whatever we put in place next preserves and strengthens that operational integration and goes further than we have been able to do until now.

I think that we have Allen Stevenson back. I am not entirely sure whether we will be able to see you, Allen, but you probably want to come in on Paul O’Kane’s earlier question, to which Stephen Brown responded.

Good morning, and thank you for giving me the opportunity to speak to the committee. Could Paul O’Kane repeat the question?

Sure. Putting the pandemic to one side, do you get the sense that integration is well embedded, or is it still very much a work in progress in terms of the wider picture?

I think that it is a work in progress. I have been fortunate to work in a number of areas in Scotland, and I see a huge desire to improve outcomes for people. A lot of the old professional barriers have gone because we know that, no matter which service user or family we are working with, we will get those outcomes only if we are as joined up as possible. However, there is still work to do.

A number of the partnerships were working in an integrated way even before the shadow year, and it is important to understand that there are organisations that have been pushing the boundaries to work closer together. However, it will always be a work in progress, as I think that my colleagues have said.

The issue for me is that we spend a lot of time talking about structures and that we will continue to spend an awful lot of our time discussing them. People within the service realise that, if there is to be a focus on outcomes, we really need have that focus when we think about how we will spend our time. We spend a lot of time on the old barriers—HR, policies and procedures and how things are set up—rather than really concentrating on getting better at delivering services that achieve outcomes.

I do not think that any partnership in Scotland will say that they are there, but a number of partnerships have been working over many years to push the boundaries. People accept that there is no single agency that has all the answers when it comes to providing assistance and support. We need all the agencies to work together.

I hope that that answers the question.

That was very helpful.

I have a question for Vicky Irons that builds on something that she said.

In 1999, there were 79 local health co-operatives, which were replaced by the community health partnerships in 2004. The CHPs were then abolished in 2014, which led to the creation of the 31 integration authorities. You talked about the will to make that work. Were any lessons learned from the previous failed attempts? If so, which lessons were learned and which issues are still proving to be problematic?

Each series of the reforms that you have just articulated tried to build on the previous series and understand which things got in the way. With each series of reforms, I think that we have definitely progressed with what we have been capable of doing in the integration space—I want to say that from the outset.

In establishing the IJBs, it is clear that the scrutiny and governance landscape has become quite cluttered. It is not unusual for chief officers to have a full set of arrangements for governance and reporting to our integration authorities. However, in many cases, we have duplicate arrangements for reporting to both the relevant NHS board and the local authority. That sometimes gets in the way of being able to fulfil our role effectively, because we spend a huge amount of our time offering assurance, reporting and going through performance management systems with three different organisations. For me, the biggest lesson that we could learn would be that there is a change in the way forward that declutters that landscape, makes the governance and accountability arrangements absolutely clear and avoids duplication.

10:30  

However, because each of the authorities that make up the partnerships have retained the ultimate responsibility for the services that are delegated to the IJB, how the IJB should function and exactly what delegated authority it has are often misunderstood.

Sometimes, my experience been great, but there have also been changes over time, largely because many of the stakeholders have changed over the period in which the IJBs have been in place. We have been operating for seven years, and as individuals and stakeholders change across the authorities that we work with locally, so does the level of understanding that underpins the legislation and what we are trying to achieve through integration.

If there is one thing that we can learn from this experience, it is that we need to make the infrastructure and the governance and accountability arrangements much clearer.

From a chief officer’s point of view, a particular issue is how unusual it feels to be accountable, in line management terms, to the chief executive, the NHS board and the local authority, when we are also, as chief officers, directing those authorities to undertake the IJB’s plans. That often feels very odd and is sometimes really quite difficult, particularly at the time of year when we are trying to agree financial settlements and to plan accordingly, because we are part of the NHS board and the local authority, but our primary role is that of chief officer for the IJB. In many places, we are negotiating with the very body that employs us or to which we are accountable, which can sometimes make life difficult. I have always managed to find a way through that complexity, but I know that it can be quite difficult in other areas where relationships are not as strong as the relationships that I have experienced throughout Tayside.

Other members want to come in on structure and governance.

Good morning. You made some strong points, Vicky, about previous reviews, how things have got better and how you worked through issues. Given your comments, am I right to think that, as we move forward, we should be looking at streamlining governance and accountability and taking out duplication? You mentioned various reporting arrangements and doing things more than once but in different avenues. Can you expand on that? I seek comments from the other witnesses as well.

The short answer is that it would make total sense if we were able to make things more streamlined. There is also something in there about reducing conflicts of interest. Trying to participate in NHS board and local authority decision making while also doing the right thing on behalf of the IJB sometimes feels quite conflicted. Those things do not necessarily always align. It would be powerful if the new authority for health and social care—whatever that looks like—was established as a board in its own right and did not report through the other two parts of the public sector structure.

However, I still have some concerns about fit and whether, given Scotland’s size, there is enough financial resource to support three public authorities. Exactly how would that work? Although we have a defined series of services that are delegated to the integration authority and outlined in our integration schemes, we still work in partnership with a huge range of other services that are retained by the local authority and the NHS board. We need to make sure that we do not cut across any of those partnerships and that we do not disintegrate the integration that we have already created in health and social care.

Judith Proctor mentioned something that certainly strikes a chord with many of us. There has been a large focus on establishing a national care service and ensuring that the new authorities have direct employment rights in relation to care staff. However, we need to make sure that we can still deploy and integrate all the health and social care teams that currently form part of the IJBs. We worry that, if the new organisation is able to plan for, deploy and employ parts of that workforce but not others, that will lead to new lines being drawn in the landscape. We need to think long and hard about some of those issues and get them right, because we do not want to unpick any of the progress that we have already made.

I am sorry if I have gone off at a wee bit of a tangent, but my point is aligned to the organisational structure that we need to look at.

I will bring in Judith Proctor. If other witnesses want to add anything, I ask them to put an R in the chat box—I will see that, because it is in front of me.

I agree with Vicky—not for the first time—that simplification and streamlining would be welcome. We look to achieve agile decision making so that we can effect real change on the ground for people. That focus on developing services that are wrapped around individuals and shaped and co-produced by the very people who need them is welcome. I do not think that our arrangements do that. They are complex and difficult to navigate within.

I would also question the focus on commissioning change. How much of that change can we commission in terms of directing another organisation—one that has its own strategic direction—ultimately to deliver in ways that are different and responsive to the community? We need to ask questions about that.

Stephen Brown has touched on the whole question—we all have—of different terms and conditions, different organisations and different systems. Those differences make life challenging for our teams on the ground and we need to do everything that we can to streamline things for them. We talk about this as a real once-in-a-lifetime opportunity to get integration and our care for people right, and we need to dig into these perennially difficult challenges and find our way through them, even if it takes some time.

My view is that the operational arrangements should sit within a single organisation that has the levers, authority and power to direct and deliver services for the people in that area. Any organisation of that sort would work closely with its community planning partners, maximising the potential and opportunities that were set out in the Christie report. Arrangements that tie in one organisation to direct others to change and deliver take time, are difficult and do not deliver the full potential of integration.

I will build on what Vicky and Judith have said. The complexity and the cluttered landscape that both have highlighted are even more evident in Orkney, where we have a population of 22,500, the local NHS and the council, and where we will have a national care service. All those bodies will have their own chief executives, and that is before you bring in the other community planning partners such as the Scottish Fire and Rescue Service and Police Scotland. As you can imagine, the whole thing feels cluttered and complex to our communities, which are looking for the best-quality outcomes and the best-quality public services they can get.

I come back to Allen Stevenson’s point. There is no doubt that we need to focus our efforts and energies on trying to improve the outcomes for people. We can welcome with open arms much of the ethos of the national care service and the move towards introducing a getting it right for everyone approach, in the same way as we introduced a similar approach in children’s services many years ago.

Public services across councils, health boards and IJBs have created strict eligibility criteria that provide for people with substantial and critical need, so in many instances we end up telling people to come back when they are worse because we have to ration our services. The ethos of trying to open that up and provide services and support at the earliest stage makes perfect sense in terms of improving outcomes for people, because the earlier we can get in there, the longer we can sustain that and the more successful those outcomes will be.

From an economic standpoint, we have known the stuff around prevention and early intervention since the Christie commission, all the way back in 2011. I am sure our public health colleagues would say the same about the need to intervene and provide support at the earliest stage possible. Some of the ethos that is coming through from the aspirations behind the national care service will help to guide us through the difficult discussions that we will have to have, and the difficult decisions that we will have to make, around the format, the structures and so on.

I have a follow-up question. The points that you have made help to clarify how we move forward with the work. I am interested in how IJBs dealt with the pandemic. Did the pandemic highlight issues? Did it make people think about things differently? What are our learning outcomes from the pandemic? How can we include those in our future reviews?

This is a personal reflection in many ways, but there is no doubt that, at the outset of the pandemic, a few things were different. People were brought together in a way that I had never seen before. We had to forget about organisational boundaries and think about how to work together effectively.

The first factor that was at play was that there was a common goal—or a common enemy, depending on how you want to view the pandemic. Everyone knew that we needed to respond and that we needed to be prepared, and everyone was involved. No one was in any doubt that the right thing to do was to ensure that we had everything in place to protect our communities, our staff and our services throughout the pandemic.

Secondly, there was no blueprint or established way of doing things. Therefore, people were not taking the view that, as they had always done something in a certain way, that would stand us in good stead. There was genuinely a blank sheet of paper, so people had to think about how we organised and arranged ourselves differently. Nobody could say that they preferred doing things in a certain way, because there was no established way.

Thirdly, and finally, there is no doubt that there was significant governance through the pandemic, but we had to be fleet of foot. Things were stripped right down to ensure that decisions could be taken at the most appropriate level without taking three weeks or, in some cases, two years to prepare a business case for a test of change—by the time such a business case is prepared and work is ready to be actioned, the world has moved on and things look very different. People had to be fleet of foot at that time, which made things very different.

We need to be clear about those three factors. First, we should focus on our ultimate goal—the outcome that we want to achieve—and get everybody on board. Secondly, we should allow people the space to think about, if we had a blank sheet of paper and were creating our public services from scratch, what they should look like to best effect. We find ourselves bolting things on and trying to join bits up, but if we had a blank sheet of paper, that would make a big difference. Thirdly—this relates to Vicky Irons’s point about the complexity of governance, which can be really tricky through all of this—if we could streamline some of the governance and bureaucracy, we could free people up to focus on what really matters: improving the outcomes for the people of Scotland.

I will build on the points that Stephen Brown made. I would go further and say that, if we had not had the foundation that we had established through our health and social care partnerships, the response to the pandemic would have looked markedly different.

I still vividly recall the first few months of the pandemic response, mainly because I had been in post in Dundee for only three weeks at that point. It was evident that, because we had robust, integrated and self-starting teams that did not necessarily require huge amounts of direction to do the right thing, the resilience response that was mobilised was quite phenomenal. For example, on the first weekend once we realised that there was going to be a problem with Covid, our general practice out-of-hours service established a treatment and assessment centre. We were also integral to the development of our testing services for all staff and, latterly, for the public as that service was rolled out, and, further down the line, to the development of the vaccination service.

10:45  

The key thing that we all need to remember is that, in those early days, we were doing everything within our power to protect the capacity that we had available in our acute hospitals, which meant that the majority of people’s care needs needed to be met in the community. For our staff, that was both a frightening time and quite an exhilarating time as they maintained care in people’s homes and the care that we were providing in our care homes. They did that very well.

I reiterate the point that Stephen Brown made. When you move into resilience mode, decision making becomes much quicker and easier. We were welcomed into local resilience partnerships with open arms in order to mobilise efforts across our local communities. I feel that it is worth reiterating that.

I will build on the points that Vicky Irons and others have made about the level of flexibility and resilience. When Covid struck, despite the level of fear in our communities, our staff group stepped forward into the breach. That included our district nurses, our care-at-home staff and our colleagues in the third sector. In my 25 years as a social worker, I have never seen the system come together as well as it did in those early days. Despite the level of uncertainty, our staff, including those in the heath board, stepped up. Staff from Inverclyde Council asked whether they could get training in order to help with care at home. In addition, our third sector colleagues stepped in to set up a humanitarian helpline so that people could get a response from people. Therefore, through partnership working in the wider system, we could enhance the offer that statutory services were able to provide.

Having come through that experience, I think that how the whole system reacted to the pandemic will always be in my head. People stepped up and thought about how we could keep the most vulnerable people safe through flexibility and agility.

Similar to what Vicky Irons said, within the first few weeks, we had set up a testing centre in Port Glasgow, at the side of the health centre. We then had the Army in to help us. All these things were coming one after the other, but staff across all levels of the organisation—from those in leadership, such as service managers and team leaders, to staff on the ground—stepped forward and put their own fears to the side. That will be my memory.

We should never forget that whole-system response. In fact, we should celebrate it and think about what that tells us about our capacity as we move forward with this latest iteration and think about what the new national care service might look like. The response needs to be not just from statutory services but from our wider group of colleagues, who have a vast amount of experience. A lot of the answers lie in that wider response to health and social care.

Paul O’Kane has a short question.

We have heard about local working at officer level, but I am keen to get a perspective from the boards themselves. How important is that democratic representation, with elected members able to scrutinise the work of health and social care partnerships and chief officers? Those people know their communities and have been elected to represent their communities. I say that as someone who served on an IJB in a previous life. I wonder whether Judith Proctor might want to share her view on that.

The make-up of the board and its interest in the work that you do are crucially important. Central to that is the fact that a board has its own personality and is a public body in its own right. Both IJBs that I have worked with have tried hard, with the chair, the vice-chair and all members of the board, to create a culture in which it is not about two different types of appointed people—elected members and non-executives—coming together with those hats on to make decisions through that lens. As members of an integration joint board, they are there to work for the community in their area and to think differently—beyond the boundaries of the organisations that they come from. That is really important.

Non-voting members of the board are also hugely important to us. In Edinburgh, we take the approach that the board includes everyone round the table. Yes, ultimately, if we need to vote, only some members can do so, but we have had a vote on only, I think, one occasion. We make decisions through broad consensus that we are doing the right thing and that we have agreement on our proposals. The voices of lived experience—people who work in our services and our professional representatives—are hugely important in helping the whole board to make decisions.

The role of local democracy is, of course, important. We link through the elected members who sit on the board, but they, of course, are not representing their communities—[Inaudible.]—on the board. We try hard to work with our local politicians, including those who are not on the board, because the experience and knowledge that they bring from their localities and from their casework are hugely important in helping us to understand how our services impact people on the ground. For example, we hear that, sometimes, we get things wrong, and we can learn how to do things better. Working through local democracy is hugely important, as is working with third sector organisations, community groups and the people who represent those groups.

We have taken seriously planning at the level of the locality in relation to how people work with their communities. Edinburgh is a large and diverse city, so we work with localities to ensure that, as far as we are able to, we shape our services to the needs of those communities. The experience and knowledge of local elected members, including those who sit on the board, are important in that regard.

As a chief officer of an IJB, I think that it is more important that the board recognises that it is a public body in its own right. Vicky Irons talked about tension earlier. As you might have experienced, the decisions of elected members who sit on an IJB can sometimes be counter to the views or directions of a certain group on the council or of the whole council. It is quite a difficult role for elected members and, indeed, for non-executive NHS directors to sit on the board and to hold in their heads the board’s ambitions while driving those forward through strategic planning and through—

Thank you. I ask everyone to be mindful of time in relation to the length of both questions and answers, because we have a tremendous number of questions still to ask. If our witnesses want to add anything to what has already been said, please use the chat box to do so.

I just have one question, which I will direct to Vicky Irons. What impact does confusion about lines of accountability have on the planning, quality and delivery of services?

The major impact relates to the pace of change, because if there is an expectation that, before any significant decision is taken, the pathway has to involve the health board and the local authority as well as the IJB, that affects the ability to make decisions timeously. That is the major impact.

There could also be an impact depending on whether there is a different sense of priorities across the two public sectors that make up the health and social care partnerships and that form the IJBs. When that is the case, there can be an impact in being able to align priorities in order to move forward with decision making.

The Convention of Scottish Local Authorities responded to the National Care Service (Scotland) Bill consultation. I will give a straight quotation, then I would like Allen Stevenson first, then Stephen Brown, to give quick responses, please. COSLA said:

“Structural change typically fails to address long-standing systemic barriers, with integration being challenged by a lack of resource, infrastructure, and staff. As things stand, we risk repeating the cycle of successive reorganisations that change how services are planned and coordinated—and come with a significant opportunity cost and disruption—but fail to address the fundamental and deep-rooted changes needed to integrate services at the front line.”

Are you concerned that all your hard work over the past few years could be undone?

Thank you for that question. Inverclyde IJB’s response to the committee talked about the fear that we are spending a lot of time going back over things that we should not be spending time on, and that we should instead be learning from successive changes. That worry and fear was not there, initially. When the national care service idea came up again, there was a great deal of enthusiasm and excitement, but with the passage of time there has been more concern that we will spend too much time thinking through things to which we already know the answers. There is a fear that a lot of energy will be spent on structures when we should be looking at outcomes.

It is for us, now, to make sure that we play a full role, as thinking develops with the senior leaders and other parts of the services across Scotland, so that we ensure that we shape services properly. COSLA is merely highlighting the genuine concerns that many colleagues whom I work with have spoken about, and the potential to score an own goal if we do not make the most of this opportunity. It is reasonable that experienced senior leaders who have been through many changes would have that fear: we need to make sure that we shape the national care service.

Before I bring in your colleague, will you say whether you are being given the opportunity to be involved in shaping the national care service?

There are ongoing conversations that Judith Proctor and Vicky Irons have been involved in with various bodies that represent us well: for example, we have our chief social work officer group. A lot of weight is attached to all the things that we will be talking about and we have been assured that we will have our opportunity to shape the service. We look forward to being at the centre of the discussion and are committed to making this work; none of our colleagues would say they are not interested in playing a full part. The challenge is there in front of us now to fully inform how we shape the service.

I agree that there is certainly nervousness about needing to spend a lot of time, effort and energy looking at our structures when we need to focus absolutely on the needs of our communities. We recognise that we have, for all the reasons that everyone at the table knows, come through two of the most difficult years, during the pandemic. We know that many of our older people became deconditioned through that period. We know that many routine operations had to be put on hold and we know the impact of that, and we know that there was an impact on people’s mental health. There is emerging need as a result of our coming out of the pandemic, which we need to be extremely focused on.

We have also to add in the financial instability across the world, the cost of living crisis that people face and the impact that that can have on people’s mental and physical wellbeing and health, so we need absolutely to be outward focused in our efforts.

I suppose that there is a question about how much time we spend on huge structural change. Again, it is about striking a balance. There is no doubt that structural change can make a difference. Vicky highlighted quite clearly at the outset the significant impact of the changes that we made for establishment of the IJBs in the first place, and the progress that was made through the early days of that. There is no doubt that structures can help to facilitate the work that we do, but there is a balance to be struck in terms of being outward focused and, at the same time, making sure that we have in place the proper structures that will help us to deliver that.

Thank you. I will move on to questions from Stephanie Callaghan.

11:00  

On leadership and chief officers, Vicky gave a good description of how difficult the role is when it is subordinate to chief executives of other bodies. We had a ministerial strategic group on how to improve collaborative working. How are the chief officers of IJBs currently supported and how do we help them? What changes do we need to make so that they have the power to lead effectively?

Judith—that seems like a good question to put to you.

Thank you for that question, which recognises the uniquely difficult role that chief officers have in health and social care integration. All leadership roles at that level could be challenging, but there is certainly a unique aspect to the multiple lines of accountability that chief officers have that make it difficult.

There are a number of things to say in that regard. First, it needs to be recognised that we want leaders to come forward across the public sector in Scotland and that we want to see leaders being developed. We want to see people thrive in those roles and to have opportunity within them. It is important for us, as a system, to think about succession planning and where the opportunities are for the leaders who are coming through. I know that there are new approaches to that. There is a strategic leadership programme that is starting this week. An important part of that is a look across sectors.

In the current cohort of chief officers, we try as a group, in Health and Social Care Scotland, to support one another. We will get back together again in person for development days to develop our role as an organisation and as a group, in terms of being the collective voice of chief officers.

How do we influence the wider system? Sometimes it can be quite difficult in our own systems to influence things because of multiple tensions. It is important: there has to be recognition that when chief officers require support, we need a route into the Scottish Government. Again, we try to work with officials there to cultivate that. However, the crucial thing is that we are able to prepare and support leaders for the future, in our national approach to the service and to their development.

Thank you. That was helpful. Is that at the centre of the high turnover in leadership of IJBs? Should we be doing anything in addition to what you have said to try to prevent that?

That is a difficult question. There are two interpretations of why there is high turnover among chief officers. One is—we have seen this—that a number of chief officers have gone into what we might think of as promoted posts as chief executives of local authorities and health boards. There is something to celebrate, in that the experience of doing this challenging job develops people as leaders in the public sector in Scotland.

Undoubtedly, some attrition has come about because of difficult multiple reporting. Some of the questions earlier about simplification, streamlining, and ensuring that chief officers can represent the change that they try to deliver, and that they can represent their organisations clearly, will be important in the new arrangements, so that their voice is not compromised by tensions that are inherent in the current model.

Emma Harper has questions on performance.

Good morning everyone, and thank you for coming today. I have a couple of questions about performance. Integration authorities have been required to report on a core suite of integration indicators within their annual performance reports. The indicators were developed to allow integration authorities to review progress towards health and wellbeing outcomes. The frameworks and the papers seem to be pretty straightforward.

I am interested to know whether appropriate measures and indicators are in place to track progress in integration. If not, could you suggest something that should be added that might be more appropriate?

Who would you like to direct that to, initially?

That is for Vicky or Judith.

We use a core suite of indicators. On balance, they are useful for telling us how we are doing in terms of local progress—how well we have performed in Edinburgh since the inception of integration and whether we are going in the right direction. They are helpful for that.

Also, we can see our position relative to the rest of Scotland. Most of us will add to our annual performance reports relevant local parameters and indicators that we think are useful, so you will get that local flavour. We will all have in place a local performance framework that we will develop and which will go beyond the annual performance reports, and will go into other services. Partnerships that go beyond the bare minimum with the integration scheme will include in their performance frameworks delivery of justice services, children’s services and so on. Those will need to be reflected.

One of the hardest things to reflect in indicators at that level is the experience of people on the ground. We have talked before in this committee and its predecessor about how to measure the impact of prevention and early intervention. We struggle to articulate good indicators around those. Of course, some of the longer-term changes that we try to put in place to reduce the impact of health inequalities and to narrow the gap are harder to implement.

For us, certainly—Edinburgh will not be alone in this—some of the challenge is about having the resource to deliver that complex level of analysis of the population. There is always room for change and improvement, but the suite that we have has been useful. It is the one that we have used over the years; we are certainly able to measure progress against some of the challenges. For us, a challenge remains in respect of discharges, but we are seeing progress against the indicators. If we change some, it will be important also to take forward some of the ones that we use now, so that we do not start with a completely fresh page and therefore cannot measure progress from where we are now into the future and—[Inaudible.]

Thanks for that response. You mentioned particular local issues that you measure, which is probably quite important in relation to rural areas versus urban areas. Integration authorities such as those in Dumfries and Galloway and the Scottish Borders are for pretty rural areas. Are you able to give a particular example of what local performance measurements you use and of successes that you feel have been good and need to be reported on, so that we can continue to build on them?

We look at variance among our localities. We operate four localities in Edinburgh in order to try to ensure that we plan and deliver at a realistic level. Our four localities are large—they are as large as some partnerships in terms of the population that they cover. At least, that gives us a greater opportunity to respond to the communities in a locality. We look at and report on variance and difference in localities, which helps us to think through the relative amount of resource that we might put into one area as opposed to another. It also helps us to think about where we need to undertake work on quality and where we need to achieve consistency of approach so that we deliver the same outcomes for people in one area as we do in other areas. That is why it is important that we look at our population and structures and report on changes.

We look, for example, at why levels of welfare guardianship in some areas are higher than they are in others, which could impact on our performance and therefore on the resource that we need. I point to that as one area in which it is helpful to think and respond locally to what we find.

I will briefly build on that.

I agree with Judith Proctor. The evolution of the annual report and the performance measures within it are useful and are a continuous method through which the IJB can gauge whether we have been making progress.

It is also fair to say that since we established the requirements a lot of service development has evolved that is not necessarily covered. In the local IJB, I have heard a request for information that is more up to date, because the process in itself can be considerably out of date in terms of data capture—sometimes by a year or 18 months.

Also, I have had a request for us to represent the work that we do. That would be one thing that I would want to be emphasised in moving into new arrangements. Many of the activity performance measures, such as those that look at voids and waiting lists, which we are judged against, essentially identify all the work that we are not doing. There is often such a particular focus on that that it feels, from a chief officer’s perspective, as though the only measure that we are ever judged on is our delayed discharge figures. That does not reflect the activity that we do successfully.

I will give you an example of that. Although the delayed discharge figures in my health and social care partnership would look to many external people as though they are quite constant, and would look as though they are not necessarily improving, they mask a 20 per cent increase in demand that we have covered and for which we provide care. We also now have in place a new measure around discharge without delay, which indicates that Dundee’s performance on the number of people whom we discharge without any delay at all is between 97 per cent and 99 per cent.

For me, the emphasis needs to be on valuing things that we do well that we can report back on, as well as on performance measures that count what we do not so well but which we continue to try to improve on.

We heard that, during the pandemic, you had some teams that were self-starting, and there has been good experience of how to support getting people out of the hospitals. There was an issue with that in the early part of the pandemic. I want to hear your thoughts about integration partners and whether they all collaborate effectively. That is about improving performance on the basis of the outcomes and the data indicators. If there are challenges, how do you foresee overcoming them?

In my experience, that is one of the areas that have thrived under integration, in that the teams that support pathways of care—from care of the elderly and consultants in the acute sector right through to primary care practitioners and the third sector, which Judith mentioned—are all pulling in the same direction. We have completely integrated teams available across the localities—that is certainly the case in Dundee city, and I know that it is the case in other partnership areas—that work on a cycle of continuous improvement.

The challenge and the demand for our services never stand still. We have all witnessed quite an increase in the level of complexity of the people we need to support, as well as in the volume of people requiring care through our systems, literally from end to end. We have a completely integrated process in place across the pathways, and our teams are integrated in how they are deployed daily. The level of improvement and collaboration that you are asking about is present, without a shadow of a doubt, and it is present daily. We need to safeguard that and make sure that it forms part of the foundations of whatever arrangements come into place next.

Vicky, I would like to pick up on something that you said in your earlier answer to Emma Harper about how the focus on delayed discharge can, in fact, mask quite a lot of the positive things that have been achieved, such as the flow of an increased amount of people out of hospital and into care settings and their getting the support that they need from the IJB and the people you employ.

We often hear that people are not coming into the care sector or are leaving the care sector because they feel demoralised. Is the way in which the good performance and the achievements that are being made when you meet the demand—in, as you say, a challenging situation—are being reported in the public discourse part and parcel of why you have challenges in terms of people’s morale?

11:15  

Yes, without a shadow of a doubt. The reality of being under constant scrutiny but also feeling like you are on the end of a continual stream of criticism can be very demoralising. These are increasingly really tough jobs to fulfil, dealing with lots of people with cognitive impairment and lots of complex care needs and dealing with everything that surrounds that, as well as ensuring that we provide care in the right place and at the right time so that people are not delayed in any part of our system. That has a major impact as well.

My colleague Stephen Brown mentioned what it feels like to provide a role in care, and particularly in care at home, where you can be quite isolated in the job that you do and the service that you provide for others. There is a perception that these are stressful roles that carry quite a level of risk. As Stephen mentioned—and I think that we still have a legacy of this following the pandemic—there were times when our workforce was genuinely frightened that the jobs that they were undertaking were putting them and their families at risk. At the same time, they were under quite a steady stream of criticism for performing those roles. We have to understand that.

We are also seeing signs of trauma across the workforce. We are now trying to develop trauma-informed support services to make sure that people get the respite and support that they need to continue in their roles. However, we have seen a high level of turnover as a result of that trauma.

Just to follow up on that, what do you think the likes of us politicians—and anyone from the media and the press, and the people who report on these things—can do to recognise more not just that it is a hard job, but that it is actually a really important and rewarding job? What should we do to be more positive, to encourage people to stay and to thank people who do that hard work?

A lot of that comes with true recognition of the roles that people undertake. I am sorry if I have misremembered this, but I think that there was something in the Derek Feeley report about parity of esteem, as well, and about people in caring roles being valued not just by us and you, but by the public as professional and essential roles on the health and social care spectrum. Sometimes, it is felt that clinical and nursing roles, in particular, are held in higher esteem. There is something we can do both to raise the profile of what people do and to value, reward and recognise it.

Thank you. I see that Judith Proctor wants to come in. I will come to Judith and then Allen Stevenson.

It is a good question and so important. One of the lessons that was learned through the pandemic is the absolute value and importance of these roles in people’s lives. There are practical things that we can do. We can think about terms and conditions—that is important; it is a difficult job, and we should value it and the way that people experience doing it—but there is also something about how we create career pathways into care and from care into other roles. I know that most of us, as chief officers in our partnerships and with our health boards and councils, are looking at that.

Also, as a nation, we have to open a conversation about what it means to be a carer. Some of the images that we see are probably not realistic. We see recruitment campaigns where somebody is having a cup of tea with somebody—that does happen, but it is also a highly pressured role. We need to show that and shine a light on the real work and its importance.

I welcome what was said in the Feeley report about that, because Feeley absolutely recognised the need for us to elevate our support for and esteem of these crucially important roles.

Thank you. I will bring in Allen Stevenson.

Judith Proctor has covered the point. I suppose that there is more of a focus on the health and wellbeing of our staff now. Each of the health and social care partnerships has put a lot of time and effort into looking at how we can support our staff groups around their health and wellbeing. Undoubtedly, people are tired. They are physically and emotionally tired, having come through the past two years.

Many of the partnerships have active recruitment campaigns. In Inverclyde, we have one for our care-at-home service, which kicked off again last week, to encourage people to think about a career in care. There are far more opportunities to move into care at home, and there will be other things that people can do after that. A big focus on health and wellbeing has to be the way forward.

I was a mental health officer when the Adults with Incapacity (Scotland) Act 2000 came in, and the Scottish Parliament has a role in that it can bring in innovative legislation. I know that there have been issues with AWI, but someone asked about the role of the Scottish Parliament. Yes, there is a big role for it, because legislation can be helpful. There is a huge challenge for us, now, in supporting the staff across the sector. No one becomes a registered social worker in order to be popular—people know what comes with the territory. But we need to protect our staff, whether they are nurses or allied health professionals.

The level of disquiet among some people in the community towards our staff has been an issue for us, and we have had to work hard to do everything we can to promote health and wellbeing. The committee would want to know about the health and wellbeing work that is going on across Scotland to support our staff in whatever role people currently work in across health and social care.

Thank you very much. Tess White has questions about strategic planning.

Thank you, convener. Allen Stevenson said that people are tired because we have been through a difficult period in the past two years. What work is going on at the moment to integrate service delivery? Has it stalled? Has the National Care Service (Scotland) Bill taken resources away from forward planning in this area? My question is about bandwidth.

Will we go to Judith on that?

Sorry—your sound cut out for a second. Would you mind briefly repeating the question?

My question is about bandwidth. Everybody is tired and fatigued after the past two years. What work is going on at the moment to integrate service delivery? Has the National Care Service (Scotland) Bill prevented forward planning in this area, because there is only so much that you can do?

Thank you for that question and for repeating it for me. There is a real risk that we are focusing on what we need to do to work towards a national care service. It is not exactly that we have taken our eye off the ball of what we are doing now, but it has disrupted our ability to look to the longer term. Ideally, our strategic planning will look beyond the three-year cycle that we have and to what we want to achieve in 10 years.

You could integrate that with the intent around the bill and the Derek Feeley report. We could be working, as we already are, on things like ethical commissioning. That should be a principle of how we commission anyway, so that should not be knocked off course by the work around the national care service. However, as more of the detail around the NCS is made available and comes through the co-production process, there is a real risk that we will begin to feel the tension between the current direction of travel—planning, relationships and allocations of budget—and what we are required to do around the national care service. That is a real issue.

The questions at the start of this session were all focused on the process of how we integrated back in 2015 and 2016. At that point, of course, we had the change fund to support us to increase our capacity and do some double running of that element of our work. Those arrangements and how we are supported to potentially double run as we transition from our current situation to the future will be important. There is a risk.

We are experiencing some of that issue with bandwidth now, because we all have a longer-term direction of travel to create sustainable and transformed health and social care services within the challenging budgets that we have, but we also need to focus significantly on winter planning, which is now a year-round activity—surge planning—as well as future waves of Covid, around which there is uncertainty. We now have an almost permanent focus on the vaccination programme, which is hugely important, and the sheer challenge that we all have in addressing this stage of the pandemic and the consequences of the past two years. The bandwidth issue relates not just to the NCS, but to the sheer pressure, demand and need for change.

I will bring in Sandesh Gulhane, who is joining us remotely.

I listened to Vicky Irons speaking. As a doctor, I, too, am confused about where IJBs sit. There is confusion about authority, governance and lines of accountability, so what she said makes real sense to me.

In relation to the National Care Service (Scotland) Bill, Audit Scotland said:

“A clearer line about Care Boards superseding Integration Authorities and the timeline for this would have been beneficial. This would assist current Integration Authorities ... with medium- and longer-term planning.”

Do you agree? Are you concerned that the bill as drafted is undermining such medium and longer-term planning?

The point about undermining medium to long-term planning potentially builds on Judith Proctor’s response to the previous questions. There is absolutely a requirement for planning. Our planning cycle is pretty much continuous these days but, particularly after Covid, each IJB has had to go through a refresh of its strategic plans to ensure that we can bank the gains that we have made on integration throughout the resilience response, and that we understand exactly how demand has changed as a result of Covid and can refresh our strategic plans and respond to that. As I mentioned, we have seen a 20 per cent surge in demand for care at home, which cannot be explained by demographic change. Something else has shifted throughout that period.

Earlier, my colleague Stephen Brown referred to the excitement that was there when we were first established. That is perhaps not present at the moment, and that leads to a bit of a risk of interruption of the planning cycle. There was a real desire to do things differently and an excitement about change and integration and what progress could be made. That has been dampened down recently, and that is partly because of the fear of the change that is ahead. People are wondering whether, if we go for significant strategic shifts in care, there might be a point in time in the next couple of years when the rug is pulled from underneath that.

That is a potential risk. That is more about feelings than any particular infrastructure or planning process that we have in place. In essence, it is the role of a chief officer to ensure that motivation is still present and that all our partners are willing to tie into that. That is our challenge in seeing us through this period of change, and we are certainly up for that challenge.

Your other question was about Audit Scotland’s reflections on the streamlining of accountabilities. I agree with that point in general, but I will flag up another area of concern from a chief officer perspective, which is about the possible development of a national care service in parallel with a national health service. We are worried that we will lose the gains of all the work that we have done on the integration of health and social care. From a personal perspective, I think that we have perhaps missed an opportunity in not building a national health and social care service as opposed to having two parallel national bodies and two parallel boards that will be present in local systems. That is one area where there is potentially a missed opportunity in the proposals that have been set out so far.

We will move on to talk about collaboration in the third and private sectors. Paul O’Kane has questions on that.

11:30  

I will start by asking for another reflection on integration. To what extent have the legislation and guidance allowed for effective collaboration with the third and private sectors?

There is no doubt that they have helped to facilitate relationships across the statutory, third and independent sectors. As was described earlier, the make-up of the joint boards and the input of various bodies and key stakeholders—from service users and carers through to trade unions, staff side and third and independent sector representatives—have all helped to shape the delivery models across the piece.

In Orkney, we do not have an independent sector. We have a thriving and mainly locally based third sector, the work of which is incredibly valuable to the system. It is truly integrated not just in our health and social care landscape but right across the community planning partnership arena, and it is an active partner in that.

For example, the third sector helps to lead on our delivery of distress brief interventions. Age Scotland Orkney works in collaboration with psychiatry, social work and others on the delivery of many of our pathways around dementia diagnosis. All that continues to thrive under the current circumstances.

In my experience, the legislation, the make-up of the integration joint boards and the approach to strategic planning have certainly assisted with some of that collaboration.

No one else has asked to come in, so I will go back to Paul O’Kane. If anyone wants to come in, please use the chat box to let me know.

We have already touched on some of the points that I want to raise in talking about the governance and scrutiny in IJBs and having different partners round the table, particularly third sector and trade union colleagues and others. Sometimes, people are present and are asked to leave when a vote happens, or they are at the table and do not have a vote. To what extent does that fray or fracture relationships and affect people’s ability to make a meaningful contribution?

I am happy to come in on that, because it is important. Certainly, in my experience, an individual would be asked to leave the meeting room when a decision is being made only if there was a potential conflict of interest through the register of interests. As I said, the chairs and vice-chairs of the IJB have worked hard to have the board act as a whole board and to make decisions by consensus. We have definitely taken that approach in Edinburgh. As I said, we have only ever had one vote, and that related to the day of the week on which we would meet.

From that, our non-voting members articulate a sense of being part of the decision making and having an equal voice on the board. We talk about the issue because, although they feel as if they have an equal voice on the board, under the legislation, they do not, and that has to be explored. However, the challenge for any individual undertaking the role is one of representation and how representative of a community they are.

As a result of having those voices round the table, we have a far richer, better and more reflective conversation about the challenging issues that we consider. The fact that we have already worked through some of those difficult, innovative and challenging matters with the voices in the room then helps us to work with our workforce and communities on implementation of those.

Similarly, in Inverclyde, we have not had to vote, which is remarkable when you think of the complexity of some of the issues that we discuss. That is because we work very much as a team.

It is interesting that, in relation to the new national care service, there is talk about a change and everyone having a vote. During the shadow year, folk were concerned about the vote and how it was split. In my experience, having worked in Argyll and Bute for 13 years and now in Inverclyde for five, the issue has not been as big as some people thought it would be. We have always managed to work in a way that gives all the people round the table the opportunity to contribute, and that shapes our decision making.

An interesting discussion has reared its head about broadening out the voting in the new national care service but, certainly in Inverclyde, we have not had to vote on any of the issues, because we have worked together with the IJB members. We have things such as development sessions outwith the IJB when there are particular pieces of work that people feel there might be problems with. The IJB will run development sessions so that the chief officer can work through issues in a non-committee setting where folk can ask all their questions and get assurance. Then, when we come together, it is more likely that we will get a joint response from people, because they have had the opportunity to be involved in the discussion.

We move on to questions from Carol Mochan on financial integration.

I think that everyone would recognise that, over the time in which there has been integration, financial integration has been one of the key factors that have been difficult. Will each of the panel members discuss why, with hindsight, they think that that has been the case? Realistically, with the Government saying that financial strains are ahead, how likely is it that better financial integration can be achieved? How can we get the organisations to work together on the budgeting?

The financial planning and budgeting in our integration arrangements is complex. As chief officers, we try very hard—I will speak from my own personal experience—to work in parallel with the financial planning arrangements and timelines of both our partner organisations. However, our NHS board and our council work quite differently in their budget setting, of course, and there are different statutory requirements on them.

In my experience, the best way through that is with solid tripartite arrangements and relationships between IJB officers, me and my chief finance officer, and the directors of finance in the council and the NHS board. We have monthly meetings in which we are able to air all our issues, work on the basis of no surprises, and support the robust discussions that we need to have as an IJB and the influence that we must try to bring to bear on our partner organisations in respect of allocations that we think are fair.

Our biggest challenge in Edinburgh is the structural deficit. When the board was set up, there was a £25 million gap, which we have never managed to repair. Therefore, we have significant year-on-year savings to achieve at the same time as we try to develop and sustain services. Some very difficult decisions have to be made. That requires the IJB members to work hard together with us as officers in identifying savings programmes that can be delivered without undermining our ultimate strategic direction and that do not cause us to reduce performance beyond an acceptable level. That is very challenging.

One issue, of course, is that the landscape is very challenging for our councils and our health boards, as well. We are all in the same game. That is why it is really important that we plan together.

On the future position, again it comes down to streamlining, looking at the arrangements that we have in place, and working through things. If we really want to create agility of services close to people to achieve the outcomes that we are trying to achieve, how can we reduce the bureaucracy and the time that is spent on budget setting in the new organisations? Derek Feeley referred to direct budgets to the new organisations as one way of doing that. I expect that that will be being explored in the discussions about the NCS now.

Will one of the panel members from one of the other IJBs contribute a wee bit to the discussion?

No one has asked to come in, but does anyone want to do that? Maybe we can go to Stephen Brown.

I agree entirely with what Judith Proctor has already outlined. It is inevitable that there are always tensions in the lead-up to every financial settlement and into the new financial year. As members can well imagine, those tensions are heightened with the pressures on council budgets and NHS budgets and, as a result, pressures on the IJBs.

In my experience as chief officer of two IJBs and from working in two different areas, I recognise that relationships are the key element of all of that. As Judith Proctor has outlined, we must ensure that we regularly meet finance colleagues across the piece, including the chief finance officer of the IJB and council and NHS colleagues. Where there are tensions and people’s priorities are maybe not always aligned, council plans, community planning partnership plans, clinical strategies, IJB strategic plans, all the work that goes into creating those at the local level, and making sure that they are as aligned as they can be help in making decisions around budgets, priorities and so on.

I recognise that I have maybe been fortunate in my own experience, but things can get very tense for colleagues across the country. There is no doubt that one way of sorting that would be through the NCS at the local level being directly funded in a way that would eradicate some of the tensions and discussions that inevitably take place every year, rather than relying on the contributions of the delegated services from the councils and respective NHS boards.

Does any particular area cause the most tension, or do things depend on what you are discussing at the time?

Various things can do that. As members can imagine, when councils, for example, look across the piece at where their opportunities are for managing within their financial envelope, they make decisions across not only health and social care priorities but across development, infrastructure, economic development, housing and education. All those things are in the mix. The council may well have a view that is different from those of the NHS board or the IJB about where some of the priorities may lie. It is about trying to navigate our way through the challenges relating to what the resultant and expected savings might be in how councils and NHS boards prioritise in the settlements.

For the past couple of years, most of the settlements have been fairly straightforward in relation to—[Inaudible.]—are passed through from councils and the NHS when they receive their settlements. There has been clear direction, which has alleviated some of the challenge in the system. However, that is probably not a sustainable approach.

I do not know whether that helps to answer the question in a bit more detail.

We have gone over time, but I am conscious of the fact that Allen Stevenson and Vicky Irons would like to come in. I ask them to be brief, please. It has been a very busy morning, and we still have quite a lot on our agenda in private session.

11:45  

I will be brief.

Part of the frustration in relation to our response on the national care service is that we in Inverclyde are very fortunate in having NHS Greater Glasgow and Clyde and Inverclyde Council as very supportive partners. The council has continued to invest in services for us for many years, even when things have been tight. We have a new £7.4 million learning disability hub, which was signed off last year. Sometimes it feels as if we are trying to sort something that is not necessarily broken.

We are fortunate in Inverclyde in that we have had two partners that have been very sympathetic, that have worked with us, and that have a history of working with us to invest in services. We appreciate that things may be a bit more challenging in other areas, but there is a sense of frustration because so much good work is going on across the partnership in Inverclyde on finances, which are potentially very difficult.

That gives members the perspective that good things are happening, and there are good conversations between the appropriate officers, chief officers, chief financial officers and chief social work officers. We should not forget that as we think about how we can move forward and make things better across the piece.

I, too, will be brief.

I want to say something that was noted throughout the Derek Feeley report. The original intent that underpinned the integration legislation was that the resources would lose their identity, and we would be able to deploy a completely integrated financial resource in line with our strategic plans. Largely, however, that has not happened throughout the development of the integration authorities. The main reason for that is that the resources that are delegated to us come in the form of our workforce. That makes up the major component of our financial resource because we do not, of course, have delegated responsibility for capital assets or other financial issues.

A lot of restriction comes with that. If there is anything that we need to learn from that to roll into new arrangements, it is that we should try to establish a new authority or a new health and social care board that has the full capacity to distribute the financial resources and to influence the human resources that form part of the organisation in an equal way.

We have a reservation. There is a suggestion that the new boards will have employing rights and controls over one part of the workforce and not another part of it. Quite a lot of restriction will come with that when it comes to managing the financial resource and strategic planning.

I thank our four panel members for their time.

In our next meeting, the committee will begin its scrutiny of the National Care Service (Scotland) Bill.

That concludes the public part of our meeting.

11:47 Meeting continued in private until 13:00.