I welcome everybody back. The next item on the agenda is consideration of the Auditor General for Scotland’s section 22 report “The 2024/25 audit of NHS Tayside”. I am very pleased to welcome our witnesses. We are joined by the Auditor General, Stephen Boyle. Good morning, Auditor General. Alongside the Auditor General is Rachel Browne, who is an audit director at Audit Scotland, and Eva Thomas-Tudo, who is an audit manager at Audit Scotland. The committee is also joined by Michael Marra for this evidence session on NHS Tayside, and I remind everyone that Joe FitzPatrick is joining us via videolink.
We have some questions, Auditor General, but before we get to those, I invite you to make a short opening statement.
Many thanks, convener, and good morning. As you mentioned, I bring to you this morning a section 22 report on the 2024-25 audit of NHS Tayside, which I prepared under section 22 of the Public Finance and Accountability (Scotland) Act 2000. The report brings to the Parliament’s attention NHS Tayside’s progress in improving mental health services and outlines the substantial issues and challenges that remain for the organisation.
Long-standing concerns about mental health services in NHS Tayside resulted in a critical independent inquiry into those services being published in February 2020. In January 2023, an independent oversight and assurance group that was appointed by Scottish ministers published its final report on the progress made by NHS Tayside against the recommendations from the inquiry. It also identified six priority areas for NHS Tayside to focus on. NHS Tayside and the three Tayside integration joint boards approved the mental health and learning disabilities whole-system change programme in June 2023 to address those priorities.
The whole-system change programme has made some progress, such as decreasing the level of mental health delayed discharges and the backlog of repairs that are needed at Strathmartine hospital, but substantial issues and challenges remain. The planned move to a single site for in-patient mental health services at Murray royal hospital in Perth is delayed and there is a lack of clarity on how concerns relating to the availability of staff and services at the new site will be addressed. Governance and leadership arrangements for the change programme are complicated, unclear and not working well. Progress is not being reported transparently enough to enable good scrutiny and oversight, and there remains a lack of clarity about the purpose, role and responsibilities of the groups that are involved in delivering improvements across NHS Tayside’s mental health services.
In late 2024, the scope for the change programme was reduced in recognition of a lack of skills and capacity to participate in change. There now need to be clearly defined priorities for improvement with specific actions, timescales and costs identified.
I am joined by Rachel Browne, who is the appointed auditor for NHS Tayside. Rachel’s annual audit report, from which I have drawn the section 22 report, covers much of the ground that is referenced in the report that we are discussing today. I am also joined by Eva Thomas-Tudo, who is part of the audit team that supported the preparation of both the annual audit report and the section 22 report. As ever, between the three of us, we will do our best to answer the committee’s questions.
Thank you very much indeed. When I read the report, and even just hearing your opening statement, I could weep, because this goes back, as the report points out, to at least 2018, but also before that. I think of Mandy McLaren, who lost her son Dale, and Gillian Murray, who lost her uncle to suicide around the Carseview site. Those very traumatic and moving human stories drove the Government to establish the Strang review, which led to reports, although we reached a point where there were complaints about reviews on reviews without progress being seen.
I read the litany of conclusions that you draw about the single site provision and what a mess that appears to be, about complicated structures and about stakeholder engagement being unclear. These are all familiar themes that we have been around the circuit on so many times. Meanwhile, people are being failed. It really does feel as though no progress has been made in the course of seven or eight years.
The frustration is very real and reasonable, convener. You are right—this is not a new issue, as I referenced in my opening remarks. Some of the themes have lingered from both the independent review by David Strang and the follow-up review by the independent oversight and assurance group. As I set out in my opening statement, although there is some important progress in some areas such as delayed discharges and the estate, it is clearly not enough. I think carefully about preparing statutory reports on any public body, but the report that we are discussing today sets out some important outstanding issues that remain to be addressed.
It may be helpful for the committee to hear from Rachel Browne. As you know, we make recommendations on findings in our audit reports. The annual audit report was not quite lifted and shifted into the section 22 report, but there is a clear read-across. The annual audit report also includes the response of NHS Tayside management to the recommendations. They are a robust set of responses but, as auditors, as always, we have professional scepticism. A robust response is welcome, but it is the action that accompanies those commitments that really matters. We will look at that by way of follow-up during next year’s annual audit and I will certainly give consideration to further public reporting on this important matter, which is not abstract but, as you mentioned, convener, has very direct implications for patients and their families.
If you are happy, I will bring in Rachel Browne to say a bit more about that.
The health board fully accepted the findings in my annual audit report, which you have before you. When we checked the factual accuracy of the draft audit report and sought agreement with senior officers, the response was immediate. The whole executive team was involved in that consideration and agreement of the management actions in the annual audit report appendix—the action plan. I clarify that I have not performed a follow-up audit in the period since that happened. I will follow up on those recommendations in my 2025-26 audit, which is in its initial planning stages.
I see progress being reported to the board, the audit and risk committee and other relevant committees in the health board. The refocus of the whole-system change programme into two models of care—the general adult mental health model of care and the learning disability model of care—is in its initial stages, and the focus is very much on progressing those models. The general adult mental health model of care is out for consultation now and the other model of care is in development. There was an immediate call to action and a cross-board statement of intent from the health board on how to move forward and step up the pace. We recognise in the report the complexity of whole-system change, and the findings reflect that. There is a realism in the refocus of that very complex work.
In the report, we mention limited capacity and skills to lead change. The health board is looking to get in place a single executive lead, which is one way of bringing in additional capacity and having unity of oversight for all mental health services. There are currently, I think, five directors of the different aspects of mental health services in NHS Tayside, and it is looking to bring in a single executive lead. I understand that discussions with the Scottish Government are quite supportive of that, but it requires the lifting of a ministerial direction from 2020. When the “Trust and Respect” report came out, the direction gave clarity at that point, with responsibility for in-patient services sitting with NHS Tayside and responsibility for community mental health services sitting with the Tayside integration joint boards, led by the Perth and Kinross IJB. The IJBs and NHS Tayside are working together to drive that forward.
11:30
Am I right in thinking that NHS Tayside is still at level 3 in the escalation process?
You are correct, convener. Perhaps it will be helpful if I set out some of the history and the context of the Scottish Government’s engagement with NHS Tayside. In respect of mental health services, NHS Tayside was escalated to level 5 in April 2018, and it reduced to level 4 in February 2019. In June 2021, following the Strang review and the independent oversight group, it was at two different escalation levels, which have remained constant for the four and a half years since then: level 2 for finance, governance and leadership and level 3 for mental health services.
I will invite Joe FitzPatrick to come in in a second, but I have one last question before I do that.
One of the features of the earlier phases of the reviews and the responses from the health board was what David Strang described as overreporting of progress and an optimism bias. Rachel Browne talked about realism and so on. What is your sense of whether the board is being given an overoptimistic picture of what is changing on the ground? What is your sense of whether the board is being presented with cold, hard facts about where things have reached? As I mentioned at the beginning, the section 22 report mentions a whole series of areas where things are not going as they ought to go.
I will offer a thought or two on that and I will then bring Rachel Browne in again. There is something of a mixed picture. As I mentioned in my opening statement, the board has reduced the scope of some of the work. We can look at that in two ways. We can see it as a reduction in services or planned activity, but it is perhaps also a realistic response to the resources that are available. We can look at it in both respects. Then are then the other aspects of monitoring and review not being in place and there being a lack of key performance indicators for progress, which are really important. We also say in the report that the governance and leadership of mental health services are not as clear they need to be. Those are all relevant components of how the system and progress would be monitored and reported to the board.
I do not think that we can take comfort that there has been the kind of progress that ought to have been wanted in the intervening period since the completion of the independent oversight group and the Strang report before that. Rachel Browne will have a closer assessment of that.
In relation to reporting to the board, I would say that my annual audit report drove the reaction across the whole executive team and action across the whole board. I am also the appointed auditor for two of the Tayside integration joint boards, and I am aware that progress reporting has been made to all the IJBs and to the NHS Tayside board. In the month or possibly two months after the annual audit report was produced, there was a whole-board workshop on the issues that considered how the board had got to where it is on mental health services and what the next steps are. Every single board member was involved, either at the workshop or in one-to-ones with the chief executive if they could not attend on the day.
There is that sight on where progress reporting has got to and the gaps that we have reported in both my annual audit report and the section 22 report. The board is sighted on that, and some of the responses to the annual audit report have been driven by the need for effective performance monitoring, KPIs and reporting within clear governance lines.
I highlight for the record that the section 22 report sets out some governance deficiencies in the system. In paragraph 13, we say:
“These structures are not yet working well.”
In paragraph 14, we note that the executive leadership group that had been in place but was disbanded was still being referred to in board discussions. Paragraph 16 cites what seem to be examples of poor governance, including a lack of minutes being taken of meetings, papers not being provided to support good scrutiny, and verbal updates being a feature.
Those are simple but important things. Not having that level of rigour in place serves to undermine good scrutiny, effective governance and, more important, the confidence that the board can give patients and families about how the system is operating. Going back to the detail of the management response, we hope that there will be a sustained response to the recommendations that we make in the reports.
Thank you very much. I invite Joe FitzPatrick to put some questions to you.
As constituency MSP for Dundee City West, which is within the NHS Tayside area, I am acutely aware of long-standing, widespread concerns about the provision of mental health services across Tayside. Like other colleagues, I am regularly contacted by constituents who have difficulty in accessing support. I am often contacted by families and friends of constituents who have not received anywhere near the level of support that they should have had. I am in contact with NHS Tayside on behalf of constituents every single day. Mental health provision—or the lack of it—is more often than not the reason that my intervention is required.
As we heard, David Strang was appointed chair of the independent inquiry into mental health services in Tayside in July 2018. His final report was published in February 2020, and the independent oversight and assurance group published its final report in 2023—yet here we are now, at the end of 2025. I know that my constituents in Dundee will be asking what progress has been made.
I am extremely concerned that NHS Tayside simply does not have the required expertise to make the substantial improvements to patient care that your report highlights or to improve confidence on the part of members of this committee, members of the wider Parliament and, most importantly, people living in the NHS Tayside area. I would be grateful for the Auditor General’s view on whether we have now reached the point where external oversight is required.
I will point to two aspects, but I do not think that I will yet be able to give you—or, indeed, the committee more widely—the assurance that you seek through your constituency responsibilities.
In a moment I will turn to Rachel Browne to talk about the governance and leadership changes that have been made. Although those are important, they are new changes—they were perhaps made in response to this report but might have been coming anyway. The management response that has been touched on feels robust but, again, to echo that professional scepticism, as you set out in your question, Mr FitzPatrick, we are not in new territory in there being concerns about mental health services in Tayside. What clearly matters is that there is sustained follow-through that builds the confidence of elected members, the Parliament, and patients and their families.
From an audit perspective, we will make recommendations, as we have done, and as Rachel Browne has done in her report, and we will follow through and report publicly the progress made on those. It will be for others to determine leadership structures and how those are supported, along with deciding whether the Scottish Government’s quite well-established arrangements for support and intervention are doing what is necessary to support the required changes in mental health services in Tayside.
Rachel Browne can say a bit more about recent developments in executive leadership and the governance changes that have been brought in.
In recent months, the chief executive has created an enhanced monitoring and scrutiny executive team, which involves fortnightly oversight to review progress on the mental health services programme and the development of the medium-term delivery plan and the models of care. That executive-level oversight happens very regularly.
The health board has also been in contact with the Scottish Government on the potential to bring in a single executive lead for mental health services. It is hopeful that that will happen in the near future, which would provide capacity and leadership for change.
The health board has also expanded the programme management office, which exists to support those who are driving change activity and to provide extra capacity.
I will follow up on the effectiveness of the responses to my audit report and the section 22 report as part of the 2025/26 audit, but those are the key governance arrangements that are in place.
The health board is also looking to set out, in a simple, understandable way, the governance arrangements for that change activity, because our report recognised that the lines of governance and accountability are complicated and unclear.
That is really helpful. My point is that there is a lack of confidence and it will take a long time for that to be restored. One factor that would help would be more transparency. You talked about having regular meetings. Will those be held in a transparent way such that my constituents, and the constituents of other MSPs in the room, will be able to access them, so that they can see that change and the required oversight are actually happening?
At this stage, I do not know what the health board’s plans are. That is a question for the board itself to answer.
Okay. That is fine, thanks. The challenge is that we have heard so many positive managerial words over the years that more transparency would be really helpful. I will leave that there for now. You may be right that I should perhaps put that question directly to NHS Tayside.
Your report also stated:
“The mental health and learning disabilities Whole System Change Programme (WSCP) in Tayside has made some progress in addressing the issues identified by the subsequent IOAG, but substantial issues and challenges remain.”
Could you advise us of the areas where progress has been made and those where issues and challenges remain?
In a second I will turn to Eva Thomas-Tudo to set those out in a bit more detail. In the first item in the section 22 report, in exhibit 1, we set out aspects of that progress. For example, mental health delayed discharges have decreased, and there has been progress on consideration of the estate.
As you mentioned, there is quite a tale to the reviews of mental health services, together with the Strang reviews and then the independent oversight and assurance group consideration. I think that the fundamental issue that remains to be addressed is the single-site provision.
A decision was made back in 2018 to move to a single site, which was identified as Murray royal hospital. Seven years later, we do not yet seem to be sufficiently clear on if or when that move will be made. Staff and others have significant concerns about the suitability of the site and how they are being engaged with. There are clearly still matters to overcome.
Although I mentioned some positive developments in delayed discharges for mental health-related discharges, we are not seeing the same level of progress on learning disability delayed discharges. Again, although there are some positives, significant and perhaps fundamental issues are still to be addressed.
If you are content, Mr FitzPatrick, I will turn to Eva Thomas-Tudo to set those out in a bit more detail.
I am happy to touch on that latter point in a little more detail.
The high levels of learning disability delayed discharges have been quite a long-standing problem, and plans that were put in place to address them have not progressed. NHS Tayside planned to recruit a complex care discharge lead, but the recruitment process was delayed. There was also a lack of suitable community provision for patients with very complex needs in Tayside, and those issues have not yet been resolved, either.
11:45Tayside has been working with health and social care partnerships to explore options such as developing shared accommodation across all three HSCP areas, but there is not yet a clear plan in place to address those delays.
Is there any suggestion of when that plan would be put in place?
We did not get that answer. I do not know whether Rachel Browne has received any further updates since our review was carried out, but we did not get a clear response on that.
There is a phased approach to the move to Murray royal hospital, but the dates for that are still to be determined because one-to-one discussions are still happening with staff about whether they will transfer. Those are very much in progress, so I cannot give you a date for that.
Okay. That is obviously a really important part of any such process. Thanks for that.
Auditor General, your report says that you
“expect to see NHS Tayside implement these actions within the timescales it has committed to”
and that you will
“continue to monitor progress with the issues highlighted in the report and consider further reporting as necessary.”
I know that the First Minister is also actively monitoring the situation and has committed to undertaking a review next month. Can you advise the committee what NHS Tayside has committed to and the options available to you for further monitoring and reporting?
Yes, I am happy to do that. I followed the exchange between Mr Marra and the First Minister at First Minister’s question time when the First Minister made those remarks.
On the information that we have from NHS Tayside on its response to the audit recommendations, some of the timescales have already passed: some were in October, and others related to the delivery of KPIs by the first of this month.
Of the key recommendations, there are management responses both to accept and to set out what will be done. Whether that would allow for definitive assurance would take a little bit longer than the date by which the recommendation should be implemented, only because of what has gone before. I say that not to question or challenge the appropriateness of the management responses, but rather to see that change is embedded, which feels like the fundamental next step.
As Rachel Browne mentioned, we will follow up those aspects and report publicly through the annual audit. Likewise I will give proper consideration to further reporting to Parliament on the progress that NHS Tayside is making during 2026.
Thanks very much for that. That will definitely be appreciated by my constituents.
Okay, thank you very much indeed. I invite Graham Simpson to put some questions to you.
The report focuses on mental health, quite rightly, but there is a section that deals with the general financial situation in NHS Tayside. We have discussed the financial situation of other boards.
Other boards have had to have brokerage from the Scottish Government—another way of putting that would be that they have been bailed out—but luckily NHS Tayside did not need any of that in 2024-25 to break even. However, it did rely on non-recurring savings and there were some late allocations. For me, that poses a bit of a risk. Do you agree?
We have said in both the NHS Tayside report and in evidence to the committee on the other two NHS section 22 reports in the past couple of weeks, on NHS Ayrshire and Arran and NHS Grampian, that there is a need for greater transparency around how brokerage or late funding allocations are made by the Scottish Government to NHS boards that are anticipating that they will not be able to break even.
NHS Tayside is different this year. As my colleagues confirmed, it was one of the boards that previously received brokerage. It did not need brokerage during 2024-25, but, as we say in paragraph 6, in order to deliver its financial targets it received late funding allocations and relied on non-recurring savings.
I will bring in Rachel Browne; she will have looked at this closely during the audit process. It is perhaps indicative of the fact that NHS Tayside is still experiencing significant financial challenges to deliver its service objectives and meet its financial targets.
The committee will be aware that we published our annual report on the NHS in Scotland earlier this month and we will have the opportunity to give evidence to you on it early in the new year. That report sets out the need for more transparency about how NHS boards are receiving financial support from the Scottish Government, whether that relates to brokerage, progress against savings or late funding allocations, and what that means for their financial position and their ability to deliver for their populations and meet the targets set for them by the Scottish Government.
Just for completeness, I add that, no, NHS Tayside did not need brokerage this year; through a combination of other measures, it delivered financial balance. I will bring in Rachel Browne to say how that manifested.
I have concluded that NHS Tayside’s financial management arrangements in general are effective. However, it does rely on non-recurring savings and late allocations. NHS Tayside delivered cash-releasing savings of £36.1 million last year, but that was still a shortfall against its target. I note that only £18.9 million of those savings are recurring, so my recommendation to the health board is to focus on improving the delivery of targeted recurring savings plans.
In the current financial year, the health board is noting a shortfall against its savings plans this year. There is strong financial management in the board, but I also note that service delivery models are not financially sustainable. The significant financial sustainability risk continues for the health board, and it needs to redesign services to ensure financially sustainable services going forward. That is not unique to Tayside, but the position is that it is delivering savings, although it has a shortfall against its target.
There are financial recovery plans in place for the current year, and reporting indicates that they are having an impact. The sustainability and recovery group has delivered just under £28 million in the current year, which is still short of target, and the health board is projecting an £11.4 million deficit for 2025-26. Those are continuing issues that are being faced and managed by the health board; those issues and the risk around the sustainability of services continue.
Just to be clear, this year it looks like it will be £11.4 million short?
Yes, that is the latest reported position to the board.
Will that impact on the services that it can deliver?
The health board will be managing what savings and financial recovery actions it can to shrink that gap and it will be in discussion with the Scottish Government about any support that may be available for that. Last year, that support manifested itself in the £12.5 million allocation at the end of the year to address acute system pressures.
Except that the Scottish Government has made it clear—I am not quite sure how it will achieve this, given the state of play in a number of boards—that it will not entertain any more brokerage. NHS Tayside has a shortfall of £11.4 million. I am not asking you to come up with a solution for the Government, but you can see the problem, can you not?
I am sure that we will cover this when we speak to you in the new year about the NHS overview report, but you are right. We think that there needs to be more transparency. If there will not be any more brokerage, what will happen to NHS Tayside or any other board that is not able to deliver within the financial resources allocated to it? More clarity on that is required.
On the one hand, you might think that it is welcome that NHS Tayside did not need brokerage during 2024-25. However, receiving a late funding allocation is another form of recognition either that there are financial pressures or that support is required to meet service requirements within the board. Setting out clearly how the Scottish Government will manage different scenarios feels like an important next step.
Of course, I welcome the fact that the board did not need brokerage, but that masks bigger problems. There is the fact that it has had to rely on non-recurring savings. In the year that you have looked at, £18.9 million of the £36.1 million savings were recurring, so the rest were non-recurring. That is quite a significant figure, is it not?
It is a significant figure, and it has been a consistent feature of how health boards have delivered their financial position that they have used typically a combination of recurring and non-recurring savings, brokerage or late funding allocations to get them over the line.
I agree with the point that Rachel Browne made: it is not a sustainable model to continue to look for non-recurring savings. You can see the strain, with seven health boards in 2024-25 requiring brokerage to get them over the line. That sense of their ability to keep delivering non-recurring savings is evidence that the Government is having to provide brokerage to get them into a balanced financial position.
Thanks, convener. I will leave it there.
Okay, thank you very much indeed. I invite Colin Beattie to put some questions to you.
The report shows that mental health delayed discharges generally decreased, but delayed discharges in learning disability services were high. Is there a reason why the figure is particularly high compared with regular mental health delayed discharges? I am not sure whether you would say “regular mental health discharges”, but you understand what I am getting at there. Why the differentiation, and why is there a specific issue with learning disability services?
I will bring in Eva Thomas-Tudo to set out why there is a difference between the two types of service requirements and why there are particular challenges associated with learning disability services.
For learning disabilities patients who are experiencing very long delayed discharges—some over a year—the reason why the board has been struggling to discharge those patients into community settings is largely the lack of community provision in Tayside. The board has been working with the health and social care partnerships in the area to identify suitable community provision, but it has not yet been able to find a solution to the problems in providing suitable accommodation for patients in the community.
What is the target for delayed discharges versus the actuality?
I do not have that detail.
We can come back to the committee in writing with the latest position that is reported on target versus actual performance. As Eva Thomas-Tudo said, some of those cases will be complex and are about the availability of suitable accommodation support packages outside of hospital. Rachel Browne might want to say a bit more, as she mentioned our role in terms of the IJB, but if we do not have the information to hand, certainly we can either signpost the committee to it or come back to you in writing on that point.
Presumably—Eva Thomas-Tudo might be able to comment on this—it is not actually a systemic problem; it is simply supply in the community that is the problem.
I will bring in colleagues in a second, but it is a combination of both of those things. In our work programme, we will soon be publishing—early in 2026—a wider report on delayed discharges and how the system in totality is working for the throughput through hospitals.
I appreciate that the committee is very familiar with some of the wider pressures in the NHS and that getting people into an appropriate setting as quickly and safely as possible is a key part of how the system either is or is not operating in different parts of the country. Again, I will pause in case colleagues want to come back on some of the specifics.
12:00
Perhaps your colleagues could also comment on the lack of a plan to reduce the delays and what more could—and should—be done in that regard.
I will comment very briefly. First, I do not have the actual versus target performance information at this point.
Availability of community provision is the key reason. In some instances, I understand that there is no suitable provision in Scotland, so it is a case of constructing provision in the community. I believe that responsibility sits with the integration joint boards for commissioning those community models.
I do not have to hand information on planning to reduce delays. I know that there are some active discharge plans for patients who are waiting for a newly commissioned model to be available, and the intention is that they will be discharged in the first half of 2026. However, in terms of the detail, I would need to get further information, or you would need to seek that from the health board.
You are talking about community-based solutions. Would those entail the construction of a specialised centre where people with these disabilities could be moved for their support, or do they go out into the community as individuals scattered around? I am just trying to get my head around how the IJBs are approaching the issue.
I do not know the detail of the plans. My understanding is that there are discussions between the three Tayside integration joint boards—the health and social care partnerships—about the possibility of shared accommodation. Some individual patients would need an individual placement. It very much depends on the individual’s needs.
We absolutely recognise that when an individual patient is discharged from hospital to a more homely setting than a hospital can provide if hospital care is no longer clinically required, that setting has to be appropriate for that patient and their family. However, in exhibit 1, we set out that some of these delayed discharge cases are of long standing, and that NHS Tayside and the three IJBs do not yet have a clear plan in place to reduce the delays. It feels fundamental and really important that progress is made. If that requires appropriate accommodation to be either acquired or built, that should be factored into plans. The extent of the delay is the issue that has to be tackled.
Are they actively working on coming up with a plan?
We say in the report that we have not yet seen a clear plan to reduce the delays. NHS Tayside, together with the three IJBs, will be better placed to explain where they go next with that issue.
Okay. I will move on a little bit to look at the change programme in support of “Living Life Well”. You comment that there is
“a lack of capacity for staff to lead and participate in change”
and that
“The new models of care workstreams and priorities had not yet been agreed, and there was not yet a clear delivery plan in place with specific actions, timescales and costs.”
You also say that the change programme is “overly complex”—I would like to understand that complexity a little bit more—and that it lacks a “clear delivery plan”. I am interested to hear more about the delivery plan that NHS Tayside is thinking of.
Finally, in your view, what needs to be done urgently to make the programme deliverable?
I will start with your final question, and Eva Thomas-Tudo and Rachel Browne can talk the committee through some of the judgments that we have made about “Living Life Well” and the whole-system change programme.
What needs to be done is the production of a clear, realistic plan—it is as simple as that. There needs to be a plan that is appropriately resourced, with staff engagement and appropriate engagement with patients and their families; with clarity about how it will be measured and monitored, and appropriate KPIs; with the right governance to support oversight; and with clear leadership.
What I do not want to risk is that people say, “Well, that is all very straightforward and simple.” If it was that easy, it would have been done by now. The issue is that it is taking too long to address the issues that are set out—and certainly not for the first time—in this report. The system can come together—NHS Tayside, the local authorities and the IJBs—to find appropriate solutions faster than is already being done for patients in the area.
I will bring in Eva Thomas-Tudo first of all and then Rachel Browne to respond to the other points that you made.
Before they come in, I have one question for you based on what you have said. Things are not moving as fast as they should be. Is there a willingness among the different stakeholders to work positively together towards a solution?
That is a question for the leaders of the organisations themselves to best evidence. What we have seen—and Rachel will have seen this through her audit work—is that there is a commitment. We have seen a renewed commitment in the management responses to our audit recommendations. However, we have had commitments before. That is why I do not wish to give you false or additional assurance. I think that the assurance that you will get is from action in tackling the challenges that are set out—and not just in the report that we are considering today. That is what matters most next.
It may be helpful to provide a bit of context. The whole-system change programme that was introduced in 2023 came on the back of the IOAG’s finding that the “Living Life Well” change programme was overly complex. The whole-system change programme was put in place to streamline that and make it more achievable. However, our review found that there was still a lack of capacity for staff to participate in change and to take forward the change that was needed.
Therefore, late last year the board decided to reduce the scope of the whole-system change programme again, in recognition of the need to streamline it further. It is taking forward the models of care as its next iteration of the change programme.
Rachel Browne’s report this year—the external auditor’s report—recommended that refreshed priorities for improvement are now needed as part of the new models of care, with a clear implementation plan and clear timescales and costs, and information about how the work will be resourced to make sure that it is deliverable.
I suppose the word I keep coming back to is “complex”. You talk about streamlining and so on. Have the organisations involved recognised that the change programme is overly complex?
There has been a response in terms of some of the programme governance and oversight arrangements. The whole-system change programme has evolved recently into the adult mental health and learning disability models of care programmes. At the risk of repeating myself, that might be an evolution into a different arrangement—an oversight and governance arrangement that is seen to be less complex.
Some of the planned changes to executive leadership that Rachel Browne mentioned might well be an appropriate next step, as well as giving an individual director more focus or authority to drive through some of the changes that are necessary. We are in a bit of a wait-and-see position at the moment as to whether any changes that come through are effective. That will be the key test.
I will move on a little bit down that road. The report also said:
“Our review found it was not clear what stakeholder engagement was carried out, or what indicators were used”
to make the assessment that the system was working well. Given that there is a mismatch between the WSCP board’s assessment and NHS Tayside’s view of the progress on integration, how confident are you that governance and leadership arrangements are supporting genuine integration across the system?
Eva Tudo-Thomas can take that question.
To expand on that point, the whole-system change programme board did a review late last year of its workstreams as part of a request from the Scottish Government for an update. It assessed that indicators suggested that the integration was working well and that stakeholder feedback showed that things were working well across the system. However, when we asked for evidence of what informed that assessment, we were not provided with any detail about how the assessment was made, so that led to the conclusion in our review.
This may be my last question. Apparently, there has not been much in the way of engagement with the workforce workstream. The report mentions that
“In October 2024, a review of progress acknowledged that this was not meeting as a formal workstream but reported that staff engagement was under way across the change programme ... It also acknowledged that there lacked a systematic approach to staff engagement.”
What improvements does the WSCP have to do to make engagement meaningful and ensure that staff engagement is incorporated going forward?
You have said much of what we set out in the report. I will repeat what the report said, just for completeness.
A workstream on staff engagement was introduced and
“In October 2024, a review of progress acknowledged that this was not meeting as a formal workstream but reported that staff engagement was under way across the change programme.”
However, the review also noted that a systemic approach to staff engagement was lacking and what are now referred to as “collaborative conversations” have been introduced. Those involve meeting with staff members every three months. We conclude, however, that it was not clear how those will feature in decision making.
As we have touched on a couple of times, of course the views of staff matter. They have to be persuaded, supported and given the right conditions and environment in which to deliver services for their patients. As Mr FitzPatrick mentioned, the move to Murray royal hospital clearly remains the biggest sticking point. How that is overcome or addressed is a matter for NHS Tayside. It needs to find a way through and to appropriately engage with its workforce to deliver the services that the workforce is there to provide.
It certainly seems to be a huge deficiency if NHS Tayside cannot take the workforce with it. I will leave it at that, convener.
Thank you. I now invite Michael Marra to put some questions to you.
Convener, I thank you and the committee for your forbearance and allowing me time to ask questions, and I thank the Auditor General for what is, I hope, a very useful report. You have highlighted, rightly, that there have already been an awful lot of reports from various sources.
To start with, I want to follow on from Colin Beattie and ask about delayed discharge. You have said that things are taking too long and that there is no clear plan in place. Ryan Caswell, a constituent of mine, has been a delayed-discharge patient for five years and 10 months in completely inappropriate settings. I have raised his case again and again and again and again, but there seems to be no progress in getting him out of that inappropriate setting and into another situation.
My question, then, is this: is the structure limiting progress? You have touched a little bit on the interaction between the health board and the IJBs. In the research that you have done and the work you have looked at, is the relationship between the IJBs and the health board just too intractable to deliver an outcome and make the change?
12:15
First of all, I am not familiar with your constituent’s case, but as an example of delayed discharge, it is clearly a matter that needs to be addressed.
The whole system exists to provide people with either an appropriate setting in which to receive care or support outside in a homely setting. I do not think that we can conclude that the system is not working well, because there are systems and partnerships across Scotland that are able to deliver services appropriately.
Forgive me—I do not know the complexity of the case that you have referred to, but I am sure that it is not an indication of any unwillingness in this respect. Clearly, there are factors that need to be addressed. In other parts of the report, we touch on issues such as leadership and governance, oversight arrangements and the monitoring of progress that are not working well enough to address the very real issues that your constituents are presenting with.
There have been changes in executive leadership, governance and oversight, but they are very new, and they all have to come together effectively if they are to tackle the very real issues that are set out in the report and which you have mentioned.
You started the evidence session by talking about the issue of leadership, Auditor General, and the comment in the report about NHS Tayside having
“Limited skills and capacity for leading and participating in the”
whole-system change programme really jumps out. You have said that the board is trying to bring in a single member of staff to do that work, but can you say more about where that capacity and that capability are missing? Is it in the IJBs, or is it in the central leadership? What is the deficit that the board is trying to make up?
Yes, I am happy to say more about that. I will probably bring in Rachel Browne, too, because she has looked at this from an audit perspective. However, there might be limitations in the view that we can offer, because some of these things are planned or new changes.
Before I turn to Rachel, I will draw on some of the wider conclusions from her audit work. We are not identifying deficiencies per se in the wider leadership or governance of NHS Tayside; instead, our focus is very clearly on its mental health services. That is where the intended action with regard to the mental health executive leadership group is now planned. Changes have recently been made to the executive leadership of the board, too.
Some of that will take time to embed, but that is what has to happen now. The impact of the change and the plan has to be felt by the patients of NHS Tayside. However, Rachel Browne can set out more of that detail.
I can briefly give you some information on that. There have been changes at executive level in NHS Tayside, including a new chief exec who has come in.
There have been such changes almost every year.
Yes, there was an interim chief exec last year, and there is now a permanently-appointed chief executive. There is also a new chair of the NHS Tayside board, who comes with Healthcare Improvement Scotland experience. I should say that the chief executive has brought in new corporate objectives in order to bring a renewed focus on driving change in NHS Tayside and delivering for the people of Tayside.
The change programme, which has now been refocused as the adult mental health model of care and learning disability model of care programme, is being led by very senior people. However, that is just part of their job, not their sole job, so there is capacity stretch, which means that, as I think that Eva Thomas-Tudo has found, capacity needs to be freed up at other levels. People need capacity; the programme management office has been created to provide support for the change programme and to free up some leadership capacity, but, as we have said in our report, there is limited capacity to make things happen and drive them forward.
Was it the new chief executive, or was it one of the previous two in the past three years, who downgraded the scope of the programme? When did the downgrading happen?
It was in November 2024 that the scope was most recently reduced. I was going to say that the chief executive joined in August 2024, but I would have to search for the right page in my report. She certainly came in in 2024.
So, one of the responses of the new leadership team, which you have said is bringing in this different expertise, was to downgrade the scope of the programme. Part of its response to the crisis was to say, “Actually, we need to narrow the focus.”
As I have mentioned to the convener, there are perhaps two aspects to that. On the one hand, you might say that, if you downgrade the scope of the programme, it will fail to address the issues. On the other—and it will be for the executive to speak for themselves as to why the decision was made—it might be about their ability to focus on and deliver against multiple priorities all at the same time. We would recognise that what matters most is having a clear and deliverable plan.
Going back to your earlier example for a second, I am sure that, over the years, multiple commitments will have been made to address your constituent’s requirements, but they have not been delivered to their, or their family’s, satisfaction. Being realistic about what is deliverable and what can be focused on is what matters, alongside committing to a plan, regardless of scope.
I want to stick with the issue of scope for a moment. Will the current scope of the whole system change programme meet the 51 recommendations of the Strang review?
Time will tell.
Is that the intention, though?
Some of the Strang recommendations have already been met. As for the outstanding ones, they will, to an extent, be rolled up into the review of the independent oversight group. It will be for NHS Tayside to set out really clearly how time has evolved in that respect. Some of the recommendations will have been met, and others will have been superseded; indeed, the whole system change programme has now morphed into the models of care programme. That is part of the complexity that we are dealing with in trying to track and monitor progress—that is, finding out whether the system of today can still evidence effectiveness and support.
Is anybody reporting to the board on progress against those 51 recommendations in the report that was brought out? A lot of work went into that analysis. Are those things being reported on? I have to say that I cannot see any evidence that they are. They are being substituted by one programme after another, instead of someone saying, “This is the mission. We need to deliver it. How do we get there?” After all, we are now six years on.
Indeed. NHS Tayside has to satisfy itself in that respect. It has a new board chair and a new chief executive. When it comes to the long-standing issues that we have revisited in the report, recommendations of six years ago might or might not still be necessary, but clearly there are still issues to be tackled. With governance this complex and with changing leadership, there is an issue about scrutiny and transparency that needs to be satisfied, too.
But surely there has to be consistency. Rachel Browne, have you seen in your examination of the issue evidence that the board has asked for, and is seeing, reports setting out progress against the 51 recommendations, or is the reporting against a whole system change programme that might represent some of them but not others and which includes things of different scope? Have we lost focus on the outcomes of the Strang report over the past six years?
The reporting to the board that we reviewed as part of the audit work was on the whole system change programme. Eva Thomas-Tudo was looking at the change in focus in that programme over time—the reporting is on the programme as it is now.
And not on the Strang recommendations.
What we can do, Mr Marra, is go back and check the records of board minutes.
They are not reporting against the 51 recommendations of the Strang review.
They are not doing that.
No.
Okay. Surely, given this changing environment, with different leadership over different periods of time, we should not be losing sight of those recommendations. They came out in 2020, and the progress report, which came back in 2021, has been described to me as
“the worst report in Scottish public life”.
As the convener has pointed out, it showed local bodies in Dundee misleading the public about progress that had not been made. We had the oversight assurance group in 2021, which reported in 2023, and now we have the whole system change programme.
All of that leads me to ask this question: do we not need external leadership to actually deliver this? The current model of leadership is just not working, is it?
As I said to Mr FitzPatrick, that will ultimately be a decision for ministers, taking into account advice that they might get from the chief executive of the NHS in Scotland.
As you know, we will make recommendations, we will follow up the issue and we will report publicly on progress through our audit work. Today’s report sets out that there are significant challenges to be addressed.
Moving on to single site provision, I would note, as an example, the state of Strathmartine hospital, which the Mental Welfare Commission for Scotland reported on in 2018, 2019, 2020, 2021, 2023 and 2024. The 2024 report on the hospital, which set out what I have described as “Dickensian conditions”, was published only half an hour before I had a meeting with the chair and the chief executive of the Mental Welfare Commission. It was months late; it would not have been published, had I not asked for a meeting. You talk about oversight and accountability—these are the reports that the leadership should have been responding to, but were not.
You have said that changes have been made to the physical environment. I agree with that—I have been to the site, and I have seen those changes—but what really concerns me is your comment that there is no clear plan and no costings for the move to single site provision. Do you think that that information has to be provided and put into the public domain by the board, for the sake of accountability?
There absolutely has to be transparency about the intention, but then there has to be a clear, deliverable plan instead of just the intention to have one. That matters, because, for all the reasons that you have touched on, patients, their families and the public need to have assurance and confidence that the plan that the board has agreed to can be delivered upon.
On 2 May, I asked the board when it will next examine the business case and associated costings for the move, and it has still not provided any indication of when it will do so. Has Rachel Browne or Eva Thomas-Tudo seen in their work any evidence that the board has looked at a revised plan setting out the costings for, and the impact of, such a move?
Before I bring in colleagues, I again highlight to the committee that, at the time of our review, it was not clear whether the move was on track, because timescales and expected costs were not available. We found a disconnect between the views of the leadership and the staff on the move, and the risk register highlighted significant risks that had to be addressed.
That is just some context for the record. I will bring in colleagues to give you any further detail that can be provided since our report was published.
I will make a very brief comment. As I said to Mr Beattie, the phase plans are in development. The full resource envelope for mental health services has been identified, but the health board is still having one-to-ones with staff to determine how many of them will transfer to the single site at Murray royal hospital and what the alternatives will be. The outcome of those meetings will determine some of the costings.
Is your understanding of that live—in other words, as of today? I have to say that I have a very different understanding of the completion of the one-to-ones. Staff were told that the process was to be completed by August, but then at the end of June—four weeks before the process was meant to be completed—they were told that it would not be happening. I had been telling the health board for many months that there was no chance of it happening in August—that was absolutely clear.
There has been no publication of the capital costs or the investment in Murray royal hospital that is required; nothing about the overtime required to transfer staff from one place to another; nothing about meeting with bank staff; and nothing about the shortfall. Have you seen plans that actually contain that detail? Has the board examined the cost of making this move versus the need to deliver for patients?
At the time of our review, those things were not in place.
When was that?
That was in May.
In many respects, the questions that you are asking are very reasonable, but they are for the board to give answers to. The purpose of our report is to draw the Parliament’s attention to the findings of our annual audit report. I appreciate that it is a live, fluid environment, and we will continue to track and monitor it.
I suppose that what I am asking—
Michael, you can ask one final question, but then we really need to move on.
Okay—I appreciate that. I suppose, Auditor General, that I am just trying to get you to say on the record that this plan should be published with the costings and a timeline for the delivery of single-site provision so that the board can scrutinise it and the public can see it.
I think that I would highlight your last point; the plan has to be subject to appropriate scrutiny and all necessary engagement with staff to ensure that it is realistic. That speaks to many of the wider points in today’s report. There have been many plans, proposals and intentions set out for the delivery of mental health services in Tayside, but what clearly matters is that the next plan is realistic and deliverable, and we will continue to follow progress and report publicly on that.
Thank you for your tolerance.
The deputy convener has one final question to put to you, Auditor General. Jamie, over to you.
12:30
Most of the ground has been covered by those with far more in-depth knowledge of the subject than I have, but one thing that has struck me throughout this evidence-taking session—and indeed in other similar sessions, particularly on NHS boards—is that these are not new issues. These matters that have been raised by Audit Scotland with previous iterations of this committee as well as with this committee and, no doubt, will be raised with future public audit committees.
However, we are not talking about financial auditing here—people are involved. Indeed, the convener opened the session by pointing out that people are suffering, and sometimes self-harming, as a result of inaction. At what point, Auditor General, does what I can only assume is your frustration at the lack of progress turn into something more statutory? After all, we cannot keep producing section 22 reports year after year after year that say the same thing and still see no adequate progress by, or accountability from, these public bodies. What more can we as a Parliament or as a committee do? Indeed, what more can you, with your statutory abilities, do?
My statutory powers are in evidence today. I have prepared a statutory report on an annual audit report for presentation to the Public Audit Committee, as the accounts are laid in Parliament for Parliament to take evidence on, to consider my findings and then to take any next steps that the committee or others wish to take. To me, that is evidence that public audit is working, because it allows Parliament to take a view, hear from officials and take evidence, if you so decide. That is the system working, deputy convener. I do not think that this evidence session represents a shortfall; instead, it is an example of Parliament’s ability, through the work of Audit Scotland, to take evidence, get greater insight into matters and thereby support scrutiny.
What I do not have—and I do not think it appropriate for Audit Scotland or the Auditor General to have them—are powers of intervention. They would change the independence dynamic that is important in this context. Other audit and oversight regulatory bodies have that sort of authority—indeed, some have been mentioned today—and it is for those organisations, together with the Scottish Government and ministers, to decide on any next steps that they wish to take.
Thank you.
Thank you very much. I will now bring this agenda item to a close and take the opportunity to thank Eva Thomas-Tudo, Rachel Browne and the Auditor General for your evidence. Some things might require to be followed up, and the committee will need to consider in due course whether it will be appropriate to get in representatives from NHS Tayside and ask them further questions.
As agreed earlier by the committee, I now move the meeting into private session.
12:32 Meeting continued in private until 12:47.