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SP Paper 555
FI/S3/11/R1

1st Report, 2011 (Session 3)

Report on preventative spending

CONTENTS

Remit and membership

Report
Introduction
Negative social outcomes
Preventative spending
Early years intervention

The benefits of early intervention

The Early Years Framework

Central and local government relationships
Measuring progress
When to intervene
Universal or targeted support
Nottingham and Glasgow

Preventative spending on health and social care

Health and the early years
Other health-related preventative spending
Health and social care
Barriers to change

Collaborative working

Integrated resource framework/ Change Fund
Barriers to preventative spending

Structure of the public sector
Conclusions

Annexe A – Extract from the Minutes of the Finance Committee

ANNEXE B – ORAL EVIDENCE AND ASSOCIATED WRITTEN EVIDENCE

Please note that all of the material in annexes B and C is published electronically only, and can be accessed via the Finance Committee’s webpages, at: http://www.scottish.parliament.uk/s3/committees/finance/inquiries/preventative.htm

20th Meeting, 2010 (Session 3), Tuesday 21 September 2010

WRITTEN EVIDENCE

Alan Sinclair, Centre for Confidence
Professor Edward Melhuish, University of London
National Endownment for Science, Technology and the Arts
Royal Society of Edinburgh

ORAL EVIDENCE

Alan Sinclair, Centre for Confidence
Sir John Arbuthnott, Royal Society of Edinburgh
Dr Michael Harris, National Endowment for Science, Technology and the Arts
Professor Edward Melhuish, University of London

SUPPLEMENTARY WRITTEN EVIDENCE

National Endownment for Science, Technology and the Arts

21st Meeting, 2010 (Session 3), Tuesday 5 October 2010

WRITTEN EVIDENCE

Housing Support Enabling Unit
Independent Living in Scotland Project, Inclusion Scotland and the Scottish
Disability Equality Forum
Scottish Federation of Housing Associations

ORAL EVIDENCE

Yvette Burgess, Director, Housing Support Enabling Unit
David Ogilvie, Policy and Strategy Manager, Scottish Federation of Housing Associations
Pam Duncan, Policy Officer, Independent Living in Scotland Project.
Jim Elder Woodward, Convener, Independent Living in Scotland Project.

SUPPLEMENTARY WRITTEN EVIDENCE

Scottish Federation of Housing Associations

22nd Meeting, 2010 (Session 3), Tuesday 26 October 2010

WRITTEN EVIDENCE

Eighteen and Under
Includem
Scottish Violence Reduction Unit
Zero Tolerance
Association of Directors of Social Work
Community Care Providers Scotland
Dr Philip Wilson, University of Glasgow
Royal College of Nursing Scotland
Dr Harry Burns, Chief Medical Officer, Scottish Government
Scottish Government officials

ORAL EVIDENCE

Detective Chief Superintendent John Coarnochan, Head, Scottish Violence Reduction Unit
Karyn McCluskey, Deputy Head, Scottish Violence Reduction Unit
Laurie Matthew, Co-ordinator, Eighteen and Under
Jenny Kemp, Prevention Network Officer, Zero Tolerence
Angela Morgan, Chief Executive, Includem
Mike Brown, Convener, Association of Directors of Social Work Resources Committee
Nigel Henderson, Convener, Community Care Providers Scotland
Dr Harry Burns, Chief Medical Officer, Scottish Government
Rachel Cackett, Policy Adviser, Royal College of Nursing Scotland
Dr Philip Wilson, Senior Lecturer in infant mental health, University of Glasgow

23rd Meeting, 2010 (Session 3), Tuesday 2 November 2010

WRITTEN EVIDENCE

Action for Children
Aberlour Childcare Trust
Barnardo’s Scotland
Children 1st
Children in Scotland
Oxfam
Save the Children
Scottish Collaboration for Public Health Research and Policy
Dr Suzanne Zeedyk

ORAL EVIDENCE

Anne Houston, Chief Executive, Children 1st
Dr Rosemary Geddes, Career Development Fellow, Scottish Collaboration for Public Health Research and Policy
Robert McGeachy, Policy and Public Affairs Manager, Action for Children Scotland
Jim Boyle, Programme Manager, UK Poverty Programme, Oxfam GB
Douglas Hamilton, Head, Save the Childen in Scotland
Dr Suzanne Zeedyk, Senior Lecturer, School of Psychology, University of Dundee
Dr Susan Stewart, Manager, Scottish Child and Family Assessment Centre, Aberlour Childcare Trust
Simon Watson, Head of Developments, Barnardo's Scotland
Dr Jonathan Sher, Director of Research, Policy and Programmes, Children in Scotland

SUPPLEMENTARY WRITTEN EVIDENCE

Barnardo’s Scotland
Children in Scotland – 1
Children in Scotland – 2

24th Meeting, 2010 (Session 3), Tuesday 9 November 2010

WRITTEN EVIDENCE

The Wave Trust
Susan Deacon, Early Years Champion for the Scottish Government

ORAL EVIDENCE

George Hosking, Chief Executive and Research Director, WAVE Trust
Susan Deacon, Early Years' Champion for the Scottish Government

25th Meeting, 2010 (Session 3), Tuesday 16 November 2010

WRITTEN EVIDENCE

Nottingham City Council
Glasgow City Council
COSLA
Scottish Council for Voluntary Organisations

ORAL EVIDENCE

Ian Curryer, Corporate Director for Children and Families and Lead Officer for Early Intervention, Nottingham City Council
David Williams, Assistant Director of Social Care Services, Glasgow City Council
Maureen McKenna, Executive Director of Education, Glasgow City Council
Ron Culley, Team Leader, Health and Social Care Team, COSLA
Sarah Fortune, Policy Mananger for Finance, COSLA
Robert Nicol, Team Leader, Children and Young People, COSLA
Ruchir Shah, Head of Policy and Research Department, Scottish Council for Voluntary Organisations.

28th Meeting, 2010 (Session 3), Tuesday 30 November 2010

WRITTEN EVIDENCE

Scottish Government

ORAL EVIDENCE

John Swinney MSP, Cabinet Secretary for Finance and Sustainable Growth
Kay Barton, Health Improvement and Health Inequalities Policy Branch, Scottish Government
Jim Stephen, Head of Early Education and Childcare Branch, Scottish Government

ANNEXE C – OTHER WRITTEN EVIDENCE

Age Scotland
ASH Scotland
ASSIST (Advocacy, Safety, Support, Information, Services Together)
Centre for Research on Families and Relationships
Chief Fire Officers Association Scotland
Children are Unbeatable
Church of Scotland
CrossReach
Dr John Sturrock QC, Chief Executive, and Charlie Woods, Associate, on behalf of Core Solutions Group
Edinburgh Community Health Partnership
Equality and Human Rights Commission
Friends of the Earth
Glasgow Violence Against Women Partnership
Joseph Rowntree Foundation
Mindspace
Neighbourhood Networks
NHS Education for Scotland
NHS Education for Scotland Psychology
NHS Greater Glasgow and Clyde
NHS Lothian
Princess Royal Trust for Carers
Public Commercial Services Union (PCS) Scotland
Quarriers
Scotland's Futures Forum
Scottish Council of Jewish Communities
Scottish Social Enterprise Coalition
Scottish Sports Association
Serenity Café Project
Sportscotland
The Prince’s Trust
Transform Scotland
Unison
Voluntary Arts Scotland
Volunteer Development Scotland
WRVS
YMCA Scotland
Youthlink Scotland

Remit and membership

Remit:

1. The remit of the Finance Committee is to consider and report on-

(a) any report or other document laid before the Parliament by members of the Scottish Executive containing proposals for, or budgets of, public expenditure or proposals for the making of a tax-varying resolution, taking into account any report or recommendations concerning such documents made to them by any other committee with power to consider such documents or any part of them;

(b) any report made by a committee setting out proposals concerning public expenditure;

(c) Budget Bills; and

(d) any other matter relating to or affecting the expenditure of the Scottish Administration or other expenditure payable out of the Scottish Consolidated Fund.

2. The Committee may also consider and, where it sees fit, report to the Parliament on the timetable for the Stages of Budget Bills and on the handling of financial business.

3. In these Rules, "public expenditure" means expenditure of the Scottish Administration, other expenditure payable out of the Scottish Consolidated Fund and any other expenditure met out of taxes, charges and other public revenue.

(Standing Orders of the Scottish Parliament, Rule 6.6)

Membership:

Derek Brownlee
Malcolm Chisholm
Linda Fabiani
Joe Fitzpatrick
Tom McCabe (Deputy Convener)
Jeremy Purvis
Andrew Welsh (Convener)
David Whitton

Committee Clerking Team:

Clerk to the Committee
Jim Johnston

Senior Assistant Clerk
Terry Shevlin

Assistant Clerk
Allan Campbell

Committee Assistant
Jennifer Bell

Report on preventative spending

The Committee reports to the Parliament as follows—

introduction

1. In June 2010 the Finance Committee published its report on the Budget Strategy Phase of the 2011-12 budget process. The report examined how the public sector was preparing for a period of tightening public expenditure and signalled that the Committee was likely to undertake a more significant piece of work on longer-term approaches to public spending, including issues such as preventative spending. The Committee subsequently decided to undertake an inquiry into preventative spending at its meeting on 15 June 2010 and agreed the following remit—

To consider and report on how public spending can best be focussed over the longer term on trying to prevent, rather than deal with, negative social outcomes.

2. From the outset, the Committee makes clear its strong support for the concept of preventative spending, particularly on the early years, and its belief that more effective use of preventative spending has the potential to deliver great social and financial benefits to Scotland. The Committee welcomes the Scottish Government’s shared commitment to this agenda, as espoused by the Cabinet Secretary for Finance and Sustainable Growth who said that “the whole concept of preventative intervention lies at the heart of the Government's policy interventions”.1

3. The Committee appreciates that there are significant obstacles to be overcome if the full potential benefits of preventative spending are to be realised.  This report examines these barriers and also explains how the Finance Committee  intends to maintain its scrutiny of this policy area over the longer term and how other parliamentary committees could assist in this process.

4. The Committee records its gratitude to all those who provided written and oral evidence to its inquiry. The contributions made by these experts have greatly informed the findings of this report. 66 responses were submitted to the Committee’s call for written evidence, while the Committee took oral evidence at seven meetings. Scotland’s Futures Forum also held a seminar on preventative spending for the Committee, while SPICe provided a series of research briefings throughout the inquiry.

Negative social outcomes

5. The Committee’s inquiry examined how preventative spending could help to prevent negative social outcomes. The Committee did not define “negative social outcomes” in its call for written evidence as it wanted to allow respondents to set out what they considered to be the most relevant issues. The examples provided demonstrate the enormous scale of the challenge facing the public sector as there are some extremely severe and deeply entrenched social problems in Scotland in terms of violence, health, poverty, alcohol and drug use, etc. Aberlour Childcare Trust’s written evidence highlighted the particularly poor outcomes for children in Scotland who have been in care—

  • over one quarter of inmates in Scotland’s prisons have been in care;

  • over 20% of Scotland’s 20,000 16-19 year olds currently outside of education or employment are recent care leavers;

  • only 3% of care leavers go on to gain any higher education qualification.2

6. Some outcomes in Scotland are recognised to be of an internationally poor standard. For example, in oral evidence the Wave Trust charity referred to studies showing that Scotland performed badly in terms of drunkenness, obesity, teenage pregnancy and violent crime compared with other countries.3

7. Considering the scale of the social problems confronting Scotland it is not surprising to note that they impose immense pressures on the public purse. For example, the Violence Reduction Unit said that while it is impossible to give an accurate figure for how much violence costs Scotland annually, estimates suggest that the cost to the economy as a whole may be around £3 billion.4 Written evidence from the Scottish Government’s chief medical officer stated that in 2007-08, smoking related disease cost the NHS Scotland over £336m, while obesity related illness cost £191 million.5 At a UK level, a joint report by Action for Children and the New Economics Foundation claimed that the economic cost of—

“continuing to address current levels of social problems will amount to almost £4 trillion over a 20 year period. This includes addressing problems such as crime, mental ill health, family breakdown, drug abuse and obesity.”6

8. To put these figures into context, Scotland’s Futures Forum cited evidence claiming that an estimated 40 – 45% of public spending is negative i.e. short-term spending aimed at addressing social problems.7

9. Perhaps in recognition of the scale of the challenge, some of those who provided evidence were candid in their view that previous approaches to social problems have not always worked.

10. Susan Deacon was recently appointed by the Scottish Government to lead a national dialogue on how to improve children's early years. She is also a former Scottish Executive health minister. Her written evidence to the Committee set out what she considered to be the prevailing political approach to problem solving—

“We can observe a pattern which goes something like this. We identify a problem (e.g. childhood obesity, youth disorder, poor literacy) and look to Government to fix it. Typically, Government accepts that challenge; puts in place a process; delivers a strategy; translates that into policy and an (often over-engineered) implementation process and, two or three years on, the problem (not surprisingly) isn’t ‘fixed’. This then becomes portrayed as a failure of the political leadership of the day so, we change Ministers or Government and start the same process all over again.”8

11. Barnardo’s pointed out that the failure to eradicate Scotland’s social problems is not simply down to a lack of resources—

“… we have doubled the amount of money that we spend on welfare in the past 10 years yet we still have the same reoffending rate among young people who come out of prison, little movement on child poverty, the same level of educational attainment for care leavers and increased problems with alcohol and substance misuse. We have doubled the amount of money that we spend, but we have barely put a dent in the problems.”9

12. Several witnesses considered that the failure of previous approaches demonstrated the need for a radically new approach to public spending. The Committee considers that a striking feature of this inquiry is that witnesses have unanimously supported the concept of preventative spending as perhaps the primary means by which some of these social problems could, at best, be eliminated or, more realistically, be ameliorated. Despite this strength of feeling however, there is also a widespread view that the full potential of preventative spending is not being realised. The challenge for both the Scottish Parliament and the Scottish Government is to identify the barriers that exist and how they could be overcome.

preventative spending

13. Having outlined some of the social problems facing Scotland, the remainder of this report considers the part that preventative spending could play in helping to resolve them.

14. The Committee recognises that preventative spending is by no means a novel or particularly complex idea. For example, a participant at the Futures Forum seminar highlighted the programmes of mass vaccination against polio and tuberculosis as well known and highly successful examples of preventative investments that have delivered considerable long term benefits.

15. In its call for written evidence, the Committee did not define the term “preventative spending”. While certain submissions did provide definitions, usually from a health perspective, there is not an established definition in use by relevant bodies that would capture all the examples that were provided to the Committee throughout its inquiry. This report does not therefore specify what is meant by “preventative spending” although it is useful to point out that not only is there spending that seeks to prevent negative social outcomes arising, but also spending that attempts to eliminate or lessen the impact of negative social outcomes once they have arisen.

16. The written evidence provided to the Committee was extremely wide ranging in terms of setting out areas where a preventative approach could be adopted. The submissions included major areas of policy such as the early years, climate change and health and social care, as well as more specific areas such as mediation, fire prevention and smoking.

17. The Scottish Government’s written evidence was the widest in scope, providing examples covering health, early years and poverty, the economy, road safety, older people and homelessness amongst others. The submission stated that—

“Preventative action is integral to the approach to government in Scotland and delivering the outcomes set out in the National Performance Framework.”10

18. Given the sheer breadth of issues raised in the written evidence and the relatively limited timescale over which the inquiry was conducted, the Committee agreed to focus its oral evidence-taking on those areas that had arisen most frequently in the written evidence. In practice this meant that the Committee spent the bulk of its time considering preventative spending from an early years perspective. The other main area that the Committee considered was preventative spending in terms of health and social care. The Committee also held dedicated evidence sessions on housing and violence, although many of the points from these discussions have been subsumed into the discussions on the early years and health.

19. The following sections discuss preventative spending specifically from an early years perspective and then from a health and social care perspective. This is followed by a discussion of the generic barriers that exist to successful preventative spending.

early years intervention

20. The Committee considers that the most compelling evidence to have emerged from this inquiry relates to the benefits that could be derived from more effective spending on early intervention. In the simplest terms early interventions aim to provide support for children, including through their families, at as early a stage in their lives as possible, including pre-birth. Such interventions, which can be provided by a variety of bodies, can significantly help to prevent or reduce the likelihood of children developing future social problems that may otherwise have necessitated an intervention by the state. The approach has the potential to save relevant public bodies significant sums of money as the number of interventions that they have to provide is thereby significantly reduced. While the Committee is obviously interested in the potential of more cost effective approaches to public spending, several witnesses have stressed that early intervention should not be viewed simply as a means of saving money. It should also be seen as an approach that will deliver wider benefits to children, their families and society as a whole.

The benefits of early intervention

21. Some of the evidence presented to the Committee was notably passionate and powerful in terms of setting out the very wide benefits that early intervention could deliver. For example, Dr Suzanne Zeedyk, a Senior Lecturer at the University of Dundee, said—

“The reason why early years services work is that they influence children's brain development. The neuroscience is now undebatable. Children's brains develop more quickly between birth—really conception—and the age of three than they ever will again. So we need to get the money into services and get support to families because, after that age, those brains are in place. If we delay, all that happens is we continue to spend our money in ways that are, frankly, dumb. We are wasting our money if we do not get it into early years services. In other words, early years services are not a luxury; they are essential if we are to do the things for Scotland that we want to do.”11

22. Alan Sinclair of the Centre for Confidence and Well-being claimed that—

“By investing in early years we have a route to ending or at least reducing a series of intractable problems: the long tail of school failure; health inequalities; alcohol and drug abuse; violence in our community and so many people being excluded from work.”12

23. The Wave Trust pointed out that an early years approach is not just good social policy but also good economics—

“Study after study … demonstrates that to invest money in prevention is simply the best economics and the best investment for national and local government … investment in the early years is the area in which you get by far the best economic return and the best impact on subsequent child outcomes.”13

24. It is also worth noting that the Scottish Parliament’s Education Committee published a report on Early Years in 2006 , which said—

“In ten years time, we want Scotland to have an early years sector that gives all children the best possible start in life, that values and develops them and is aspired to by the rest of the world. We challenge the Scottish Executive to show us how it will do that.”14

25. The Committee was provided with numerous specific examples of early interventions in the UK and abroad that had demonstrated success in preventing or lessening social problems and that had generated significant savings for the public purse in the process. This report obviously cannot describe in depth all the interventions that could be or that are being made in Scotland. Rather, the Committee’s intention is to inform decision makers and other interested parties of the benefits of early intervention, so that future public sector resources and activity can be skewed accordingly. The following list of interventions also gives a flavour of some of the broader debates around early years.

An intervention in one area can bring benefits in another

26. Professor Melhuish of the University of London gave the example of free pre-school education for three and four-year-olds as an intervention that boosts educational attainment and also changes children’s behavioural profile “in a way that is likely to have outcomes other than educational ones by, for example, increasing the likelihood of employment, reducing the likelihood of criminality and so on”.15

Interventions must be of a good standard

27. Professor Melhuish also made the simple but vital point that interventions must be of a good standard if they are to deliver benefits—

“high-quality child care in the early years fosters good language development and subsequently better social development, for example, whereas poor-quality child care can inhibit language development and other aspects of development.”16

Interventions can deliver short and long term returns

28. In terms of interventions that provide parenting support, Dr Zeedyk said that contrary to some views, early interventions can deliver short term as well as longer term returns.17

Rolling out successful programmes

29. Voluntary sector groups spelled out in considerable detail the preventative programmes that they undertake and the results that they deliver. However, the SCVO highlighted the need to “learn from, replicate and scale-up what works”,18 while Children 1st called for longer term, more sustainable funding for services to children and families, pointing out that this would “save the inevitable costs of recruitment, project start-up and ‘reinventing the wheel’, not to mention the benefits for children and families of longer term relationships with service staff”.19

Parents also need support

30. Oral evidence provided by Children in Scotland on foetal alcohol harm made several key points, namely that some early interventions will also have to be targeted at parents, that some very significant social problems are not currently attracting any funding, and that preventative work can often be delivered fairly easily.

31. Children in Scotland argued that there is a “cultural blind spot” in Scotland about foetal alcohol harm despite evidence to show that it is a leading cause of brain damage and developmental delay in children. Children in Scotland pointed out that much of the damage is done by women drinking alcohol when unaware that they were pregnant. The charity also said that money spent on “raising awareness about foetal alcohol harm, or to deal with it in any way, is remarkably close to zero”. It went on to suggest that existing peer health programmes on smoking and binge drinking could readily be broadened to include discussion of alcohol.20

We already know what works

32. The Scottish Government’s chief medical officer claimed that knowledge about which early interventions work already exists, it just has to be applied—

“If, as a system, we did consistently and at all times for every parent and each baby all the things that we know work, we would make a huge difference to the capacity of our kids to behave appropriately. We could do that within five years.”21

33. Other witnesses shared Dr Burns’ view that the benefits of early intervention are very clearly evidenced, well understood and that the focus should now be on effective implementation rather than on further discussion or evidence gathering. That said, the Scottish Government published helpful research during the course of the Committee’s inquiry which set out the potential benefits that could specifically be realised in Scotland from greater early years investment. Some of the main findings of the research are that—

  • “… savings from investing in earlyyears / early interventions from pre-birth to aged five suggest that there are potential net savings of up to £37.4k per annum per child in severe cases and of approximately £5.1k per annum for a child with moderate difficulties in the first five years of life.”

  • “… there are potential medium term net savings to the public sector, that can be realised 10 years after the earlyyears period … the total potential saving resulting from 100% effective interventions early in life (pre-birth to aged eight) could initially be up to £131m per annum, in the medium term.”

  • “… a failure to effectively intervene to address the complex needs of an individual in early childhood can result in a nine fold increase in direct public costs, when compared with an individual who accesses only universal services.”22

34. The summary above illustrates the sheer scale of evidence provided to the Committee. The Wave Trust alone provided a report containing forty seven examples of good international practice, while the Scottish Collaboration for Public Health Research and Policy (SCPHRP) submitted a report that evaluated 26 early childhood interventions.23

35. As well as evaluating interventions, the SCPHRP report contains a very detailed “Framework for action” setting out practically how interventions to assist early child development could actually be implemented. It also suggests that such a framework could be provided to local authorities to guide them in their actions. Witnesses also referred to a review of parenting programmes by the Children's Workforce Development Council in England, which identified around 10 programmes that, if implemented, would lead to improved parenting, outcomes, targeting, etc.

36. The Committee is persuaded by the evidence in support of early years intervention and therefore welcomes the work being undertaken by the Scottish Government through its Early Years Framework (EYF). The Committee notes that this builds upon the work of the previous administration in this area and welcomes the Scottish Government’s emphasis on a consensual approach. However, the Committee agrees with many of the witnesses that the focus for all decision makers, including the Scottish Parliament and the Scottish Government, should be on the more effective implementation of early years policy. The Committee recommends that both the Scottish Government and the Scottish Parliament take the lead in delivering a radical step change in the existing approach to early years intervention.

The Early Years Framework

37. The EYF was launched on 10 December 2008 “signifying the Scottish Government and COSLA's commitment to the earliest years of life being crucial to a child's development”. The Scottish Government’s website states that—

“It is increasingly evident that inequalities in health, education and employment opportunities are passed from one generation to another. The framework signals local and national government's joint commitment to break this cycle through prevention and early intervention and give every child in Scotland the best start in life.”24

38. The EYF covers the period from pre-conception to age 8 and sets out a list of priorities for action that need to be taken forward in partnership over the next 10 years. Other key points of the EYF are as follows—

  • it states that “Ultimately, improving outcomes will be the test of success”;

  • it acknowledges a need to identify early years indicators to demonstrate whether early years policies are supporting progress towards higher level national outcomes;

  • it notes that “There is no simple solution which allows resources to flow immediately and without consequence from acute services to pay for early intervention. It would be difficult if not impossible to come up with a solution to early intervention which would work in every local area. However, there is a broad agreement that, over a period of years, there is a strong case for a shift of resources into early years and early intervention”;

  • it states that “There are elements of the action plan that are deliverable through universal services at relatively modest cost, such as providing a greater focus within existing services on the development of parenting skills, developing broader roles in the workforce and enhancing the role of childcare, pre-school and school in family learning.”25

39. The Committee fully acknowledges that some of the measures set out in the EYF may take several years to materialise. However, the Committee is concerned that there was very little mention or discussion of the EYF in evidence. Considering the number of ideas proposed as to how early years policy could be improved, this suggests room for improvement in the current approach. In particular, there are four key issues that the Committee wishes to explore—

  • central and local government relationships;

  • measuring progress;

  • the best point to make early interventions; and

  • universal versus targeted services.

Central and local government relationships

40. Various witnesses expressed concern about whether the relationship between central and local government would be able to deliver effective implementation of the EYF, with some witnesses calling for greater direction from the centre. For example, the SCPHRP said—

“Detailed plans and strategies are required for the implementation of the Early Years Framework. If these are left entirely to the discretion of the local authorities, there is a distinct risk that many parts of Scotland will not achieve the Framework’s stated goals. Central guidance based on scientific evidence is required in programme design, implementation and evaluation.”26

41. The Violence Reduction Unit outlined a similar position—

“if the national Government thinks that far more should be done about early years, there might come a time when it needs to decide that X amount of expenditure must be ring fenced and that, instead of leaving it to 32 autonomous local authorities—as we did with the sure start money—it will have intrusive supervision of how that money is delivered. Sure start was a fabulous idea that received £65 million, but where is it now?”27

42. NHS Greater Glasgow and Clyde expressed particularly strong concerns about current efforts on the early years—

“The essence of our view is that there is not a coherent and comprehensive approach to early intervention despite the clear evidence base and the fact that a number of key national policy objectives espouse that approach. Although we have made good progress in developing and beginning to implement parenting strategies with the local authorities we work with we have not been able to make much progress on wider early intervention not least in the face of current resource pressures which are seeing councils reducing any discretionary expenditure which the limited early intervention type services often are.”28

43. Research commissioned by Scotland’s Commissioner for Children and Young People noted that a “coherent mandated approach to early childhood is needed” and that while the Scottish Government is responsible for national policy “it is no longer in a position to formulate local expectations”. It therefore recommended that “A stronger national implementation approach is needed to achieve the EYF aims”.29

44. Bearing in mind the comments made throughout the inquiry about the existing evidence base around early years, it is also worth recording the report’s findings on practitioners’ knowledge of the Scottish Government’s Early Years Framework. A survey of relevant professionals found that while agencies need to be convinced of the importance of investment in the early years, only 61% of respondents were “very familiar” or ‘familiar’ with the Early Years Framework. However, over 90% of respondents did report having some knowledge of the Framework.30

45. While there were calls for a more directive approach from the centre, other witnesses expressed caution about the state being too intrusive. For example, Susan Deacon said—

“Government – and other public bodies – have a key role to lead, support and invest but they can only do so much. In allowing too much responsibility to transfer to professionals, and to government and its agencies we have, inadvertently, disempowered people themselves and this has militated against the very behaviours – in the home, the family and in our communities – which are widely understood to be a vital part of our social and economic well being.”31

46. The Violence Reduction Unit also highlighted the need for communities to be better supported and  pointed out the potential for inefficiencies when the public sector takes over activity from voluntary groups—

“If a voluntary group that is doing a little bit of work in an area is given £1,000, we get back £10,000-worth of work. With all due respect to voluntary agencies, if £1,000 is given to a big agency, we get £250-worth of work back—the rest goes on rates, computers and employees.”32

The Scottish Government’s view

47. In oral evidence, the Cabinet Secretary for Finance and Sustainable Growth provided a brief overview of the split in responsibilities between central and local government in terms of early years policy—

“There are many examples of achievements at national level, such as the single outcome agreements, the family nurse partnership and the getting it right for every child programme, but the key to success on our early years and early intervention priorities is what happens at local level …”.33

48. In response to questions about whether the Scottish Government should provide a greater steer to local authorities, the Cabinet Secretary added—

“… although we do not have that directive relationship—I cannot sit here and say that the Government has directed 32 local authorities to do this and it will happen—we have made strenuous efforts, through the creation of a policy framework, to get local authorities and national Government working collaboratively and co-operatively in the same direction.”34

49. The Cabinet Secretary went on to stress that the Early Years Framework was not simply for local authorities and that the health service and the criminal justice service had substantial roles to play. Practically speaking, this approach is evident from the way in which the Scottish Government publicised the report on the economic benefits of early years investment that is referred to in paragraph 33. Four cabinet secretaries jointly wrote to chief executives and directors across health, education, social work and local government to publicise the study. The letter said—

“It will be for our local partners in Scotland's councils, NHS Boards and elsewhere to decide on how best to set their budgets to support local children, families and communities, but this report shows that savings are possible …”

“We commend this study to our partners in local government, the NHS, our justice system and more widely as a means of supporting local decision-making processes in these difficult times.”35

50. Although not speaking specifically within the context of early years, the Cabinet Secretary also said that—

“We would like to think that the community planning partnerships are essentially a model whereby we can build up collaborative activity at local level, because it is not just about how one budget holder spends their budget.”

“The community planning partnerships essentially encourage the process of reflecting on the best ways to deploy resources and spending.”36

51. The Committee emphasises that one of the key findings of this inquiry is the need to provide greater clarity on the roles of the various levels of government and various service providers in delivering the more effective implementation of early years policy. The Committee recognises the clearly defined and established relationship between the Scottish Government and local government but, given the strength of some of the evidence above, urges the Scottish Government to ensure that there is a meaningful joint commitment to early years and a greater synergy between the actions of central and local government. The Committee also invites the Scottish Government to consider whether there is a need to provide clearer guidance on how to deliver the aims of the EYF.

52. The Committee notes the Scottish Government’s claim that “There are many examples of achievements at national level” but that “the key to success … is what happens at local level”. The Committee invites the Scottish Government to set out its criteria on why some interventions are made at a national as opposed to a local level. It would also be helpful if the Scottish Government could say whether it has any current plans to roll out more interventions at a national level.

53. The Scottish Government is also invited to say how it could support the nationwide roll out of successful early interventions delivered by the voluntary sector, bearing in mind the concerns set out in paragraphs 45 and 46.

Measuring progress

54. The preceding section considered the roles of the Scottish Government and local government in delivering early years policy. This section looks at the equally crucial issue of how progress in this area can be measured.

55. The SCPHRP raised both these issues in oral evidence—

“... local authorities are finding things really difficult at the moment. They are allowed to choose any number of indicators from a menu of 52 and, indeed, can make up some of their own if they like. However … If everyone is measuring a lot of different things, you will not really know whether the country is moving forward, and local authorities need a simpler and very carefully chosen list of what has to be measured if they are going to be measuring anything at all. I realise that this is a terrible thing to say, but there should be more prescription.” 37

56. The Scottish Government’s national performance framework sets out various national outcomes, including “We have improved the life chances for children, young people and families at risk.” However, concerns about supporting indicators were expressed by Zero Tolerance and Children 1st which both pointed out that there was not a national indicator on child wellbeing. Zero Tolerance also said that there was no general indicator on child health or parenting and argued that “we have to look at the indicators, because they push community planning partnerships in their decision making”.38

57. In oral evidence, the Cabinet Secretary repeatedly stressed the importance of the Scottish Government’s national performance framework and its focus on outcomes. He said that the outcomes “give all players in the public sector clarity about what the Government is trying to achieve as a consequence of the way in which public expenditure is being deployed”. He also pointed out that—

“In some of the early years work, the fruits will take perhaps five years to come to the surface in the achievement of some of the more significant outcomes.”39

58. In response to questioning from the Committee, the Cabinet Secretary went on to suggest that there may be merit in establishing a numeric target for reducing the number of vulnerable children in Scotland.40

59. Given the discussion on outcomes and local authorities’ delivery role, the Committee asked what would happen if local authorities were not delivering successfully on the early years. The Cabinet Secretary responded that—

“If it does not all materialise, a question arises as a consequence for all of us as policy makers about the best way of delivering policy. The Government takes the view that local authorities are democratically elected organisations and we should respect their right and ability to implement the priorities.”41

60. The Committee notes the Cabinet Secretary’s view but, bearing in mind the comments in paragraph 51, invites the Scottish Government to further explain the measures it could take if local authorities were not contributing to the successful delivery of a national outcome.

61. The Committee notes from the Scottish Government’s written evidence that it intends to “work with a wide range of external partners to develop a new suite of early years data and indicators”. The Committee requests that the Scottish Government considers the evidence provided during this inquiry as part of that work. The Committee’s intention of holding a chamber event to discuss this report is set out later. The Committee considers that this event would be an ideal forum for participants to consider how data and indicators could be improved.

When to intervene

62. There is an ongoing theoretical and practical debate about when early interventions can most effectively be made. As noted, the Scottish Government’s EYF focuses on the 0-8 age group.

63. Perhaps the best known proponent of early intervention is Professor James Heckman of the University of Chicago. Unfortunately, the Committee was unable to take oral evidence from Professor Heckman but his work was cited several times in other evidence. In essence, the professor’s view was reported as being that the highest rate of return in education is to be derived from investment in the pre-birth to 3 age group, with pay-off from later educational investment being much lower. Various submissions pointed out that actual investment in the UK is often made in precisely the opposite way, i.e. far more is spent on tertiary education than on the earliest education.

64. Several other reports also stressed the importance of investing and providing support at as early an age as possible. For example, Dr. Zeedyk’s written submission cited evidence showing that “for every £1 that is invested between the years of birth – 3 years, somewhere between £3 and £14 pounds is saved later on”.42

65. A recent joint report by Graham Allen MP and Iain Duncan Smith MP emphasised that the 0-3 age range is the vital period when the right social and emotional inputs must be made. The report said that “A child’s development score at 22 months can serve as an accurate predictor of educational outcomes at 26 years” and warned that “the way children are treated in their first three years has a direct bearing on whether they grow up to be pro- or anti-social, adjusted or dysfunctional, peaceable or violent, healthy or unhealthy”. The report also pointed to recent scientific research on brain development which graphically illustrates the crucial importance of providing support in the earliest years.43

66. While sympathetic to such views, Professor Melhuish warned of an over-emphasis on 0-3 years, although his views are equally challenging for policy makers—

“It can be recognised that a three-year-old will have a very bad outcome, but it is not as if that outcome cannot be changed. It is still not too late to intervene for three-year-olds, but it is too late to intervene by the time those children are five.”44

67. Other contributors to the inquiry, particularly voluntary sector organisations, did provide examples of interventions made at a later age that had generated savings. Also, in the context of discussing the benefits of very early intervention, the charity Includem warned of the dangers of this approach leading to people “writing off” teenagers with severe social problems.45

68. The Committee notes that much of the evidence it received in relation to the early years emphasised that the earlier the intervention is made, the greater the return on the investment will be. In particular, investment in the pre-birth to 3 age group has been repeatedly highlighted as essential in delivering improvements to child health and well-being. However, the Committee also notes that the EYF covers the 0-8 age group. The Committee, therefore, invites the Scottish Government to consider whether, given the findings of this report, the EYF should be more focused on the 0-3 age group.

Universal or targeted support

69. Some witnesses made the point that a public and political consensus on, and commitment to, the early years can be a factor in securing better outcomes. The Netherlands and Scandinavian countries in particular have been held up as exemplars of excellence in child well being, at least in part because of their open commitment to the early years agenda. For example, Alan Sinclair stressed that the first objective of the Finnish Ministry of Social Affairs and Health is “problem prevention and the provision of support through sufficiently early action by primary services”.46 Professor Melhuish pointed out that UK Government spending on early years services is around 1 per cent of gross domestic product but 2.4 per cent in the Scandinavian countries. He also said that—

“Scandinavian countries … have said that certain early years services—such as universal child care from birth onwards as well as high-quality pre-school provision and family support—will be provided for the population. They regard those things as essential to a civilised society, in the same way that we view sending all our children to school.”47

70. The apparent success of Scandinavia and the Netherlands has also been attributed to their universalistic approach to early intervention, as opposed to the approach in the United Kingdom and the USA where interventions can be made on a more localised basis. For example, when asked to explain the differing success rates between Scandinavia/ the Netherlands and the United Kingdom/ USA, the Wave Trust said “We are talking about the difference between the benefits of a targeted approach and the benefits of a universal approach.”48 This view is shared by Alan Sinclair, who argued that—

“In the UK and USA we have exercises conducted with relatively small control and programme groups. In the Netherlands and the Nordics programmes to improve parenting and the life chances of babies have been introduced universally in great sweeps right across the country.”49

71. From a Scottish perspective, Dr Burns considered that

“In part, the reason for our failure has been that we have tried to target and identify individuals. We have said, "They need this, but they don't." … The system should be set up so that the default position is that every baby and every mother is supported; in that way, no one will fall through the cracks.”50

72. On a more specific basis, Dr Phil Wilson is a general practitioner and senior lecturer who has a specific interest in children’s language development. In oral evidence, he said that “If there is not a universal approach to identifying children with language delay … half of all the children affected will be missed”. He claimed that his colleagues from Scandinavia were “absolutely horrified that we have dismantled universal contacts with children in our health service” 51. He pointed out that a universal screening system means that people can go on to be offered the most appropriate services.

73. Dr Zeedyk pointed out that not making universal provision could have expensive longer-term implications—

“The trouble with not funding early years services is that families' need does not go away—it just goes unmet. When we take money out of universal services, we must put more money into targeted services to deal with the problems that universal services would have helped to prevent. The need for targeted services, which are more expensive, rises.”52

74. However, Professor Melhuish appeared to see the merit of a more targeted approach, particularly in times of budgetary reductions—

“I suggest that one needs to focus the high-quality early years services, to the fullest extent, in the 30 per cent most deprived areas in the country, where 70 per cent of poor children live, because that is where you will get the biggest bang for your buck. I suggest that in the remaining 70 per cent of areas, where 30 per cent of poor people live, the voluntary and private sectors should be involved by subcontracting from them provision of services for poor children in the more affluent areas.”53

75. The SCPHRP acknowledged the “huge returns” that could be made from investing in investing in vulnerable people, but pointed out that this group represents a small proportion of the population. While investments in “medium-risk or lower-risk proportions of the population” would generate smaller returns, this is a much larger group of the population. It advocated a combination of targeted and universal services, or "proportionate universalism", where “services are called universal, but there are different levels of support, depending on people's needs”.54

76. The Scottish Government has stated that preventative intervention lies at the heart of the Government's policy interventions”. Given the apparent success of the early years approach in the Netherlands and Scandinavia, the Committee invites the Scottish Government’s view on how much scope there is to adopt a similar approach in Scotland. In particular, the success of a universalistic approach to services has been highlighted and the Committee therefore calls on the Scottish Government to state whether it has any future plans to roll out preventative programmes on a universal basis.

Nottingham and Glasgow

77. The Committee was made aware from the written evidence that Nottingham has branded itself “Early intervention city” and decided to take oral evidence from a council official in order to understand what this approach actually meant in practice. Officials from Glasgow city council provided oral evidence at the same meeting, so that the Committee could understand how its approach to the early years compared. These evidence sessions were extremely helpful in demonstrating how two authorities with significant social problems are actually dealing with the types of challenges around early intervention that are discussed above.

Nottingham city council

78. Nottingham city council pointed out that having a strong local strategic partnership and governance framework was key to establishing itself as early intervention city. 16 early interventions have been established, many of which have been funded through collective, pooled funding of around £4 million. The city has a “zero-to-100 agenda”, meaning that it sees preventative work as being relevant for all age groups. That said, the majority of programmes are concentrated on the earlier years of children's lives.

79. Other relevant points from the evidence are that—

  • all preventative services have been re-engineered to provide an integrated service team;

  • the council did not specifically target families, rather it targeted areas of multiple deprivation;

  • delivery involves the health service, the community and voluntary sector, schools and the council itself;

  • although the council said that “professional barriers concerning who does what have been removed”, it stated separately that professional boundaries had been an issue.

80. The council acknowledged that trying to calculate how much the city might save from its approach has been very challenging although it was considered that savings could be “quite staggering”. The council pointed out that it could take 20 years to show the benefits of the early intervention work being undertaken.

81. A significant point was made about the actual “savings” that could be made—

“Quite a lot of our cost savings do not necessarily demonstrate as cashable savings that we can put in the bank; they are savings to the system or to services.”55

82. The Committee asked whether the council, in reconfiguring its work, learned from any good practice in Wales or Scotland. The council replied that—

“When we started the work, we found that there were not that many places in the United Kingdom that were doing substantial work in that regard. We decided to create an early intervention city, in which all the public sector organisations would invest in that. We found that to be unique.”56

Glasgow city council

83. Glasgow council’s written evidence described Glasgow’s Early Intervention programme as an investment of £2 million matched by resources by partners, which “brings together individual services integrated into a holistic, long-term approach across the city”.57

84. In oral evidence, the council explained that its programme involved both universal and targeted approaches. Its universal approach initially involved primary one schoolchildren and the intention is to expand this to early years centres, which cover the three-to-five age group. While the council agreed there was a need to involve the zero-to-three age group it acknowledged that “we have neither the resources nor access to all parents”.58

85. The Committee questioned officials about the effectiveness of partnership working in this area. Officials responded by saying that there was “enormous strength in the partnership working in Glasgow” and that other agencies “genuinely share” the need to do things completely differently.59

86. The Committee notes that council officials recognised the approach being undertaken in Nottingham is more advanced in certain areas—

“Nottingham appears to be several years further on from where we are. I am interested in how it is measuring the impact and outcomes; it is much more sharply focused than we are on those measurable outcomes.”60

87. Officials added that—

“We are at the early stages of implementation, and we need the results and early indications of how well we are doing before we can determine what to do in shifting resources. The intergenerational issue is that we are constantly responding to different pressures in terms of the deprivation in a city such as Glasgow and, to be very honest about it, I am not sure that we will ever tackle it absolutely.”61

88. As with the evidence provided by Nottingham, it is relevant to note that Glasgow found that “there is not a huge amount of evidence around” in relation to this area and that research work is ongoing in the council to establish relevant information.62

89. Current budgetary restraints make it even more important that early interventions by public bodies are the ones that will deliver the best possible economic and social returns. It is therefore imperative that delivery agencies are able to identify these interventions.

90. The statements from Glasgow city council about the lack of existing evidence raise serious questions about why such key delivery agents are not familiar with the available wealth of information on early intervention that is discussed throughout this report.

91. The Committee considers that there has to be greater dissemination of this evidence, both in order to inform public opinion and to provide an impetus to relevant bodies to improve their performance in this area. Indeed, one of the aims of this report is to improve the understanding of early intervention across the Parliament, the Government and the public sector. The Committee has already noted the Scottish Government’s emphasis on the role of local authorities in delivering early years policies. Given this and the Committee’s comments on Glasgow city council, the Committee would welcome the Scottish Government’s views on how it could help to raise awareness amongst local authorities of existing research on the early years.

preventative spending on HEALTH and social care

92. The previous section of this report has established that many early interventions could be delivered by health professionals or could deliver health-related benefits. This section considers this specific issue in more detail before going on to examine preventative spending from a broader health and social care perspective.

Health and the early years

93. Alan Sinclair’s written evidence suggested five key early interventions that could be made in Scotland, on the basis that similar policies have worked well elsewhere. His suggestions make clear that there would be a role for health professionals in delivering some of these interventions—

  • all teenage mothers to be supported by specially selected nurses from as early in their pregnancy as possible for a two year period.

  • mother and well-baby clinics, to provide immediate support to parents from birth to school age. Clinics would be staffed by doctors and nurses, who would concentrate on baby care, parenting, feeding, toileting and sleeping.63

94. Dr Phil Wilson’s submission said that—

“In the past ten years, a number of policy developments have progressively undermined their [general practitioners and health visitors] involvement with children to the extent that most Scottish children do not see either profession except on an opportunistic basis after the age of four months.”64

95. He went on to call for:

  • the reinstatement of statutory recognition of health visiting;

  • provision of trained health visitors at a minimum ratio of one health visitor to 250 preschool children;

  • increased funding for training new health visitors; and

  • specific expenditure to increase academic capacity in early childhood mental health.65

96. Children 1st agreed thatHealth visitors have always provided a very important protective and preventative service” but warned that—

“they are increasingly being targeted to where there are child protection issues or other major issues. So, something that was intended to be a universal service and which had a huge impact in protecting our children is now so targeted that those involved are unable to provide that universal service.”66

97. The Committee invites the Scottish Government’s view on whether there is a need for greater investment in health professionals such as health visitors in supporting early years programmes.

Other health-related preventative spending

98. In recent years spending on health has equated to around a third of the total devolved Scottish budget. It is it therefore fair to expect that this is an area where preventative work could generate significant savings.

99. Written evidence from the chief medical officer suggested that significant cost savings for NHS Scotland could be made by investing in preventative measures to reduce the future incidence of smoking, obesity and excessive alcohol consumption. However, the Association of Directors of Social Work (ADSW) cautioned that while initiatives on smoking and alcohol will make a difference, “the percentage that each of them saves to the public purse is not massive compared with the spend”.67 The Royal Society of Edinburgh (RSE) also warned in written evidence that while there may be significant pressures to prioritise preventative spending on expensive and high profile issues, such as obesity, “there may not yet be programmes proven to have an impact”. The submission added that “obesity in the population … has been the subject of many intervention initiatives with few perceivable results”.68

100. The RSE’s written evidence also suggested that more could be done in terms of the preventative agenda in health. Its submission noted that 4 per cent of the total health budget in England was preventative and that it expected the figure for Scotland to be “broadly similar”.69

Health and social care

101. The Committee acknowledges that preventative spending on health, including on the issues mentioned above, is an area that may well be worthy of an inquiry in its own right. In oral evidence, however, the Committee focussed primarily on the interface between health and social care and the potential savings that could be made in this area.

102. In simple terms, there is a debate about the extent to which people can be supported in their own homes, rather in far more expensive institutional settings such as care homes or hospitals. The following examples illustrate the type of issues and sums of money involved—

  • The chief medical officer’s submission contained forecasts showing that the cost of long-term care is estimated to rise to £15 billion by 2040 and suggested that relevant preventative activity in this area “could produce very substantial cost savings”.70

  • The National Endowment for Science, Technology and the Arts (NESTA) highlighted the specific example of spend on emergency admissions of older people to hospital, pointing out that this costs £1.4 billion each year in Scotland. It argued that this cost “could partly be avoided through more preventative interventions particularly at the local community level”.71

  • Age Scotland provided written evidence comparing the costs of a care home place, a Housing with Care tenancy and support in the community. While the evidence was limited to West Lothian, a care home place cost three times more than support in the community (£21,840 versus £7,121).72

Barriers to change

103. ADSW highlighted some of the broad difficulties involved in realising savings from the health and social care budgets—

“The great challenge to be faced in integrating resources is how to free the money that is locked up in acute care and hospital provision, which is a bit higher in Scotland than in England, so that it can be put into preventive services at a time when there will not be enough funds to continue with the current service model aims to meet the needs of people with high-level needs…

“If we want to invest more money in new initiatives or new areas … almost certainly we will have to take money away from somewhere else. We need a much better national process for making the major decisions about disinvestment, which could involve some of our major acute areas of spending.”73

104. COSLA echoed ADSW’s views about the challenges involved in investment and disinvestment in the health and social care sectors—

“Often local government argues that we need to invest more in building community capacity and keeping people independent in their homes through the provision of social care, low-level support and so on and that, in a period of diminishing public finance, that may require some disinvestment from elsewhere in the public sector. Rightly, NHS colleagues argue that that is all well and good, but a reduction in demand is required, so that fewer people turn up at accident and emergency departments. Those are terrifically difficult problems to address, because there is a chicken-and-egg element to them. We must invest in building social care capacity, but it requires a leap of faith to be persuaded that that will result in reduced pressure on the NHS.”74

105. COSLA also considered that demographic change, rather than budgetary pressures, was the main challenge—

“… when we look at the structural problems that we face around health and social care, we often examine the issue in budgetary terms, because it is well known that … there will be a diminishing amount of public finance available in Scotland. However, that is not the major problem. It is demographic change that will create the primary challenges in the health and social care networks throughout Scotland.”75

106. The SCVO questioned whether some of the challenges in this area had been over-stated—

“It strikes me that the cost of investing in preventative approaches is far smaller than the cost of investing in acute services. Sometimes I wonder about the problems to which [COSLA] refers, because preventative services produce such a huge impact for so little money.”76

107. The Committee also took evidence on preventative spending from a housing perspective, some of which is relevant to the current debate. For example, the Scottish Federation of Housing Association (SFHA) referred to the Supporting People programme, which was set up to help people live independently with appropriate housing support. The SFHA noted that—

“Various evaluation studies completed in different parts of the UK have shown that investing in housing support via the Supporting People programme delivered significant savings to other budgets including health, homelessness and residential care. Research carried out in Scotland (2007) demonstrated benefits of £441m, compared to an overall cost of housing support of £402m.”77

108. The SFHA further argued that the removal of the Supporting People ring fence has led to “an increasing tendency amongst local authorities to redirect resources away from low-level preventative support towards social care budgets, which provide more intensive (and costly) care packages”.78

109. Technical barriers to realising savings in this area were also discussed in evidence. For example, the Committee asked why the same questions are still being asked about health outcomes when the health budget has increased so dramatically over recent years. The chief medical officer said—

“The reason is that finance directors do not like programme budgets because they are ring fenced, which limits their capacity to make trade-offs across the whole of the system.”79

110. ADSW added—

“One of the reasons why health boards and councils do not carry out better financial planning is because they receive their yearly allocations at different times in the financial year. Unlike councils, the NHS often does not know its final budget until after the start of the financial year.”80

111. This section has set out the very clear benefits that could be derived from closer and more effective working in the areas of health and social care. It has also set out the very real difficulties in realising these benefits. The Committee notes that the main challenge as set out by ADSW and COSLA is, in essence, how to make the shift to investing in cheaper social care services by disinvesting in more expensive health services.

112. The following section of this report considers in more detail some of the challenges around collaborative working, which includes discussion of how the Scottish Government is responding to this challenge.

113. The Committee invites the Scottish Government to address the specific issues highlighted by the Chief Medical Officer and the ADSW in paragraphs 109 and 110.

Collaborative working

114. Having considered some of the barriers in health and social care, this section of the report considers the specific issue of collaborative working both from a health and social perspective, and then from a more general perspective. A recurring criticism made by witnesses is that relevant public sector bodies do not always work together on tackling Scotland’s social problems.

Collaboration in health and social care

115. The Independent Living in Scotland Project (ILSP) provided a simple example of the type of benefits that can be derived from collaborative working. It pointed out that a health authority in England had given £0.5m to a local roads department to salt the pathways in freezing conditions. This funding reduced the pressure on their A&E department, by cutting the number of presenting cases of sprains and broken limbs after falls.81

116. In oral evidence the ILSP argued that—

“There needs to be a more global look at how we provide services. We need to break down silos between housing and social work, housing and health and health and social work.”82

117. ADSW acknowledged that “there is a lot of territorialism in the public sector” but argued that—

“It is wrong to think that bureaucrats are somehow stopping preventative expenditure and are not being innovative and so on. Bureaucrats are delivering services according to the current statutory frameworks and sets of guidance that are laid down by Government in legislation and so on …

“If I thought that it was just a matter of knocking a few bureaucrats' heads together with my own, I would recommend that.”83

118. COSLA took a slightly different position, arguing that there was a need for public sector budget holders to think of the bigger picture—

“On occasion, challenges emerge from the sense of ownership of a particular budget. We are trying to move away from such arrangements. We want budgets to be thought of more as being part of the public purse than as belonging to the council or the NHS.”84

Broader concerns around collaboration

119. Some of the broader evidence around collaborative working in this inquiry has been particularly strident, especially on the question of professional territorialism and the defence of vested interests. For example, the Royal Society of Edinburgh stated that—

“Whether it is between police forces and local authorities, local authorities and health boards, the fire service and the police force, or early responding organisations and health organisations, we have all seen examples where interagency working has let us down.”85

120. These concerns were echoed by the Violence Reduction Unit—

“There is still a deal of territorialism between agencies, including the voluntary agencies, that is more corrosive and pernicious than that between the gangs in the east end of Glasgow.”86

121. The chief medical officer considered that some progress is being made in partnership working, but that far more is required—

“Within community planning partnerships and so on, there is evidence of interventions developing across agencies—local authorities, the health service and the third sector—very effectively. It is happening at different rates in different areas. In part, that is dependent on the complexity of the relationships in those areas, but it is happening. My point is that it needs to happen faster and needs to be built very firmly into the public sector ethos.”87

122. The need for more effective collaborative working and the greater use of shared services was also one of the main themes to have emerged in the Finance Committee’s report on the Budget Strategy Phase. In response to the Committee’s report the Cabinet Secretary stated that—

“We believe there are a number of opportunities to deliver further examples of collaboration and Ministers are actively involved in dialogue to secure these opportunities. We will elaborate as necessary our approach to driving forward more efficient public services, including through shared services, in the context of the draft Budget for 2011-12 this autumn.”88

Integrated resource framework/ Change Fund

123. The Scottish Government is piloting an integrated resource framework” (IRF) which can be seen as a means of addressing some of the issues outlined above. According to the ADSW, the IRF aims to establish “the greater integration of resource planning between the national health service, councils and the voluntary sector in terms of their social care provision”.89

124. The IRF is related to the “Change Fund”, details of which are set out in the Scottish Government’s 2011-12 Draft Budget—

“In recognition of the pressures on the health and social care system in a challenging fiscal climate, the Scottish Government has allocated £70 million in 2011-12 within the NHS Budget to a Change Fund for NHS Boards and partner local authorities to redesign services to support the delivery of new approaches to improved quality and outcomes. By ensuring that older people remain independent in their own homes, Health Boards and local authorities will be able to focus on reducing unnecessary hospital admissions and speeding discharge after a crisis. This will result in better outcomes for older people and ease the pressure on acute hospital provision.”90

125. In oral evidence, the Cabinet Secretary for Finance and Sustainable Growth further explained that the fund is designed to support the redesign of services to help shift the balance of care away from the acute sector and towards primary and community care. He described the fund as a means of giving the IRF “greater potential” and a way of putting “greater practical resource behind it”. He also rejected criticisms from ADSW and the Royal College of Nursing that progress on the IRF has been slow—

“The more people are supported in their home rather than in an acute hospital, the more it helps us with the long-term management of public resources. The work on the integrated resource framework is going well, but it is something that needs to be constantly reinforced, which is what the change fund will help to do.”91

126. The Committee welcomes the fact that the Scottish Government is responding to the pressures on social care and health through the IRF and the change fund. Work on both these initiatives is at an early stage and it is therefore too soon to determine their success in realising some of the potential savings that can be made in this area. The Committee acknowledges the difficulties in ensuring a better relationship between health and social care, but also notes the SCVO’s view that “the cost of investing in preventative approaches is far smaller than the cost of investing in acute services”.

127. The Committee invites the Scottish Government to consider whether the principles behind its work on IRF and the change fund could also be applied to ensure greater collaborative working and pooling of budgets in early years policy.

128. Considering the Scottish Government’s focus on the key role played by Community Planning Partnerships (CPPs) in fostering collaborative working, the Committee would welcome the Scottish Government’s response on the following questions which are relevant to the early years, and health and social care—

  • how can the concept of preventative spending be embedded in CPPs, so that there is a focus across the public sector on trying to prevent social problems arising rather than on dealing with their consequences?

  • is there merit in establishing a new financial settlement for CPPs so that relevant bodies are better able to pool their resources?

  • what is the best means of ensuring that CPPs are making satisfactory progress in delivering better outcomes?

  • how can the work of CPPs best complement the essential work carried out by the voluntary sector, families and communities?

  • how can the views of the expert witnesses who have contributed to this inquiry help to shape the decision making of CPPs?

Barriers to preventative spending

129. Having considered the specific challenge of collaborative working, this section sets out some of the other key generic barriers to more successful preventative spending.

Who benefits?

130. Bearing in mind the discussion above on partnership working, it has been suggested that if a particular public sector body makes a successful investment in preventative spending it may not be that same body that derives the benefits. This risk was acknowledged by the Cabinet Secretary who said that “That must not act as a barrier to preventative action”.92

The political cycle

131. Some witnesses pointed out that while elections are conducted every four years or so, the benefits of some preventative spending will be realised over a much longer timescale. Governments may not therefore have the same incentive to invest as they would in an area that could deliver immediate benefits. The Cabinet Secretary again acknowledged this point and stressed the importance of the national performance framework as a mechanism for addressing long term issues.93

Cause and effect

132. Several written submissions highlighted the difficulties of proving conclusively that a specific intervention was responsible for delivering a particular outcome. This is especially the case in relation to the early years. Proponents argue that early interventions may deliver far better outcomes for individuals in terms of better education and employability and reduced likelihood of committing crime. However, it can be difficult to prove conclusively that these long term benefits resulted from a specific intervention made in the very early years. Susan Deacon acknowledged this point in her written evidence but argued that this should not be seen as a justification for doing nothing—

“The fact is that it is difficult - in some cases nigh on impossible - to quantify the impact of preventative spend. It is hard to prove that if we had not acted or intervened there would have been a poorer outcome or to demonstrate short term improvements where change may be generational. But existing evidence, not to mention professional judgement, human intuition and experience – and sheer common sense – can take us a very long way.”94

Impact of budget cuts

133. The Committee also explored whether the current public sector budgetary restraints could make a focus on preventative spending less likely. NESTA argued in oral evidence that budgets cuts may actually be an opportunity for decision makers to consider new approaches to public spending rather than simply identifying cuts in areas that may not be delivering anyway—

“Let us not think about this as a matter of seeing out a few years of cuts and then thinking about reform; the thinking about reform needs to happen now, because our decisions will influence the situation.”95

Maintaining reactive services

134. Several witnesses made the point that increasing investment in preventative spending does not mean that existing ‘reactive budgets’ can be cut. The level of demand for such services, given Scotland’s social problems, will not simply go away in the short term and there may therefore be a need for dual funding of both preventative spending and reactive spending. COSLA’s written submission called for a new model “that would allow us to redirect resources away from crisis intervention to crisis prevention”.96 Such an approach would involve disinvestment and reinvestment within individual public sector organisations, between public sector organisations, and at a government level.

135. The Scottish Government’s written evidence set out various ways in which the barriers summarised above could be overcome, including the following—

  • “In a time of financial constraint the challenge for decision makers is to identify the appropriate mix of policies and interventions that will both respond to short term necessities, some of which can be statutory, and deliver the longer term benefits. Good appraisal and impact assessment of policy options is key to getting this right.”

  • “we should not exclusively look to preventative programmes to prevent negative social outcomes and should recognise the preventative elements of wider programmes. Mainstream services should be delivered with an eye on prevention, and in a tighter fiscal environment we should ensure that we make the most of these opportunities by improving service design and partnership working. Evidence of effectiveness and efficiency in achieving our desired outcomes should form the basis of prioritisation of programmes.”

  • “It is perhaps understandable that some parts of the public sector may focus increasingly scarce resources on meeting their statutory obligations, but the evidence suggests there is substantial and ongoing value in supporting preventative services.”97

136. This section has set out some of the potential barriers to the greater use of preventative spending. While some of these barriers are considerable, the Committee has heard evidence to suggest that none is insurmountable. The Committee in encouraged by the fact that the Scottish Government appears to share this view.

137. Perhaps the key challenge to the preventative agenda is the need to redirect resources away from crisis intervention to crisis prevention. The Committee notes COSLA’s suggested “new model” to allow for this and ADSW’s call for a “much better national process for making the major decisions about disinvestment”. The Committee recommends that the Scottish Government takes the lead on delivering this approach.

138. Paragraph 135 summarises suggestions in the Scottish Government’s written evidence as to how the public sector could maintain a preventative spending approach. The Committee would welcome further explanation of the following elements—

  • the importance of “Good appraisal and impact assessment of policy options”;

  • that “Mainstream services should be delivered with an eye on prevention”;

  • the implication that bodies should not simply “focus increasingly scarce resources on meeting their statutory obligations”.

Structure of the public sector

139. Over the course of its inquiry, witnesses have voiced some fundamental criticisms of the way that the Scottish public sector is organised. For example, a criticism made by several witnesses is that the public sector is designed to react to social problems by seeking to manage them, rather than by seeking to tackle their root causes. Alan Sinclair considered that—

“The overwhelming mindset that lurks behind how our public services are delivered is that we should invest at point of impact when things have gone wrong—indeed, when things have gone seriously wrong—instead of going back and putting something in systemically. We are far away from that latter approach.”98

140. NESTA took a similar view and set out what it considered to be the consequences of such an approach—

“The prevalent approach to tackling these challenges is to deal with the symptoms rather than striving to prevent their development. Despite often heroic efforts, returns on late interventions can be meagre. For example, health expenditure per head per year is 12-16% higher in Scotland than England, yet Scotland is not experiencing the improved health outcomes and continues to suffer from higher mortality rates for each of the main causes of death – heart disease, stroke and cancer, with overall mortality rates 15% higher than England.”99

141. There was also widespread criticism of the way that the public sector designs services for people rather than with people. For example, the chief medical officer pointed out that—

“The interventions that are most effective in changing individuals' health behaviour are those that—for want of a better word—activate them. The public sector—by which I mean the public sector in the UK, not just in Scotland—tends to do things to people, but the successful programmes, projects and organisations do things with people by, for example, finding their internal assets.”100

142. Community Care Providers Scotland agreed with this view and suggested an alternative approach—

“We hear a lot from local authorities about their duty of care to people. Unfortunately, that often means that we take people into the system, wrap them up and hold on to them and make them dependent. I would far rather that, instead of a duty of care, the mindset was about a duty to promote independent living. That gets us thinking differently—rather than doing things to or for people, we are doing things with people and constantly checking to consider whether we can let go and back off a bit. There is a tendency to make people more dependent on services than they need to be.”101

143. There have also been criticisms made, particularly by voluntary sector groups, that some public sector bodies may not actually be trusted by the very people for whom their services are designed. For example, the written submission from Eighteen and Under said that “The statutory child protection agencies are feared by the very people they are there to help.”102

144. The Committee has already addressed some of these concerns but considers that there are others criticisms that, if accurate, suggest the need for a radical overhaul of the way that the Scottish public sector is currently organised. While this broader debate is outwith the scope of this report, the Committee considers that these matters will be of particular concern to the Commission on Public Services which was recently established by the Scottish Government. The Committee also considers that this report as a whole will be of relevance to the Commission’s work.

Conclusions

145. This is the first time since devolution that a parliamentary committee has examined the concept of preventative spending in-depth and across a range of public spending areas. In the process, the Finance Committee has heard remarkably strong evidence about the benefits that such an approach could deliver, as well as receiving an insight into the barriers to realising its potential.

146. In Scotland there is currently a strong political focus on outcomes. It is universally acknowledged that some of the social outcomes in Scotland are completely unsatisfactory. Moreover, some of the problems described in this report have endured for decades and have remained stubbornly resistant to improvement. However, this report has set out some of the steps that could make a difference at a time of unprecedented pressure on the public finances. In essence, there will have to be a shift from reacting to crises, to a greater focus on prevention and early intervention.

147. A striking feature of the inquiry is that participants, including the Scottish Government, have unanimously supported the concept of preventative spending, particularly in relation to the early years. The Scottish Government has also acknowledged that the current balance of spending is skewed too much towards reactive spending.103

148. Considerable and sustained planning and investment will be required over the long term to ensure that the transition to a more preventative approach can be achieved. The Committee is therefore greatly encouraged by the widespread recognition that current patterns of reactive spending are not sustainable. The Committee agrees with many of the witnesses who emphasised the need for a sustained political commitment to preventative spending over the longer term and calls on the Scottish Government and the Scottish Parliament to provide strong leadership in delivering the necessary shift away from the current emphasis on reactive spending. While the Committee has clearly expressed its support for early intervention, it recognises that this approach will not be a panacea for all of Scotland’s considerable social ills. There are broader societal and economic factors that will impinge on the effectiveness of preventative spending programmes.

149. The Committee strongly believes that, given the weight of evidence it has received during this inquiry, it would be counter-productive and short-sighted if budgets were to be cut in areas such as the early years. The Committee  therefore welcomes the proposed £5 million fund in the Scottish Government’s 2011-12 draft budget for early years and early intervention, and the £70 million “change fund”.

150. The Committee also welcomes the Government’s emphasis on preventative action as being “integral to the approach to government in Scotland and delivering the outcomes set out in the National Performance Framework”.104

151. However, despite this commitment, there is no indication within the draft budget as to the extent to which spending proposals are preventative. The Committee therefore recommends that future budget documents should include an assessment under each portfolio heading of the progress being made towards a more preventative approach. The Committee also addresses this point in its report on the 2011-12 draft budget.

152. The Committee considers that there is a risk that all public spending could potentially be defined as being in some way preventative. Therefore, the Committee recommends that the Scottish Government provides a robust and measurable definition of “preventative spending” that could be used across the public sector.

153. Given the breadth of the issues raised during the inquiry, the Committee will hold an event in the chamber of the Scottish Parliament on 4 March 2011 in order to discuss this report, the Scottish Government’s response to it and, most importantly, how the barriers to preventative spending can be removed. The event will involve the Finance Committee, the Scottish Government, other parliamentary committees and those who have contributed to the Committee inquiry. This will allow all those with an interest in preventative spending to come together and challenge decision makers. It will also help inform the Committee’s legacy paper and hopefully inform the scrutiny process in the next session of the parliament.

154. The Committee will also recommend to its successor in its legacy paper that the scrutiny of preventative spending should be integral to the annual budget process and that the guidance that is issued to subject committees should invite them to scrutinise the Scottish Government’s progress in moving towards a more preventative approach to public spending.

155. Finally, the Committee wishes to emphasise the need for a consensual approach in moving towards a more preventative approach to public spending and investment in the early years in particular. This will require leadership across all political parties within the parliament and constructive dialogue with the Scottish Government, COSLA, Health Boards and other partners including the third sector. The findings of this report are published as a contribution to the debate. As well as being submitted to the Scottish Government, a copy of this report will be submitted to the Commission on Public Services.

ANNEXE A – EXTRACT FROM THE MINUTES OF THE FINANCE COMMITTEE

20th Meeting, 2010 (Session 3), Tuesday 21 September 2010

Inquiry into preventative spending: The Committee took evidence from—

Alan Sinclair, Centre for Confidence;

Sir John Arbuthnott, Royal Society of Edinburgh;

Dr Michael Harris, National Endowment for Science, Technology and the Arts;

Professor Edward Melhuish, University of London.

21st Meeting, 2010 (Session 3), Tuesday 5 October 2010

Inquiry into preventative spending: The Committee took evidence from—

Yvette Burgess, Director, Housing Support Enabling Unit;

David Ogilvie, Policy and Strategy Manager, Scottish Federation of Housing Associations; and

Jim Elder Woodward, Convener, Independent Living in Scotland Project.

22nd Meeting, 2010 (Session 3), Tuesday 26 October 2010

Inquiry into preventative spending: The Committee took evidence from—

Detective Chief Superintendent John Carnochan, Head, and Karyn McCluskey, Deputy Head, Scottish Violence Reduction Unit;

Laurie Matthew, Co-ordinator, Eighteen and Under;

Jenny Kemp, Prevention Network Officer, Zero Tolerence;

Angela Morgan, Chief Executive, Includem;

Mike Brown, Convener, Association of Directors of Social Work Resources Committee;

Nigel Henderson, Convener, Community Care Providers Scotland;

Dr Harry Burns, Chief Medical Officer, Scottish Government;

Rachel Cackett, Policy Adviser, Royal College of Nursing Scotland;

Dr Philip Wilson, Senior Lecturer in infant mental health, University of Glasgow.

23rd Meeting, 2010 (Session 3), Tuesday 2 November 2010

Inquiry into preventative spending: The Committee took evidence, in a round-table discussion, from—

Anne Houston, Chief Executive, Children 1st;

Dr Rosemary Geddes, Career Development Fellow, Scottish Collaboration for Public Health Research and Policy;

Robert McGeachy, Policy and Public Affairs Manager, Action for Children Scotland;

Jim Boyle, Programme Manager, UK Poverty Programme, Oxfam GB;

Douglas Hamilton, Head, Save the Childen in Scotland;

Dr Suzanne Zeedyk, Senior Lecturer, School of Psychology, University of Dundee;

Dr Susan Stewart, Manager, Scottish Child and Family Assessment Centre, Aberlour Childcare Trust;

Simon Watson, Head of Developments, Barnardo's Scotland;

Dr Jonathan Sher, Director of Research, Policy and Programmes, Children in Scotland.

24th Meeting, 2010 (Session 3), Tuesday 9 November 2010

Inquiry into preventative spending: The Committee took evidence from—

George Hosking, Chief Executive and Research Director, WAVE Trust;

Susan Deacon, Early Years' Champion for the Scottish Government.

25th Meeting, 2010 (Session 3), Tuesday 16 November 2010

Inquiry into preventative spending: The Committee took evidence from—

Ian Curryer, Corporate Director for Children and Families and Lead Officer for Early Intervention, Nottingham City Council;

David Williams, Assistant Director of Social Care Services, and Maureen McKenna, Executive Director of Education, Glasgow City Council;

Ron Culley, Team Leader, Health and Social Care Team, Sarah Fortune, Policy Mananger for Finance, and Robert Nicol, Team Leader, Children and Young People, COSLA;

Ruchir Shah, Head of Policy and Research Department, Scottish Council for Voluntary Organisations.

28th Meeting, 2010 (Session 3), Tuesday 30 November 2010

Inquiry into preventative spending: The Committee took evidence from—

John Swinney MSP, Cabinet Secretary for Finance and Sustainable Growth, Kay Barton, Health Improvement and Health Inequalities Policy Branch, and Jim Stephen, Head of Early Education and Childcare Branch, Scottish Government.

30th Meeting, 2010 (Session 3), Tuesday 21 December 2010

Inquiry into preventative spending (in private): The Committee considered a draft report, and agreed to consider a further draft by correspondence.


Footnotes:

1 Scottish Parliament Finance Committee. Official Report, 30 November 2010 Col 2833.

2 Aberlour Childcare Trust. Written submission to the Finance Committee.

3 Scottish Parliament Finance Committee. Official Report, 9 November 2010 Col 2564.

4 Violence Reduction Unit. Written submission to the Finance Committee.

5 Scottish Government’s chief medical officer. Written submission to the Finance Committee.

6 Action for Children and the new economics foundation. (2009) Backing the Future. Available at: http://www.neweconomics.org/publications/backing-future. [Accessed 23 December 2010]

7 Scotland’s Futures Forum. Written submission to the Finance Committee.

8 Susan Deacon. Written submission to the Finance Committee.

9 Scottish Parliament Finance Committee. Official Report, 2 November 2010 Col 2625.

10 Scottish Government. Written submission to the Finance Committee.

11 Scottish Parliament Finance Committee. Official Report, 2 November 2010 Col 2614.

12 Alan Sinclair. Written submission to the Finance Committee.

13 Scottish Parliament Finance Committee. Official Report, 9 November 2010 Col 2655.

14 Scottish Parliament’s Education Committee. (2006) Early years. Available at: http://www.scottish.parliament.uk/business/committees/education/reports-06/edr06-07.htm. [Accessed 23 December 2010]

15 Scottish Parliament Finance Committee. Official Report, 21 September 2010 Col 2477.

16 Scottish Parliament Finance Committee. Official Report, 21 September 2010 Col 2493.

17 Dr Suzanne Zeedyk. Written submission to the Finance Committee.

18 SCVO. Written submission to the Finance Committee.

19 Children 1st. Written submission to the Finance Committee.

20 Scottish Parliament Finance Committee. Official Report, 2 November 2010 Col 2621.

21 Scottish Parliament Finance Committee. Official Report, 26 October 2010 Cols 2582/3.

22 Scottish Government. (2010) Financial Impact of Early Years in Scotland. Available at: http://www.scotland.gov.uk/Topics/Research/by-topic/children-and-young-people/FinancialImpactEarlyYears. [Accessed 23 December 2010].

23 Scottish Collaboration for Public Health Research and Policy. (2010) Interventions for Promoting Early Child Development for Health. Available at: https://www.scphrp.ac.uk/node/103. [Accessed 23 December 2010]

24 Scottish Government and COSLA (2008). Early Years and Early Intervention: A joint Scottish Government and COSLA policy statement. Available at: http://www.scotland.gov.uk/Publications/2008/03/14121428/0. [Accessed 6 January 2011]

25 Scottish Government. (2009) The Early Years Framework. Available at: http://www.scotland.gov.uk/Publications/2009/01/13095148/1. [Accessed 23 December 2010].

26 Scottish Collaboration for Public Health Research and Policy. (2010) Interventions for Promoting Early Child Development for Health. Available at: https://www.scphrp.ac.uk/node/103. [Accessed 23 December 2010]

27 Scottish Parliament Finance Committee. Official Report, 26 October 2010 Col 2574.

28 NHS Greater Glasgow and Clyde. Written submission to the Finance Committee.

29 Scotland’s Commissioner for Children and Young People. (2010) The Early Years Framework – scoping its impact. Available at: http://www.sccyp.org.uk/publications/adults/policyandresearch. [Accessed 23 December 2010]

30 Scotland’s Commissioner for Children and Young People. (2010) The Early Years Framework – scoping its impact. Available at: http://www.sccyp.org.uk/publications/adults/policyandresearch. [Accessed 23 December 2010]

31 Susan Deacon. Written submission to the Finance Committee.

32 Scottish Parliament Finance Committee. Official Report, 26 October 2010 Col 2562.

33 Scottish Parliament Finance Committee. Official Report, 30 November 2010 Col 2832.

34 Scottish Parliament Finance Committee. Official Report, 30 November 2010 Col 2836.

35 Scottish Government. (2010) Financial Impact of Early Years in Scotland. Available at: http://www.scotland.gov.uk/Topics/Research/by-topic/children-and-young-people/FinancialImpactEarlyYears. [Accessed 23 December 2010].

36 Scottish Parliament Finance Committee. Official Report, 30 November 2010 Col 2838.

37 Scottish Parliament Finance Committee. Official Report, 2 November 2010 Col 2626.

38 Scottish Parliament Finance Committee. Official Report, 26 October 2010 Col 2563.

39 Scottish Parliament Finance Committee. Official Report, 30 November 2010 Col 2386.

40 Scottish Parliament Finance Committee. Official Report, 30 November 2010 Col 2839.

41Scottish Parliament Finance Committee. Official Report, 30 November 2010 Col 2841.

42 Dr Suzanne Zeedyk. Written submission to the Finance Committee.

43The Centre for Social Justice. (2008) Early intervention: Good parents, great kids, better citizens. Available at: http://www.centreforsocialjustice.org.uk/client/downloads/CSJ%20Early%20Intervention%20paper%20WEB%20(2).pdf. [Accessed 23 December 2010]

44 Scottish Parliament Finance Committee. Official Report, 21 September 2010 Col 2493

45 Scottish Parliament Finance Committee. Official Report, 5 October 2010 Col 2576.

46 Scottish Parliament Finance Committee. Official Report, 21 September 2010 Col 2476.

47 Scottish Parliament Finance Committee. Official Report, 21 September 2010 Col 2498.

48 Scottish Parliament Finance Committee. Official Report, 9 November 2010 Col 2658.

49 Alan Sinclair. Written submission to the Finance Committee.

50 Scottish Parliament Finance Committee. Official Report, 26 October 2010 Col 2583.

51 Scottish Parliament Finance Committee. Official Report, 26 October 2010 Col 2585.

52 Scottish Parliament Finance Committee. Official Report, 2 November 2010 Col 2622.

53 Scottish Parliament Finance Committee. Official Report, 21 September 2010 Col 2487.

54 Scottish Parliament Finance Committee. Official Report, 2 November 2010 Col 2615.

55 Scottish Parliament Finance Committee. Official Report, 16 November 2010 Col 2701.

56 Scottish Parliament Finance Committee. Official Report, 16 November 2010 Col 2713.

57 Glasgow City Council. Written submission to the Finance Committee.

58 Scottish Parliament Finance Committee. Official Report, 16 November 2010 Col 2717.

59 Scottish Parliament Finance Committee. Official Report, 16 November 2010 Col 2726.

60 Scottish Parliament Finance Committee. Official Report, 16 November 2010 Col 2733.

61 Scottish Parliament Finance Committee. Official Report, 16 November 2010 Col 2723-24.

62 Scottish Parliament Finance Committee. Official Report, 16 November 2010 Col 2729.

63 Alan Sinclair. Written submission to the Finance Committee.

64 Dr Phil Wilson. Written submission to the Finance Committee.

65 Dr Phil Wilson. Written submission to the Finance Committee.

66 Scottish Parliament Finance Committee. Official Report, 2 November 2010 Col 2617.

67 Scottish Parliament Finance Committee. Official Report, 26 October 2010 Col 2591.

68 Royal Society of Edinburgh. Written submission to the Finance Committee.

69 Royal Society of Edinburgh. Written submission to the Finance Committee.

70 Chief Medical Officer. Written submission to the Finance Committee.

71 Scottish Parliament Finance Committee. Official Report, 21 September 2010 Col 2477.

72 Age Scotland. Written submission to the Finance Committee.

73 Scottish Parliament Finance Committee. Official Report, 26 October 2010 Col 2579.

74 Scottish Parliament Finance Committee. Official Report, 16 November 2010 Col 2745.

75 Scottish Parliament Finance Committee. Official Report, 16 November 2010 Col 2736.

76 Scottish Parliament Finance Committee. Official Report, 16 November 2010 Col 2745.

77 Scottish Federation of Housing Association. Written submission to the Finance Committee.

78 Scottish Parliament Finance Committee. Official Report, 26 October 2010 Col 2590.

79 Scottish Parliament Finance Committee. Official Report, 26 October 2010 Col 2590.

80 Scottish Parliament Finance Committee. Official Report, 26 October 2010 Col 2592.

81 Independent Living in Scotland Project. Written submission to the Finance Committee.

82 Scottish Parliament Finance Committee. Official Report, 5 October 2010 Col 2523.

83 Scottish Parliament Finance Committee. Official Report, 26 October 2010 Col 2599.

84 Scottish Parliament Finance Committee. Official Report, 16 November 2010 Col 2743.

85 Scottish Parliament Finance Committee. Official Report, 21 September 2010 Col 2482.

86 Scottish Parliament Finance Committee. Official Report, 26 October 2010 Col 2561.

87 Scottish Parliament Finance Committee. Official Report, 26 October 2010 Col 2597.

88 Letter from the Cabinet Secretary for Finance and Sustainable Growth to the Convener of the Finance Committee dated 6 August 2010.

89 Scottish Parliament Finance Committee. Official Report, 26 October 2010 Col 2577.

90 Scottish Government. (2010) Scotland’s Spending Plans and Draft Budget 2011-12. Available at: http://www.scotland.gov.uk/Publications/2010/11/17091127/0. [Accessed 23 December 2010]

91 Scottish Parliament Finance Committee. Official Report, 30 November 2010 Col 2832.

92 Scottish Parliament Finance Committee. Official Report, 30 November 2010 Col 2832.

93 Scottish Parliament Finance Committee. Official Report, 30 November 2010 Col 2842.

94 Susan Deacon. Written submission to the Finance Committee.

95 Scottish Parliament Finance Committee. Official Report, 21 September 2010 Col 2486.

96 COSLA. Written submission to the Finance Committee.

97 Scottish Government. Written submission to the Finance Committee.

98 Scottish Parliament Finance Committee. Official Report, 21 September 2010 Col 2496.

99 NESTA. Written submission to the Finance Committee.

100 Scottish Parliament Finance Committee. Official Report, 26 October 2010 Col 2593.

101 Scottish Parliament Finance Committee. Official Report, 26 October 2010 Col 2594.

102 Eighteen and Under. Written submission to the Finance Committee.

103 Scottish Parliament Finance Committee. Official Report, 30 November 2010 Col 2842.

104 Scottish Government . Written submission to the Finance Committee.