Published 3 October 2019 SP Paper 595 10th Report, 2019 (Session 5) Health and Sport Committee Comataidh Slàinte is Spòrs Looking ahead to the Scottish Government - Health Budget 2020-21: When is Hospital bad for your health? Published in Scotland by the Scottish Parliamentary Corporate Body. All documents are available on the Scottish For information on the Scottish Parliament contact Parliament website at: Public Information on: http://www.parliament.scot/abouttheparliament/ Telephone: 0131 348 5000 91279.aspx Textphone: 0800 092 7100 Email: [email protected] © Parliamentary copyright. Scottish Parliament Corporate Body The Scottish Parliament's copyright policy can be found on the website — www.parliament.scot Health and Sport Committee Looking ahead to the Scottish Government - Health Budget 2020-21: When is Hospital bad for your health?, 10th Report, 2019 (Session 5) Contents Introduction ____________________________________________________________1 Budget setting process___________________________________________________3 Link between budgets and outcomes _______________________________________5 Delayed discharge_______________________________________________________7 Reasons for delayed discharge ___________________________________________ 11 Cost of delayed discharge _______________________________________________12 Intermediate care_______________________________________________________13 Unplanned acute bed days _______________________________________________14 Housing adaptations ____________________________________________________19 Changing perceptions___________________________________________________21 Transformation of services_______________________________________________22 Set aside budget _______________________________________________________25 Leadership and cultural change __________________________________________30 Scrutiny of NHS boards _________________________________________________30 Sharing good practice __________________________________________________33 Conclusions___________________________________________________________35 Annexe A _____________________________________________________________36 Extracts from the Minutes of the Health and Sport Committee Meetings ___________36 Annexe B _____________________________________________________________37 Written evidence ______________________________________________________37 Supplementary written evidence __________________________________________37 Official Reports of meetings of the Health and Sport Committee _________________38 Health and Sport Committee Looking ahead to the Scottish Government - Health Budget 2020-21: When is Hospital bad for your health?, 10th Report, 2019 (Session 5) Health and Sport Committee To consider and report on matters falling within the responsibility of the Cabinet Secretary for Health and Sport. http://www.scottish.parliament.uk/parliamentarybusiness/CurrentCommittees/ health-committee.aspx [email protected] 0131 348 5524 Health and Sport Committee Looking ahead to the Scottish Government - Health Budget 2020-21: When is Hospital bad for your health?, 10th Report, 2019 (Session 5) Committee Membership Convener Deputy Convener Lewis Macdonald Emma Harper Scottish Labour Scottish National Party George Adam Miles Briggs Scottish National Party Scottish Conservative and Unionist Party Alex Cole-Hamilton David Stewart Scottish Liberal Scottish Labour Democrats David Torrance Sandra White Scottish National Party Scottish National Party Brian Whittle Scottish Conservative and Unionist Party Health and Sport Committee Looking ahead to the Scottish Government - Health Budget 2020-21: When is Hospital bad for your health?, 10th Report, 2019 (Session 5) Introduction 1. At the start of the Parliamentary Session, the Committee agreed to adopt a full year budgeting approach, building an element of budget scrutiny into all aspects of its work, as detailed in its 2nd report, 2016 (Session 5) Health and Social Care Integration Budgets . 2. In 2018, the Committee undertook pre-budget scrutiny in May/June and published a report in October 2018 aimed to feed into the budget process, rather than responding to the Budget when published. The Scottish Government provided a detailed response shortly after the Budget was published, in December 2018. As such, the Budget Process Review Group recommendations were reflected in the Committee’s approach. 3. In recent years, the focus of the Committee’s budget scrutiny has been on Integration Authorities (IAs). The Public Bodies (Joint Working) (Scotland) Act 2014 required local authorities and NHS boards to form partnerships called integration authorities by 1 April 2016. The aim of the policy was - To improve the quality and consistency of services for patients, carers, service users and their families; to provide seamless, joined up quality health and social care services in order to care for people in their homes or a homely setting where it is safe to do so; and to ensure resources are used effectively and efficiently to deliver services that meet the increasing number of people with longer term and often complex needs, many of whom are older. 1 4. IA budgets totalled £8.9 billion in 2018-19, of which £6.3 billion was delegated from the NHS budget. IAs therefore direct almost half of the total health and sport budget. The Committee agreed a continued focus on IA budgets in the pre-budget scrutiny for 2020-21, particularly in light of the ongoing concerns raised by the Committee in respect of the progress of integration. 5. The 2018 Audit Scotland report identified that Integration Authorities (IAs) are “operating in an extremely challenging environment and there is much more to be done”. It made a number of recommendations in six areas - • Commitment to collaborative leadership and building relationships; • Effective strategic planning for improvement; • Integrated finances and financial planning; • Agreed governance and accountability arrangements; • Ability and willingness to share information; and • Meaningful and sustained engagement. 2 The Ministerial Strategic Group for Health and Community Care (MSG), Review of Progress with Integration of Health and Social Care - Final Report, agreed with the Audit Scotland recommendations and comments that the recommendations should be acted upon in full by the statutory health and social care partners in Scotland. It 1 Health and Sport Committee Looking ahead to the Scottish Government - Health Budget 2020-21: When is Hospital bad for your health?, 10th Report, 2019 (Session 5) also acknowledges that “the pace and effectiveness of integration need to increase.” 3 6. To inform our work, we held informal sessions, in private, with Scottish Government officials and Audit Scotland. We also invited selected Integration Authority chief officers to give evidence to the Committee on 21 May and 4 June 2019. These meetings focussed on budget setting challenges, reporting against outcomes, operation of the set aside budget, performance data specifically in respect of delayed discharge and unscheduled care hospital admissions. 7. The timing of this report, in advance of the publication of the Scottish Government’s budget, is to provide the Scottish Government with time to consider the implementation of our recommendations in its forthcoming budget 2020-21. 2 Health and Sport Committee Looking ahead to the Scottish Government - Health Budget 2020-21: When is Hospital bad for your health?, 10th Report, 2019 (Session 5) Budget setting process 8. Integration authorities direct health board and local authority funding. IA budgets consist of two elements, which may vary in size and scope depending on the functions delegated to the integration authorityi - • Health care (including primary and community health, as well as relevant hospital services); and • Social care. 9. To set IA budgets, the integration authority, NHS and local authority partners work together to determine how much is required to deliver the delegated services and how much each partner will contribute to these identified costs. This budget is then directed to the integration authority. 4 10. An issue the Committee has pursued vigorously over recent years is access to comprehensive and timely information on IA budgets. In response to Committee recommendations, the Scottish Government is now providing quarterly financial updates. While this is welcome, there is a time lag in reporting. This means that in May/June 2019, when the Committee was undertaking pre-budget scrutiny, no information was available on the budgets agreed for 2019/20. Through the normal reporting timescales, this information would not be available until September – six months into the financial year to which they relate. Therefore, whilst some progress has been made and welcomed, there remains a considerable delay in accessing information on budgets agreed at the start of the financial year. 11. We have previously been informed the reason for the delay in IAs agreeing budgets was due to the difference in financial planning timeframes in local authorities and health boards which has impacted on the agreement of budgets in advance of the start of the financial year. In response to this the MSG report recommended budgets be agreed by the end of March 2019 and, in response to a question in the Chamber, the Cabinet Secretary indicated she expected this timetable to be met. 5 It is understood that budgets are now being agreed more timeously. However, it remains challenging to access this information on a consistent