Finance and Public Administration Committee

Meeting date: Tuesday, June 6, 2023

Official Report 673KB pdf

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Public Service Reform Programme

Welcome back to the second half of our meeting this morning. We now continue our evidence taking on the Scottish Government’s public service reform programme. Today, we will hear from Claire Burden, the chief executive of NHS Ayrshire and Arran, whom I welcome to the committee. We were meant to also be hearing from a representative of the Argyll and Bute integration joint board, but they are unable to attend today. I apologise that you are in the spotlight, Claire, but I am sure that we will get on okay.

We have about an hour, but we do not have to use all that time—we will see how we get on.

We are looking at public service reform. Initially, we thought that the Government was going to have a very clear path for that; more recently, it has been more the case that each organisation will be looking at reform itself. Do you think that that works, or do we need a stronger steer from the Government about the kind of reform that it is looking for and where we should be going? Are you comfortable that your organisation and similar organisations can drive forward reform yourselves?

Good morning. As ever, there is a mixture with regard to NHS Ayrshire and Arran. Given the unique nature of our population, there are things that I can do within the health and social care arena that perhaps would not be transferable to other parts of Scotland. In that way, in order to meet the needs of our local people, there are certain things, particularly for operational delivery, for which it is helpful to have that local flavour and a response that meet the needs of local people, as well as responsibility and accountability for designing services.

The opportunities in digital reform are perhaps where we start to touch on the scale of national policy, including making it more accessible and equitable. As a smaller territorial board, our finances are for the 385,000 people in our territory, which limits our capital capability. We know that, to get the greatest reform, we need to ensure that digital infrastructures and our infrastructure as a whole are as robust as possible. That will need a wider national steer and subsidy leverage, somehow, so that there is equity across all 14 territorial boards.

Last week, we heard evidence on the information technology side, which was not just about health, that all sorts of public bodies are fishing in the same pool for IT experts. There seems to be a shortage. Has that been your experience?

Absolutely. We currently have quite a low baseline in NHS Ayrshire and Arran, and we are putting in foundations. We are not seeking whistles and bells; we want infrastructure that means that we are resilient and can cope with a power surge or the westerlies when we get cut off. If we are to do that with the best of technology, we would go to cloud and seek those larger enterprise opportunities. It would be more cost effective to have local servers, but it is not as resilient, so doing the right thing requires digital expertise and maintenance of a system for a wider population. Trying to do that for 385,000 people is just not the same.

You have mentioned a couple of times the number of people you have. The Argyll and Bute IJB is not here, but its population is 85,000, so it is an even smaller organisation.

Last week, we heard from the police, and they are obviously an example of a major reform in recent years. They went from eight police authorities, or whatever it was, down to just one. Making anything like that kind of change in the health service could not be done internally, could it? It would have to be driven by central Government.

Absolutely. There are regional and national networks over and above our territorial boards. The west of Scotland works as a region, and there will be opportunities to optimise what is available. At the moment, the response to digital by our 14 territorial boards will be meeting our local needs and working from our local infrastructure. Glasgow’s current position is very different from mine, so it would take disproportionate investment for me to catch up. It would be as though I was slowing Glasgow down in order for us to catch up.

The important bit is scale. We started by thinking about where we could get the greatest reform, and digital is an area in which getting us all into the same ball park, at the national and regional level, would make a significant difference in terms of public reform. If we get our digital network right, we will meet our ambition of getting our health and social care partners aligned to a single patient record, so they will all have access to the same information. We need to future proof our digital platforms.

One of the terms that we politicians hear from the public is “postcode lottery”, which I personally detest and which I think really means local decision making. However, there needs to be a balance, does there not? When someone turns up with a broken leg, they get the same treatment in Ayrshire as they would in the Highlands, Glasgow or anywhere else. On the other hand, you are dealing with a particular situation: you have two islands, the Highlands are completely different from that, and Glasgow and Edinburgh are different, too.

How do we get that balance? The police model has become more centralised. Does health need to have a more centralised model?

In our sub-specialties, there is a need for regional and national models. They are already in place for vascular cardiac services, in which people go to a specialist centre. There are other areas where Scotland could consider working at a regional and national level, building on the NHS Golden Jubilee ambitions.

It is definitely a walk-before-we-can-run situation, in that our workforce is territorial. My workforce for Ayr is absolutely dedicated to Ayr hospital. Recruiting to Ayr hospital is no mean feat, with Crosshouse hospital being much closer—13 miles closer—to Glasgow. You would not have believed that recruiting to one of those hospitals would be so different from recruiting to the other, but the fact remains that it is.

That takes us back to where we started, on providing local services. When you break your leg, you need an emergency service that will fix your leg. It feels reasonable to have that within a 14 or 15-mile radius, in order that someone can get to hospital, wherever that is, within the golden hour.

The sub-specialty is where we get into replication. What is happening in vascular and cardiology might mean that you travel a little further, but you get to see the specialist who can fix you in a shorter period, because that is the nature of specialists. That has to have benefits in relation to outcomes. Our medical colleagues are in the best place to determine what those zones might be.

My final question was going to be aimed more at the health and social care partnership, but I will try it with you anyway. Your area covers three local authority areas. Is that a problem, does it not matter or is it a strength? We know that other health boards, such as NHS Fife, for example, pretty well match the local authority area. Is that an issue for you?

Without doubt, it would be easier to have one partner. There are four of us, and each of us is trying to deliver for our local population. The needs of people in the north, east and south parts of the area are different; given how small the area is, it is extraordinary how different those needs are. Our councils in the east know their populations well. Each has developed services around the needs of local people, so diversity is offered across the three board areas.

I have been fortunate to have inherited health and social care partners who are committed to working together. The caring for Ayrshire strategy is not new, but I have been here for 18 months and it is clear to me that, if the fire and police services, along with the council, engage with the strategy, it means something to people in Ayrshire. That is currently sufficient to bind us together. We have our bumpy periods, because we all want to provide the best that we can in the here and now. The nature of emergency and urgent care in this post-pandemic era is such that we are not quite as focused on prevention as we would like to be. In an ideal world, we would put so much more into primary and community care, because that is the right thing to do, but at the moment the hospitals are spinning like tops, so they become our focal points.

That opens up a discussion on preventative spend, which is a huge area on which the committee has already spent a lot of time. I will restrain myself on that point, though, and hand over to Michael Marra.

You have talked a little about IT programmes, and I notice that in your submission you say that the work that you have been doing

“starts us on the journey of delivering”

the Scottish Government’s

“2015 Cloud First Strategy.”

Is that correct? Are you saying that, although the strategy that you are working to was published in 2015, you are only starting to deliver it now?

It has since been revised. My understanding is that the IT strategy was revised in 2022, and we are aligned with the commitment to move to a unified platform and an enterprise model for Scotland. Any local platforms and interfaces that we put in place are compliant with the cloud first strategy.

Thank you.

On reading your submission, I wondered about the scale of the change required. In the course of the committee’s inquiry, we have discussed the shift to preventative spend and the demographic challenges. Is the range of the programme that you are undertaking commensurate with the scale of the challenges that you, as a leader in your field, are seeing in demographics, technology and new forms of healthcare? Is the change that you have represented in your submission up to that task?

I still think that it is conservative, but it is affordable. In the private sector, we would be looking at 3 per cent of budgets being dedicated to IT, whereas ours is less than 1 per cent titrated over three years. The reform that we have put in place enables us to work with NHS Scotland with some parity with our digital capability; it sorts out our infrastructure so that it will be compatible with NHS Scotland requirements; and it will also unify our health and social care partners with regard to primary care.

I know that £10 million sounds like a lot when I am sitting with a year-end £25 million hole. However, we will have to spend £3 million, £5 million and £4 million in various places in order to get us where we need to be. It will be from interoperability that we will get our greatest return.

I want to broaden that question out beyond the digital infrastructure to the delivery of health services across the whole board area, including where services are situated, and the way in which you are looking at the future of your geography and your people. Do you have a change programme that addresses that broader set of issues?

The software that comes with the upgrades just puts us in a completely different place. In each of our two acute hospitals, we do not have a bed board; bed managers still have to go round in order to find out where people are and then manually note that. We have to run three operating systems in order to manage an acute hospital, but it is that one piece of kit that will enable us to know where patients are at any one time. That will help us manage risk, improve safety and reduce avoidable waste throughout the building and, as a result, change the landscape of emergency medicine in the body of the hospital. At the moment, the emergency department is not attached to the main hospital—it is a standalone system.

11:15  

On the broader issue of how you deal with a rapidly ageing population, are you advocating a technological approach to changing services instead of talking about, say, which areas of primary care might be addressed, how we might piece all of that together and so on? I am trying to think about this in a slightly broader way by looking at the driving forces, but you seem quite focused on the technology aspect.

The aims of this year’s plan are threefold. First, we have to address our bed-based care, which is the most expensive component in the delivery of care. We talk about bed-based care as if it just happens in hospital, but that is not the case—we have beds all over the system. They do all sorts of things and are not necessarily in places where we want them to go. The second aspect is financial recovery and sustainability, as we have some very high spend.

The third aspect is digital, which has an impact on the other two. We have remote and mobile technology, but that is only the tip of the iceberg in terms of what we are capable of doing. If I can equip clinicians at the patient bedside, wherever it is—in their home, in the community or in hospital—so that they can all see exactly the same thing, we will make better decisions on their behalf. That also relates to people’s independence with regard to keeping them in their own homes. If I can equip decision makers with that information, they are more likely to be able to keep those people at home.

On workforce planning, you have said in your submission that you have “around 9,400” permanently contracted full-time staff. Is that correct?

That figure waxes and wanes by about 400, but that is right.

In some of the evidence that we have had so far, there has been a little bit of dubiety about the Government’s absolute position on managing the workforce. The resource spending review, which came out a while back under the previous cabinet secretary for finance, committed the Government to reducing head count to pre-pandemic levels. However, you seem to be indicating that your intent is to remove non-full-time-equivalent permanent staff by trying to manage down your bank nurses and other contractors. Is such a characterisation right?

In the first instance.

In the first instance?

Until we can get into reform and dramatically change the way in which a hospital works, our ability to bring our head count down demonstrably and sustainably is limited. Our vacancy rates are such that we would be robbing a blind space, whereas there is the reality of the agency and bank spend, and the way that we choose to work with independent partners.

So you think that your ability to meet any broader intent in that regard is limited until we get into reform. Is that a process that needs to be led more—with more indication—and perhaps in the direction that the convener talked about? Would it involve more intent from the Government? Is that what you mean when you talk about the need to “get into reform”?

It is about our ability, as a health and social care system, to get into that more generally. Those in primary care are desperate to do more. If they were to speak to me—or to any of us—this afternoon, what they would say is that if we were able to move money around with a bit more fluidity, they would be able to offer more support to patients at home in the community and get into the prevention arena, which would reduce demand on the acute setting.

At present, I do not have sufficient headroom to create that reform. It feels as if we need a year to 18 months of basics just to get our house in order and a really dedicated core workforce in place. It is not unusual in a rural territory, but we need more core staff to get teams to optimal levels of cover. Currently, I am running on the minimum. We have to focus on that recruitment, which will bring down our costs.

But you have had consistent budget deficits for the past six years, and perhaps longer, prior to the pandemic.

Yes.

What would headroom that allowed you to invest in that shift look like? Would it eliminate the deficit, reduce it or give you a surplus? Have you had any guidance in that regard?

It would reduce the deficit. I do not have an end point by which we can turn things around. I cannot overstate how important it is that we wrestle with what the models for bed-based care should look like. Our system is heavily dependent on unscheduled bed-based care being provided in an acute setting, but it does not have to be like that—there are other, successful systems. There are considerable margins for change in NHS Ayrshire and Arran but, at the moment, it does not feel as though that is possible. We are all in a position in which we are faced with what we are seeing. That is what I am working with at the moment.

You said something very interesting about some people in the workforce taking a territorial approach. The same is also true of patients and families, who get very attached to their local hospital or medical service; indeed, we have seen what can happen when there is any hint that a hospital will be closed or that certain parts of it will be shut. However, you are correct to say that, for the benefit of medical services in the future, that is exactly what will have to happen to make the system more efficient. Given the nature of the reform that is needed, do you have any suggestions for what we should do to bring the public with us? I think that that will be a very difficult challenge.

It is the medical voice that will make sense of that. The definition of a district general hospital is that it is there 24/7, when people need it. Maintenance of life, pre-hospital care and acute settings are core to the NHS. We need to be clear with people.

Ayr hospital is a perfect example of this; if you move anything, people get really worried that you are going to shut it. I cannot possibly support health provision in NHS Ayrshire and Arran without having both hospitals, so I need to find a way to keep both of them. However, should someone be unfortunate enough to have a brain haemorrhage, we need to get them to a neurological centre, because that is where their outcomes will be different, just by the nature of specialist care. If people hear from, say, the medics that we are able to move patients around Scotland effectively and give them speedy access to the right surgeon—and if the system is designed to say yes—the offer will become different.

You are, in effect, saying that the better decisions—and the ones that will probably be more accepted by the public—will be those made by clinicians and medics rather than by administrators.

In relation to the Covid era, it is interesting that, given how serious the situation was for everybody, decision making in hospitals was pretty effective, because clinicians decided how they had to run the wards. It provides quite an interesting lesson for the future, as it shows how incredibly important clinicians and medics will be in changing the health service’s whole set-up. I am interested in hearing your views on how easy it is in modern health services to ensure that the medics, rather than the administrators, take these decisions.

We have just embarked on a change programme called clinically led, managerially enabled. Things have been a little bumpy, as this is not an insignificant change for both schools. For a start, we are putting medics in a position that requires some really difficult decisions to be made. There are some amazing services in Ayr, but I am finding it difficult to recruit into critical care. I cannot just magic up staff, but I can, with the clinical teams, build in all sorts of contingencies while we seek new staff.

There is also an issue for management in making clinicians’ lives as easy as humanly possible by doing the things that they do not do. As a manager, you can bash out business cases and come and make cases in a political space. We can support clinicians through that space; they do not have to be good at everything, but they are steering us towards what is medically right and what will get us the best outcomes for Scotland. That feels the most appropriate and safest place to be.

So you are recommending that the structure of oversight of the health service change a bit to facilitate that. I realise that we were due to speak to other witnesses, too, but does that include the integration joint board structure? Would you recommend any changes on that front?

We have had changes in clinical leadership in that area, too. Of course, I am representing only NHS Ayrshire and Arran, and our primary care clinicians and medical sponsors within those arenas are strong and vibrant. I think that the situation mirrors that in the NHS. We need to be clinically led. After all, this is the NHS—that is what it says on the tin, so we need that steer and guidance.

With modern medicine and what that means, and the desire for care closer to home, I am going to be asking something very different of our clinical leaders. There are what might called helicopter roles, where I am saying, “Come and be my medical director and look after 385,000 people.” That sort of thing is not necessarily in clinicians’ first language, but they do it.

There is a huge opportunity to think about healthcare provision in a genuinely different way, and manager logic goes only so far. You need somebody to help steer things, as outcomes are generally going to be different.

Thank you.

Good morning, and thank you for joining us. Last week, we had interesting evidence from Police Scotland in which it was made clear that that body simply would not have been created had it not been mandated by Government. I want to ask you some perception questions about your world. In Scotland, with 5.5 million people, we have 14 territorial boards and five national boards, and there is duplication of human resources directors, information technology directors and finance directors. Have you and your equivalents had discussions about attempting to change the scale and the current organisational structure? I know that the British Medical Association has released a report on that, but have you looked at the issue or suggested some change with your face-off equivalents in other boards?

No, I have not discussed that as a tack. Personally, there are things that I cannot do because I lack the scale. I am a proportional slice of 14, and that limits reform. That goes back to the original questions. Providing a national health service for 5 million people with this footprint is a health economics challenge. Therefore, working with our clinicians, there is a piece of work to be done through health economics about what needs to be done at scale. That is not an easy question, which is maybe why we have not gone there. However, in the 18 months that I have been in Scotland, for sure, whenever we have suggested something, we have found that it has been considered four or five years ago.

I imagine that, if you were talking to a CEO with more experience of Scotland under their belt, you would find that that work on health economics will have been done at some stage. Possibly, the way in which Scotland has tackled the complexity of the social care agenda and the health agenda through integration and IJBs as a vehicle was an option in that initial appraisal.

11:30  

My next question follows on from that. Local boards might employ individual staff under different terms and conditions. Does that inhibit flexibility when trying to move staff around? Is there not the same ease of transition because they are employed by different boards? Do you experience that when trying to attract people into your area?

The issue is banding, and that situation is extraordinary. Across the 14 territorial boards, we can have the same job banded at different rates. We have had a great challenge in employing digital practitioners—particularly network practitioners—and a head of estates. We are a band lower than NHS Greater Glasgow and Clyde. We are only a stone’s throw away from each another, but we are encouraging people to come to a territory to do exactly the same job at a different band.

I have not come across terms and conditions being wildly different; they are pretty much transferable. However, banding is a national challenge.

Thanks for that clarification. Given the autonomy of all the different boards, the Centre for Sustainable Delivery was designed to stop NHS boards working as autonomous units. Is it your experience that it does that?

That it stops us working autonomously?

Yes.

That has not been my experience.

At this time, we are doing post-Covid recovery. We have to give ourselves a quick pinch, because nobody has done that before; no senior leadership team has led a recovery from a pandemic. We are pretty much learning on our feet. There are specialties in which people had to do something completely different from their day jobs for three years and we are now asking them to go back to those roles. There are other people whose jobs ticked over. You might think that merging those two groups of people back together sounds horribly simple, but they had two very different experiences. In addition, some of the administrative workforce has been able to work well remotely, but we need to get people working alongside one other. That is the challenge at the moment.

In relation to the Centre for Sustainable Delivery, our discussion has very much been about how we get people back together, hence our clinically led reform that tries to provide a nucleus—a purpose—to bring people back together. Covid required the management of a single disease and we were all focused on that one thing at that time. We had to keep the front door running because people still had coronaries, heart attacks and everything else, but it was about wrestling that one disease. We are now back to the plurality that is the provision of health and social care. We cannot respond in the way that we did for three years because of that plurality. We need the specialists in the room to help us to make decisions. The Centre for Sustainable Delivery has been working with us to help to create that congruence of purpose again.

I went through your submission and I note that you mention deficit reduction, efficiency in delivery and distributed working. I have asked you about staff—you corrected me to say that the issue is banding—and about the number of territorial boards and the Centre for Sustainable Delivery. At the start of this inquiry, Police Scotland commented that it would not have been created had that not been mandated. Are they the sorts of things that you would expect to see mandated by central Government? Is your primary focus therefore on the areas that you have set out both in your evidence today and in your submission?

In terms of the delivery plan, there is quite a clear steer in the guidance that is given. I am not sure how much more mandated it could be. In relation to our elective recovery, there is a very clear steer on what good practice looks like—

I meant with regard to changing something at significant scale—such as, for context, the 14 territorial boards and the five national boards—and restructuring it. I mentioned the Centre for Sustainable Delivery. I am talking about that scale of change and organisational restructuring. Is that something that you would expect to see mandated by the Government rather than being fed upwards from you or people who you face off with in other boards?

I am sorry—I will try to answer through that lens. From a territorial perspective, the flexibility that we have is welcome and it is sufficient to allow us to design things locally. If there was more of a mandated steer, it would be around the performance outcomes. Our concerns from a chief executive perspective—you talked about what the CEs are discussing—are about the ability to maintain the service that we have with the future that we have. With regard to change being mandated, I am working with the public, so I suppose that helping to manage expectations and thinking about how we have these discussions would be in that mandated area.

We are in a different position now. We are not the same service that we were three years ago. We are very different, and we are learning at pace how to get ourselves back. In the outcomes arena, more mandate is therefore an opportunity.

You will be aware that there are Covid inquiries in Scotland and the UK. They will look at various things including the shortcomings of politicians, mainly, and others. However, having heard you speak, I think that it is worth saying that it was an absolutely fantastic achievement to get through Covid and keep the services running. I hope that, in due course, people will recognise the scale of that achievement.

Going back to the subject of Michael Marra’s questions, I note that you said that you intend to reduce the numbers of supplementary staff by half this year. We are only about three months into the financial year, but do you have any idea how things are going so far?

They are going well. In the past year, a considerable amount of work has been done to understand our dependence on agency and bank staff. A lot of work was done to encourage staff to consider their core hours in contracts. As we approached the celebration period and new year, we asked anyone who was on a reduced contract to take on additional hours, even in the short term, and some people very kindly did that. We expanded our bank, and in the past four weeks our agency ask has been 20-plus per cent lower, so that is a very positive start.

The committee will be aware that we were challenged to reduce our agency spend and that a cap was put in place on break-glass payments for out-of-framework agency staff. We are literally seven days into that. I think that people were expecting a bit of a mushroom effect from the NHS, but that has not happened. Some areas across Scotland have had to make break-glass payments for sub-specialists to get cover, but I am pleased to share that we have not had to break glass in the past seven days. However, as you say, it is really early in the financial year, and if there is ever a steady state in the NHS, it is this 16-week period between spring and summer.

We have reduced our bed base by 60 and we have reduced our delayed discharges—not to where we want to be, but they are at least 50 lower than at the beginning of the year. The metrics show that those important aspects that make a difference to core services have started to be embedded.

Thanks for that. With regard to the staffing issues that you have mentioned, and perhaps the additional problems for significantly rural health boards, I note that, a long time ago, I was in the military, and if you trained to do something specific that was quite expensive, they would keep you in the military and tell you where you would serve. In the NHS, whether in relation to GPs or other services, could there be some kind of local or national control whereby, once someone graduates from medical school, they would be obliged, at least for a period thereafter, to go to where there are shortages of GPs or whatever? Could there be a role for that or would such an approach simply not fit in today’s health service?

I am not sure that it would help us with retention if people were directed to where they were needed. I would like to think that keeping people in the country is an incentive. Our medics, our nurses and our allied health professionals all work hard. Once they have gone through their training, if there were a way of retaining them in Scotland by providing good job opportunities and giving them access to technologies, new practice, research and so forth, I think that that would be more of an incentive for members of our workforce to stay with us than mandating where they need to work.

Three years ago, our medical director introduced a new medical workforce into which clinical fellows were injected at pace. We used to have 20 clinical fellows and we now have 120. By incentivising colleagues to work in teams of a decent size, we can give them the opportunity to be the medics, nurses or practitioners that they trained to be, which I think is a most attractive way of keeping people.

I recognise the pressures that you have mentioned. I live in an area that, like Ayrshire, has three local authorities, although it is probably not as big a land area as the Ayrshires. It has only one general hospital, which was built around 15 years ago.

I do not want to put words into your mouth but, in the areas where you said that you think that a more national role might be beneficial, to what extent do you think that health boards as they are currently constructed help or hinder the taking of such an approach, where it might be more appropriate and beneficial for the service? I realise that that is a difficult question to answer.

I think that it would be fair to say that, by nature, we are parochial in the sense that we are trying to make our territorial boards sustainable. We are softly competing with people for staff and kit. The way that boards have been set up means that each of us is looking out for the survival of our own. I therefore do not think that taking a more national approach would be the easiest thing to do.

However, as a group of chief executives, the most important thing for us is sustainability for NHS Scotland. We have significant conurbations with major hospitals and we have district general hospitals that have managed to bring in exceptional specialties. I will do a quick shout-out for our urology service and our orthopaedic service. I will have missed someone out, which will be bad. There are services in rural boards that have managed to collect exceptional people who have created special teams around them. If there were opportunities to expand on that and offer regional and national services, I believe that every territorial board would have such an exceptional person.

The only other point that I want to share is that we regularly talk about what good practice we can replicate. A lot of effort goes into that. However, there are opportunities that emerge as a result of a board having a service that is led by someone exceptional. Perhaps that is the mushroom that we should be looking for. Rather than trying to replicate a situation in which we land up with exceptional individuals who attract other exceptional people and create something different, maybe we should ask how we can grow such an environment in that place for the benefit of more people.

Thank you for that. I also thank all your staff for their work over recent years.

Thank you—that is very kind.

I apologise if I missed this in your answers to Michael Marra’s questions about digital enhancement, but are you able to quantify the financial savings from upgrades? For example, do you know how much the bed management and patient tracking system that you mentioned has saved you? I am interested to know how much you would expect to save from such an upgrade—not that it is all about the money, obviously.

11:45  

I do not have that in a trajectory, but I will get it in a trajectory within the year. I mentioned how 3 per cent of budgets going to the independent sector would be normal; our figure is less than 1 per cent. Digital reform could be expected to return anything up to 11 per cent in internal efficiency, but I need to find something that meets all the requirements of finance in order to get that into my cost avoidance.

I can share with the committee that a ward round in our current combined assessment unit takes four hours because staff have to go through the red file, the yellow file and three digital systems, and they have to look up labs and get into the primary and acute care systems. That should be a board-and-ward round in which clinicians can get round a ward in less than an hour. If I could save that amount of time for a clinical team by board rounding, it would genuinely mean time going back to being with patients.

That is not in the budget because there is not a piece of reform that I can lift and shift into a finance spreadsheet with any validity, but I challenge the system and say that we have to do that. We need to be able to demonstrate that £10 million against our budget over three years is not significant—but it is significant when I am not doing other things. I have a critical care unit that needs work and I have a day-case unit that needs to be expanded. We are sacrificing things to get the digital systems right so that we can make change, so I need to demonstrate to people what that is giving back to the system.

It has been mentioned already that NHS Ayrshire and Arran has been running at a deficit since 2017, but quite a lot of progress was made in closing that deficit between 2017 and the start of the pandemic, when everything went out the window somewhat. How did you manage that year-on-year reduction in the deficit over that three-year period before the pandemic financial years?

That was pre-me. The deficit went to £20 million in 2017 and my predecessor brought in a financial service improvement director who worked systematically with operations to reduce the bed base. Reducing the bed base in the acute sector year on year resulted in a baseline improvement across a wide spectrum of measures—not just in relation to the workforce and bed space but in relation to all the other logistics that go alongside them. Over a 24-month period, the deficit got down to £14 million just before the pandemic, but there was a systematic process of reducing beds in the acute sector.

Your submission mentions opportunities for collaboration, particularly with local authorities when it comes to property and estates. Do you have any examples of where such collaboration has worked well to increase efficiency?

We are possibly talking about the two areas of delayed discharges and sharing working spaces within hospitals and community hospitals. Rehabilitation and our stroke pathways were put into a community hospital to share that facility and reposition rehabilitation services. The cancer unit was moved to the Kyle unit. Those services were in the acute setting; we took the non-critical patients into a community setting and developed a unit within the community. That was at the height of the pandemic and people were quite worried about it. Now, the patients prefer that to the acute setting—not least, those who are poorly with cancer who can pitch up to the community unit and walk in, as opposed to pitching up at the front door of an emergency department and having to walk past everybody, when they are feeling a little grim. That was significant.

There is also distributed working in which we share office space and can book desks anywhere in the system. The zero-desk policy is still new: once again, it is a little bit bumpy as we navigate our way through it, but it means that we can look to centralise where we need accommodation.

Thanks very much.

I want to ask about shared services. Obviously, we have multiple health boards, 32 local authorities and the IJBs. Each has its own finance director, HR director and IT director. Is there scope in the public sector landscape to reduce the number of such roles and to consolidate into more of a shared-service model?

Yes. As ever, however, it is not simple because there are well-established structures now. My understanding in relation to NHS Ayrshire and Arran is that work that was done in 2016-17 was close to unifying IJBs in a single IJB with North, East and South Ayrshire collaborating. After a period of months it was all but there, when the infamous Covid came along—and here we are. The backdrop of the proposed national care service is a bit of a distraction from that. We are in the process of renewing our partnership agreements—to go back to those. We are in the five-yearly review of partnership agreements and, at the moment, the IJBs are still within the three councils. There has been no discussion of going back to what was achieved in 2017 and I have not heard that there is any appetite for that.

Can organisations make such a change voluntarily, or does this go back to the point that Michelle Thomson, I think, made—that it would have to be mandated from the centre before we would get real reform among those organisations?

I think that that would take a mandated change. Structures are already in place, so the change would be quite difficult. It would be like me thinking about having a single west of Scotland board and thinking that taking away a health board would be the right thing to do. I have 13 colleagues who might completely disagree with me. A health board serving a population of 1 million would have a slightly different landscape to navigate than would four or five boards that cover the same population.

You mentioned prevention earlier and seemed to suggest that you would like to do more on that but do not have the resources of people or cash to make that switch.

Yes.

How do we break that cycle? We hear from Government ministers that prevention and early intervention are key and are how we will make savings later, but I do not see a firm change to using the prevention model.

I need to reduce spend in the acute sector in order that we can reinvest in the community. Rafts of work are still referred to the secondary and tertiary services for advice, and we are following traditional models. We have outpatients—the person is added to the list and then they get there. I have teams of people desperately trying to work through those lists.

Primary care practitioners in the community want a discussion or a test or access to something. If it were simple, of course we would have done it. In the transformation wheel that we have at the moment we understand that we are cash-strapped, which means that we have to get to the stage at which we can lead through our clinicians.

Primary care people have said that they want to do more in the prevention arena. I am fortunate to have very strong positive primary care provision, both in and out of hours, and those people will help us to scope out what they need in order to do more. There are already diabetes and respiratory programmes that are run perfectly well with a community-led bias; we need to lean on those again.

It is about safety and opportunities, and also about working with our medical colleagues who have chosen secondary and tertiary care to help them to understand that this is not about taking activity away from them but about wanting to give them more time for the people who genuinely need to be in their arena. That will be made so much more possible if we have the voice of the clinicians in the middle of it. We are short of medics and nurses, so there is plenty of work for everybody. I have a five-year order book for acute services. This is a case of, “Please don’t worry about your jobs. What I’m desperate to do is get the right patient in front of you so that you can be the best person you can be.”

Absolutely. You mentioned 60 beds being removed. You are looking to reduce supplemental staffing support by half, which by my calculation would be 475 full-time equivalent positions. How can you do that without impacting on patient care, especially when waiting times are already increasing?

I do not think that it would involve quite that many staff, just because of average salaries.

When we rolled forward, we had 185 additional beds in the acute system. That additionality cost us £13.5 million last year and has made everything else slower. Our average length of stay in Ayrshire is longer than the average in many other parts of Scotland because we are spread too thinly. For us to reduce our average length of stay to the average for Scotland, I would have to have no additional beds. Because of our additionality, we also immediately have £13.5 million against our deficit. If we were to get to the upper quartile of lengths of stay, I would have two empty wards. Two empty wards would give us £3 million to do whatever can we do differently, and/or flex for winter.

I am very careful where I have these discussions, because when you look at the system at the moment, where we have people who are living in a malaise—that is, in Covid recovery—and we have suboptimal staffing and not enough people to go round, I sound like a lunatic, because there are ambulances queuing outside, so of course the currency must be beds. The currency is not beds—it is workforce and decision makers. They are what genuinely make us efficient. I appreciate that the numbers feel really high, and hearing about averages does not fill one with confidence, but at the heart of running a hospital is the ward round, and wards need teams. I think that you would be hard pressed to find a fully resourced team in any part of my service.

You mentioned the length of stay, which is obviously key, in that you want to get people in and out as quickly as possible. Why is the length of stay so high in your board, and how will you change that?

It is high, first, because of the additional beds. As you have seen, the workforce has gone up, but not all the new staff are on the wards. I am running with minimum staffing levels, which means that I am not making optimal decisions every day for every patient, because there are 185 people in the wrong place. At its peak, we had 200 delayed discharges, so 15 per cent to 20 per cent of the bed base was filled by people waiting to go home. Those are all things that you can go at.

The average waits for a response for patients with my three health and social care partners are between three days and two weeks. It is nobody’s fault. Their operating models are different. South Ayrshire had a model that was heavily dependent on the private sector, and the private sector has withdrawn from home care. Rural home care, in particular, is a very difficult thing to pull off in a private enterprise.

Within what we have, there is absolutely scope to do more and to do things differently, but I have 10,000 people to convince that it is within their gift. When you are working at 110 per cent, it is quite difficult to sound sensible—but that is the job.

Thank you.

Thank you very much, Ms Burden. You have been very frank and open. Maybe it has been beneficial that you have not been in your job for a long time, as you have given us a fresh approach and been prepared to be honest with us. I am very grateful for your input this morning.

Is there anything else that you would like to say that we have not touched on?

No. Thank you very much.

Thank you. That concludes the public part of the meeting.

12:00 Meeting continued in private until 12:21.