Health, Social Care and Sport Committee

Meeting date: Tuesday, March 21, 2023

Official Report 756KB pdf

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Scrutiny of NHS Boards (NHS Ayrshire and Arran, NHS Borders and NHS Forth Valley)

Item 2 is the first in a series of scrutiny sessions with all the national health service boards in Scotland. I welcome to the meeting Ralph Roberts, chief executive of NHS Borders, and Cathie Cowan, chief executive of NHS Forth Valley. Although she is not quite with us at the moment, we expect Claire Burden, chief executive of NHS Ayrshire and Arran, to join us remotely.

I will kick things off. Thank you for coming in today. By no means—[Interruption.] I am sorry; I forgot to go to Sandesh Gulhane first.

Thank you, convener. I declare an interest, having worked in NHS Ayrshire and Arran and NHS Forth Valley.

Thank you. That is now on the record.

We are not singling out any particular boards; we are trying to fit in a session with every board over the next couple of years.

I want to ask about financial sustainability. I am particularly interested in how inflation and the increased cost of fuel are affecting your boards. We tend to talk about these things in domestic terms—how they affect families. That is how it comes out in the media, but such costs will have an impact on your boards and people who need their care. I am interested to hear about your boards’ financial sustainability and the impact of inflation and fuel costs on your operations.

It is a significant issue. The overall position around financial sustainability is extremely challenging. We can get into more detail on that.

Your point about the impact that inflation and the cost of living have on our patients and staff is also important, and they are certainly having an impact on our costs. You will have seen from the draft financial recovery plan that we submitted to the committee that our financial position has deteriorated during the past couple of years and going into next year. There is no doubt that part of the reason for that is inflation. I would need to double-check this, but I think that we are projecting about £1 million more in energy costs going into next year. That is not an insignificant figure. I will double-check that and make sure that I am quoting the right figure.

However, it is not just about energy costs; it is also about procurement costs across the board. Prescribing costs are also going up. Some of that is to do with activity, but I have no doubt that there will also be underlying cost pressures in the supply chain for medicines. We have to recognise that those cost pressures are significant, and the reality is that they are not matched by the general uplift that health boards have had in the past couple of years and will have going into next year.

Like NHS Borders, we pull financial sustainability and value together. The situation is extremely challenging, although we are reporting a break-even position for 2022-23. Our three-year plan, which we have shared with the committee, highlights the areas that we will focus on during that period. Our big focus will be on inequalities and trying to shift resources into prevention through primary and secondary interventions and transformation.

In relation to inflation, we have a unitary charge issue in relation to our three big estates—Forth Valley royal hospital, Clackmannanshire community healthcare centre and the Stirling health and care village. That is linked to the retail prices index, and when inflation goes up, it goes up. We will therefore see an increase of about £5.2 million in alignment with inflation.

We are projecting a 30 per cent increase in energy costs. Like Ralph, I do not have the exact figure and would like to check it, but we are planning for a 30 per cent increase.

The price of medicines is also subject to inflation, and our staff and patients are being affected by the cost of living and by fuel costs. We are keeping a very close eye on our patients and on non-attendance rates, to see whether there are trends within communities.

I was going to ask about that. Are you monitoring the impact that the cost of living crisis might be having on people presenting to you, as well as on things such as staff absence?

We are looking at patients in particular. Our director of public health is looking at links to deprivation categories, so that we can have more insight into how to work in partnership with councils to help our patients get to hospital or to consider how to take services to our patients.

That is really interesting. Ralph Roberts, are you doing something similar to ascertain how the situation is impacting on your patients?

We are trying to. Our public health department is looking again at how it runs services and at what support can be put in to build greater resilience in communities. We are not focusing on individuals, but are looking more broadly at how to build resilience in communities.

I would have asked Claire Burden about the situation, too, but she does not seem to be online yet. I throw the questioning open to my colleagues. Paul Sweeney has some questions for our panel.

My main interest is in how capital investment can be used to drive revenue savings in the national health service. I would be interested to know what your boards have done to utilise capital investment as a way of reducing revenue costs for utilities in particular through investing in things such as district heating networks.

There is a good model at the Golden Jubilee hospital, which has recently worked in partnership with West Dunbartonshire Council to introduce the Queens Quay district heating network scheme. The scheme will deliver a major cost saving for the hospital estate as well as benefiting the wider community and getting people off the gas grid by using the river-sourced district heating network. Could that kind of model, which offers a high return on capital investment, be a way of conquering the current challenge of high utility costs?

We are looking at every opportunity to reduce energy costs in our acute hospital. I do not have the exact figures in front of me, but we are implementing a grant that we got from Scottish Government and are taking every opportunity to reduce costs, particularly for lighting and heating. As you would expect, we are also investing significantly in electric vehicle charging at all our sites to help both staff and patients. We are very committed to that. I do not have the exact figures in front of me—I apologise for that—but I am happy to share information about our schemes.

That would be helpful. Do you have a slate of proposed capital investment schemes and a formula that tells you your expected return on investment?

We do. We take our capital plan to the board and analyse how we use and heat rooms, where we could invest and what the return in benefits realisation would be. We have that information. I do not have it in front of me, but would be very happy to share it with committee members.

That is definitely helpful. Thank you.

Emma Harper has some questions.

My questions are about investments and saving money on energy. NHS Dumfries and Galloway has a £200 million hospital but has not put a single solar panel on the roof. Has NHS Borders assessed the opportunities that would come from investing in solar panels?

09:15  

We are certainly looking at a variety of energy efficiency projects, and solar energy will be part of that. Going back to the previous question, we need to consider district heating systems. I was in Shetland in my previous job, and that was part and parcel of the approach there. The hospital was on the district heating system, but such systems are not that common. There would be no opportunity to do that in the Borders because the local infrastructure is just not there, but we are looking at other forms of energy efficiency.

In our plan for next year, we have assessed potential savings of around £390,000 from a variety of energy efficiency schemes. In the longer term—over 10 or 15 years or more—we will be looking to refurbish and replace our district general hospital. We are conscious that the overall availability of capital is restricted. We have a formula for the allocation of capital for minor schemes, and the vast majority of that is allocated to equipment replacement, infrastructure maintenance and some of the energy efficiency schemes, but we have to build long-term business cases for the more fundamental redesign of our estate.

I want to bring you both back in before I move on to other colleagues—I will bring Paul Sweeny back in in a second.

The purpose of the uplift that you got from the Scottish Government was to reduce waiting times, and, I imagine, to support a certain amount of recovery from Covid. You mentioned that it was not to deal with things such as fuel costs and inflation, because at the point at which the uplift was decided, those issues were not as acute as they are right now.

This is an obvious question—it is almost a rhetorical question—but what is your assessment of how the two factors that we have talked about affect your ability to deal with waiting times?

Our uplift is there to address the broad range of costs that we have, which changes from one year to the next. It is fair to put on the record that in addition to the core uplift that we get, we have had a commitment that, going into next year, the additional funding over the basic level of uplift that we got for the pay awards will be funded separately. It is important to recognise that.

The money that we get for access and waiting times normally comes as a separate allocation. NHS Borders has its NHS Scotland national resource allocation committee share of the waiting times money for next year, which is just over £2 million, and the breakdown of how we suggest we will spend that is included in our submission.

We talk about the financial challenge, but it is important to recognise that although there is no doubt that finances are challenging, the workforce position is equally challenging. The headline figure in our financial plan shows a projected overspend next year in the order of £22 million. However, the reality is that if you gave me an additional £22 million tomorrow, I could not spend it, because I would not be able to recruit the staff.

The challenges around access are not purely about the money. They are as much, if not more, about our ability to attract the workforce that we need and create the capacity in the system as a result of that workforce, which then allows us to protect our elective programme.

A number of colleagues are going to look at staffing, but that is a good and helpful basis for that discussion.

My comment is similar to Ralph’s. Our 2 per cent uplift, which equates to around £12.4 million, and our NRAC share, which is £600,000, has been added to our baseline of £630 million. We have in-year allocation of just over £108 million to come in, and we have factored that into the plan, which we have shared with you.

As Ralph says, workforce is a big issue. We took a decision in 2021-22 to invest in the workforce in a recurring way, which has benefited our scheduled care position. Members will see that our scheduled care position is reasonable compared with that of other areas, but there is still a long way to go when it comes to patients waiting. Taking that decision has given us an advantage. We took it through a risk-based approach with regard to non-recurring allocations coming year on year and, rather than using that money in a non-recurring way, we decided to invest recurringly. Taking that decision has paid dividends for us. However, as Ralph Roberts has said, we are now all looking for a workforce together, and that workforce is short of workers in certain key areas.

I will not impinge on my colleagues who want to come in on staffing.

Thank you, convener, and good morning. I want to follow up on the issue that was raised around people attending inappropriately, if you like. There was an ambition in the recovery plan, as part of the review of urgent care, to reduce the use of hospitals as the first port of call by 15 percentatge points to 20 per cent, although Audit Scotland highlighted that there has been a lack of progress on that. Are you tracking the number of people who attend accident and emergency as their first port of call when that is not the appropriate setting for them? What impact are those attendances having on the overall budget?

My background is nursing, and I worked in an emergency department a very long time ago. I am a bit cautious about people attending inappropriately. At NHS Forth Valley, we are very keen for patients who could have gone elsewhere to redirect, but we are also keen to provide support and education so that the next decision that they make is the right decision—the right place, right time, right personnel and so on.

I worry about older people, in particular, who hear messages about us being really busy—they are the patients who usually do not turn up, but I suggest that they are the patients who should turn up. We are taking a measured approach, including through our triage system. When people present to the emergency department, they quickly go through primary triage, and we are very clear in saying when a patient could go elsewhere—to a pharmacy, the minor injuries unit in Stirling or wherever—and in doing redirection and education work about what else is there, particularly with mums who have young babies. We do a secondary triage so that people are very quickly moved around the department to meet their needs.

The emergency access standard is a system measure, and it is not even half of the story; behind that measure are a number of critical safety measures. As chief executives, Ralph Roberts and I watch our time-to-triage numbers very carefully, and when it starts to creep up over 15 minutes, there is a safety alert in our systems that make us think about what to do next. I say that in answer to your question about redirection.

There are people who are repeat offenders—they turn up when they could go elsewhere—but our approach is that we try to educate the public in our space and we look to national campaigns to support that. I hope that that is helpful.

I echo everything that Cathie Cowan has said. I want us to understand slightly better what is going on. If you look at the overall numbers of people coming through emergency departments—certainly those in our system—you will see that they are only just back to, or slightly under, pre-pandemic levels. That suggests that a number of patients are now being seen elsewhere in the system and that those who are coming into emergency departments are the ones who absolutely need to be there. We have our flow navigation centres—that is our primary care bit at the front door, which is streaming out some patients.

From the data that I have seen, there is no doubt that the level of activity in primary care is higher than it was pre-pandemic, although it is not as good as I would want it to be. We are making progress in ensuring that people are seen in the right place. Our front-door clinicians do not say to us that they are seeing a lot of patients that they would say were inappropriate. As Cathie Cowan has said, the challenge and responsibility for us is to ensure that, when patients come in through the front door, we triage them and, where appropriate, we turn them around and signpost or move them on to other services; where appropriate, we treat and discharge them; or, where appropriate, we assess, admit and treat them.

Paul Sweeney will now ask questions about performance, although we have touched on that already.

The witnesses have already talked about people presenting at A and E departments. Among member countries of the Organisation for Economic Co-operation and Development, Scotland has the highest acute hospital expenditure but the lowest preventative and community-based expenditure. The equation seems to be very lopsided. There are worrying metrics that show that there is, for example, low provision of key diagnostic equipment and beds per capita. Do you tend to keep track of those metrics? For example, do your boards keep track of how the provision of MRI or CT scanners per capita compares with international benchmarks?

We do not measure our service in that way, but we are very conscious of the level of capacity in our diagnostic services. As part of our access plan for next year, we are providing additional mobile CT and MRI capacity. We have just gone through a process of replacing our MRI scanners, and we are due to replace our CT scanners next year so that they are up to date. Instead of looking at things on a population basis, we focus on the capacity and demand in our system. To some extent, given that we cover a relatively small population, the figures would be skewed if we looked at things purely on a population basis.

We are very conscious of our diagnostics. We believe that we have a very good record of performance against our cancer targets, and a key aspect obviously relates to the diagnostic stage of someone’s cancer pathway. We focus an awful lot on ensuring that we have the capacity to deliver against our targets.

I will jump to the other end of the patient journey in acute hospital settings. Do you actively track the opportunity costs of delayed discharge in hospitals and the impact that that has on your overall capacity to deliver community-based services? Is there almost a reflex situation in which delayed discharge denies us opportunities to invest in more appropriate care settings?

There is no doubt that delayed discharge is a very significant issue. We monitor daily where our delayed discharges are and what they are waiting for. The responsibility is with the whole system. It is not just about social care; it is about the way in which our clinicians make decisions and how we support people through the system.

Something like 30 per cent of our beds in the Borders are currently occupied by delayed discharges. Before the pandemic, there were probably about 20 delays at any one time, and we felt that that was too high at that point, because, notwithstanding the impact that delayed discharge has on the system, every delay represents an individual not receiving the care that they need at the right time in the right place.

We have been running at upwards of 50 delayed discharges—yesterday, we had 68 in our system. That represents a huge opportunity cost. One consequence of delayed discharge is its impact on our elective capacity. Another one of the number of issues is that delayed discharge increases the overall length of someone’s stay, so we have been required to open additional beds, which we have struggled to staff. That has had a knock-on impact. As of yesterday, we had 15 additional beds open in the hospital. Up until last week, that number was 20. We have also opened eight additional spaces—which we aim to staff—in our emergency department to reflect the fact that we have additional people in our system. Delayed discharge is therefore a fundamental issue.

It certainly is, as you have observed. Can you envisage a viable mechanism for unravelling the situation so that a more sustainable approach is taken? It seems very much to be wrapped up in a self-perpetuating cycle at the moment. How do we recover the situation?

09:30  

For me, there are two issues. One is ensuring that, in the health system, we make the right decisions at the right time to support people through their treatment programme, and that includes the point at which we make decisions around what sort of support they will need. We discharge well over 90 per cent of our patients without any delays, and it is important that we remember that.

During the past six months, we have done quite a lot of work focusing on continuous improvement of our individual processes. There are issues around realistic medicine—or value-based medicine, whatever phrase you want to use—about the choices that clinicians make with patients about the level of treatment that is appropriate for their needs and without being unrealistic about that.

However, beyond that, there is no doubt in my mind that there is an issue with the level of social care support that we have. I recognise that a large part of the driver for that is the recruitment and retention issues that exist in social care—I have a lot of conversations with our social care colleagues about that. The health and care systems have to address that.

I do not want to repeat everything that has been said but, yesterday, our system had 93 delayed discharges in it. On top of that, we had just over 50 transfer waits. Those have a huge impact, particularly on the acute site. That also has a huge impact on our four-hour emergency access standard, because that is a system measure, which means that it has implications. Included in those figures, we have about 33 patients who have adults with incapacity issues, and we are thoughtful about how we support families through the decision-making process.

Equally, I would not want you to think that we are not investing in prevention or community care, because alongside that—similar to Ralph Roberts’s board and other NHS boards—we have been particular about investing in respiratory pathways and in community teams so that we treat patients at source when they present at hospital. We have put a big emphasis on outpatient parenteral antimicrobial therapy, so we are doing that in the community.

We also focused on a rapid assessment and care unit so that patients go through a different front door when they present at the hospital with issues related to that. That means that we redirect ambulances and so on to treat patients who have long-term conditions. If they have heart failure, we want to do a quick and thorough diagnostic assessment so that we can support people in the community.

Our whole-system approach is very much about prevention. The thing about prevention is that it takes a while to see changes come through, but it is absolutely the right thing to do.

Coming out of the Covid pandemic—although we still have a lot of Covid around; we have 40-plus patients at our acute site today—we are very keen to focus on how we support an infrastructure that takes account of patients who did not present during Covid, and who have high blood pressure and so on. That could also include some of the secondary prevention around diabetes and hypertension, for example. I agree with Ralph Roberts that the patients who present are acutely ill; we see that acuity at the acute site, and we are desperately trying to sort that out, but we also think about prevention.

Okay. You mentioned the preventative spend bill, and I want to ask about preventative maintenance, in particular. We know that some health boards have severe repair backlogs on capital investment. Such repairs can end up becoming far more expensive over time if they are not preventatively tackled. Is that a challenge in your health boards? Do you have a repair backlog that is concerning? Is it a risk that you see to be significant? How do you approach preventative maintenance?

In our health board, we are fortunate—although unfortunate in respect of the conversation that we had earlier about inflation and the RPI, and so on. We have one facility in our community hospital estate, in Falkirk, and there are some issues at Bellsdyke hospital, where we have about a £30 million backlog. We are addressing that through our capital spend and ensuring that our decisions mean that we are using our estate really appropriately.

The other big area that we are considering as a whole system with the local authority is our primary care infrastructure, because if we are serious about supporting services in the community, we have to ask what that infrastructure should look like. Some of our primary care facilities are really outdated. Notwithstanding what Ralph Roberts said about capital and business case development, we have a programme of investment to turn those facilities around.

We are thinking with the council about whether we can do things jointly to add value to the public purse.

We must move on, Paul. A lot of members want to come in.

Claire Burden has now arrived. She had significant connection issues. Good morning, Claire. I will not bring you in immediately and try to make you catch up with everything that you have not heard. You can put an R in the chat box if you want to come in on anything but, otherwise, I will leave members to bring you in.

Gillian Mackay has a question.

My question on this theme has been adequately covered so, in the interest of time, you can move on, convener.

I have a supplementary question on the back of what Paul Sweeney asked about the availability of CT scans, additional capacity and prevention in the community. On Friday, when we met at our usual elected members briefing, Ralph, you talked about how beds were used as a currency when we should be looking at the services that are delivered, such as pulmonary rehabilitation or mental health care in the community, which prevent acute admissions.

A lot of work is being done on how we deliver things differently. I heard about a diabetes outreach bus that is being developed in Glasgow by Dr Brian Kennon, which goes to Ibrox stadium, for instance, and helps to do some of the health inequality outreach for people with type 2 diabetes.

Should we focus on that? Rather than just looking at beds as a measurement of how successful things are, should we look at service delivery? Will you comment on that?

As I said on Friday, we absolutely have to consider that. If you look at the way that healthcare has evolved over my career of 30-plus years, it is completely different now. When the Borders general hospital was built, it had an ophthalmology ward. We do not admit people as in-patients for ophthalmology now; it is nearly all done on a day-case basis. Healthcare continues to evolve in that way. As Cathie Cowan said, we are considering virtual respiratory pathways and hospital-at-home services.

In addition to the delayed discharges that are measured as formal delays, a number of times a year, we do an exercise to consider what the needs of all the patients in our hospitals really are. From that, we can see that a significant proportion—well over 30 per cent and, at times, towards 50 per cent—are people who could be cared for differently. Therefore, we need to think differently about that.

In the Borders, we have four community hospitals, one of which is relatively new—it was opened in the early 2000s—and three of which go back to the 1950s and before. To return to the backlog, maintaining the standards of those hospitals is a significant issue. However, on how we use those facilities, different alternatives could be put in place to support people in the community, which is not about a traditional hospital service.

We must change the dynamic around that and not get hung up about hospital beds. The issue is the need that the individual patient—the person; the member of our population—has. There are different ways that we can approach that, such as some of the examples that you used, and different ways of providing care in the community. Our local council has been considering care villages and is in the process of developing business cases for two of them. That will change the way in which we provide support in the community for people in the long term.

I suspect that my other questions will come up later, so I will pause there.

This is a good opportunity to bring in Claire Burden from NHS Ayrshire and Arran. We have talked about financial sustainability, and it is only fair to ask for your assessment of how your health board is managing its finances and balancing its budget, given the current strains on its finances.

Good morning. I apologise that, along with my information and communications technology challenges, I have a voice challenge from the local cold.

I inherited a deficit of £26 million, which we have been unable to chip into over the past year. The themes are similar to those that colleagues have shared—we have been unable to pull ourselves away from the additional beds in our system, and some of our reform ambitions have been achieved more slowly than expected.

Going into 2023-24, our underlying position is deteriorating. However, that does not stifle our ambition, in that we know what good looks like and we have good support from system partners.

As has been discussed, dealing with delayed transfers of care—getting people into the right climate—is where we will make the greatest gains against our deficit. We have a core bed base of about 850, but we have extended into a bed base that is just shy of 1,000. Because of post-Covid legacies and so forth, we have 185 beds that we need to remove from the system. We, too, are struggling with Covid outbreaks, which have been the rate-limiting factor in 2022-23.

The year has been very difficult for teams but, as a system, we have a greater understanding of where we can work together to make positive inroads into the deficit. About £14 million of it is associated with bed-based care alone; other pressures in the system are from medicines, energy and our infrastructure.

People have talked about the investment that is required in our infrastructure. We have some ageing estate. When I came into the system, the caring for Ayrshire programme was about preparing the system for a new hospital, but it is clear that that will not happen in the very near future. The backlog maintenance programme and some reform have slowed up over the past three or four years. The pandemic had a dramatic impact, which has resulted in backlog maintenance and underlying infrastructure weaknesses being a bit more exposed as we go into 2023-24.

Thank you—I wanted to give you the opportunity that others have had to set out your challenges.

Stephanie Callaghan has a question.

Convener, can you hear me?

Yes—we can.

Thank you—I could not find the right button. I will pick up on what Cathie Cowan said about community pathways and teams. The committee often hears about the importance of early intervention and preventative care. Should we be doing things in key performance standards to ensure that early intervention and preventative care are better reflected as a higher priority? Does that fit in at all?

Yes—that gives me the opportunity to build on what Ralph Roberts said in response to a previous question. Our performance framework counts the things that we can count, but we must think about what else we need to focus on, because the framework directs attention, and what we pay attention to improves performance.

We chief executives have been talking about what else we could measure in prevention and early intervention, in ways that demonstrate not only value but best practice that we could share and could replicate to fit local circumstances—not everything is transferable from A to B. It would be beneficial to focus on that and have such measures, so that we could begin to think about how we pay attention to those and direct and support change.

09:45  

That question is really important. If we are honest with ourselves, we have had an ambition for—again—probably as long as I have been in the health service to invest more in preventative care, but we have not done that.

That leads us to some really challenging policy choices. I accept that those are difficult, but, over that period, we have continued to invest heavily in acute care, because of access issues, and have not got upstream around preventative activity.

We have continued to invest very significant moneys in high-cost medicines. I accept the argument around that for individual patients—obviously, it is very emotive, and the desire to do it is very understandable—but it means that we are spending more and more money on some of that acute and very specialist care, and are not releasing the resource to spend on preventative care.

There are therefore some very challenging policy choices in there for us as a society, about how we choose to use the resources that we have. We have to get into conversation with our communities about the type of health and care system that we want in the future.

Certainly, if my medical director was here—going back to that question about realistic medicine—she would say that we have to have honest conversations with patients about what is realistic when it comes to their long-term care—or even their short-term care, depending on the circumstances.

As I have said a couple of times, we as a society have to get into some very significant policy issues.

I was going to raise similar issues to Ralph Roberts. We have made some positive inroads with realistic medicine, in all care settings. We have good working relationships with primary carers, who do their best with the living well agenda through the proactive management of patients who have chronic disease, and we link well with our community partners.

It is fair to say that, if we can distribute more funds to the prevention and living well agendas, so that we tackle the health inequalities agenda for the longer term, that will bear fruit. However, as was mentioned earlier, pressure draws resources back into acute medicine, here and now, and into addressing the backlog. It is not for the want of enthusiasm in our health and social care partners and council colleagues for working with us on that agenda.

We move on to Covid recovery.

I will start with Ralph Roberts. Does NHS Borders expect to be able to access the treatment centre in Inverness, in the Highlands?

We would probably not expect our patients to go to Inverness, but we expect them to go to the Golden Jubilee hospital—as they already do. As other treatment centres come on stream, it is important that we increasingly look at them as a national resource and look at how they will help us to address the backlog across Scotland and achieve as much equity as possible in access.

As a board, our primary focus is to ensure that, whenever possible, patients get care locally, but in our case, we need to be realistic that a number of patients will always travel outside the Borders. They do that for specialist treatment and will increasingly do it for some of the general—

I am not talking about specialist treatment; we all accept that patients have to travel for really specialist treatment. I am talking about ASA 1 and 2 patients who need, for example, a hip or knee operation. You are saying that, when the treatment centre is online, you will expect such people to go not to the Highlands but to the Golden Jubilee.

I would not expect such people to go to the Highlands, but I would expect them potentially to go to Fife, to Lothian when that comes online or to the Golden Jubilee. The bit that we will need to get right in the Borders is the balance between patients going outside the Borders and patients whom we can treat locally. We have to sustain a trauma service and an unscheduled care service in the Borders, and that requires us to ensure that we have orthopaedic surgeons. Our surgeons are not split between elective and urgent care, so we need to get the balance right and continue to ensure that such jobs are attractive for our orthopaedic surgeons.

There will be a balance in what is treated locally. However, I am absolutely up for a conversation on what access we get to address the backlog in particular and then, beyond that, what the balance of care is between what we provide locally and what we provide elsewhere.

So you will need a further conversation to find out about things such as the extra costs that might be associated with a 23-hour in-patient stay and other resources that you might need to put into a patient going to the Golden Jubilee or other treatment centres.

Yes. We need to look at that and compare it with the cost of providing that care locally.

Okay—thank you.

I have questions about the health recovery plan. In the reading that I have done, it has been suggested that the recovery plan was not discussed extensively with health boards. When the recovery plan came out, how close were you to being back to pre-pandemic levels of out-patient elective work?

It is fair to say that we have been challenged to get back to pre-pandemic levels of activity. Over the past three or four months, we have been running at just under 80 per cent of our previous out-patient activity and at between 50 and 60 per cent of previous in-patient activity. Some of that is about capacity in the system in relation to beds, particularly for the elective care programme, and some of it is about challenges that arise from issues that are specific to us in one or two specialties.

A significant part of the deficit compared with pre-Covid activity in out-patients is associated with ophthalmology and dermatology, which is to do with the workforce rather than capacity. In orthopaedics, the issue is more about elective bed capacity and theatre capacity. The situation is different for individual services.

The position is mixed. I ask Cathie Cowan the same question. What levels of elective work are you at compared with pre-pandemic levels?

At 1 March 2023, we had a total of 4,271 patients waiting, so we are making inroads. Within that, we have 2,372 who have been waiting more than 12 weeks. We have tried—

I am sorry, but my question was about the comparison with pre-pandemic levels of elective work.

In terms of pre-pandemic levels, percentage wise, certainly in diagnostics, we are probably about 86 per cent on track to get back to where we were. As I said, we have invested significantly in scheduled care in—

I am sorry, but my question was specifically about where you are with elective surgery now compared with pre-pandemic levels.

In terms of waiting times, I would say that we will be back on track in specialties such as orthopaedics and trauma in the next six to nine months. That is very clear in our recovery plan, in terms of out-patients. Targets have been set to get us there—on 78 and 52 weeks and so on—and we will meet our 52-week target at the end of March.

Sorry—

Sandesh, I need to bring in Claire Burden.

I am just trying to ascertain the answer to the question, which was about the comparison with pre-pandemic levels. It is not about the 52-week wait.

I understand that, but we have half an hour left and a multitude of themes to cover. You have had several questions, and you have come back with the same question a few times. I appreciate that you may not be satisfied with how Cathie Cowan has answered it. I will bring in Claire Burden to answer your question.

We had 8,553 patients on our surgical waiting list at its peak in 2022. We now have 7,947. We are at 99 per cent of our pre-Covid rates in out-patients and at 78 per cent in surgery. Our limiting factor has been that our critical care unit was no longer fit for purpose in its original area, and it is where day case activity used to take place. We have had some change in baselines.

We were not at those levels at the beginning of 2022, and it has taken a good eight to 12 months to get back up to them. Although the swing is of only 600, it is positive that we have started to achieve a modest reduction in total numbers. For our constant improvement in returning to pre-Covid levels, our ambition is to be at 90 per cent of pre-Covid levels. That is rate limited by access to theatres because of the relocation of our critical care unit at Crosshouse.

I wonder if I can expand on your Covid recovery plans. Audit Scotland was critical of the lack of consultation with NHS boards on the development of the national recovery plan. It also highlighted that many boards desired greater autonomy in their own recovery plans. Would it have been helpful to have had a more localised recovery plan that you could have worked to within your resource allocation?

The national recovery plan has a number of headlines that are not dissimilar to the headlines in NHS Forth Valley. We have flexibility in the actions that we can take, whether that is investment in primary care, in urgent and unscheduled care or in community care.

I referred to best practice. It is really good to learn from each other about what we are doing, but local circumstances sometimes prevent us from doing exactly the same thing and getting the same return. Our population might differ in its demographics or in its epidemiology, in terms of presentation.

I do not think that our recovery plan in NHS Forth Valley is at odds with the national plan, and there is local flexibility within that. As Ralph Roberts and, I think, Claire Burden mentioned, the rate-limiting factor is the workforce and how ambitious we can be about that. In Forth Valley, we have invested in the workforce that we have. You will see from my submission that we have invested in creating more band 3 jobs and that 800-plus people have moved from band 2 to band 3, because they have the skill set to do that. We are really trying to get everybody up to the top of their licence to beat the backlog, to go back to the previous question. I am not uncomfortable about the national approach versus the local one.

Did the Government ask you specifically about workforce issues in relation to the national recovery plan?

As a health board, we were asked to submit our workforce plans, which we have done. Those plans identify gaps in specialties or in the workforce and the things that we are doing on that.

In my system, we are working with local authorities and so on to think about how we can get people into health and care. Health boards’ workforce plans are on record and have been shared with Government colleagues.

We will go to Ralph Roberts and then we will have to move on. We need to dig into a number of themes, including staffing, and I am conscious that we have only half an hour left with the panel.

10:00  

I will probably just repeat what Cathie Cowan said. I have no problem with there being a national recovery plan, because it is helpful to see the overall policy direction that people want us to take. Individual boards have adapted that to their local circumstances, which vary. As Cathie Cowan said, we engage with Scottish Government officials monthly, if not more frequently, when issues that affect the workforce are flagged and discussed. The balance between having an overall direction at national level and then understanding what that means for us locally and having an on-going discussion about progress is perfectly appropriate.

Emma Harper has questions on progress under the recovery plan. I know that we have mentioned it, but if you could ask your question, Emma, we can then move on.

Sure—I will be quick. I have two questions, but we could park for later the question about the use of the long Covid pathway, rather than the long Covid clinics that have been established in the NHS Borders area. I am interested in knowing about the best way to look after long Covid patients.

The other issue goes back to what Ralph Roberts said on Friday, which was that making progress on recovery has required working with registered social landlords to look at housing and wider aspects of supporting people in order to practise reablement. We do not use that word a lot, but it simply means supporting people to get the best care and to get them home. Is that part of what you are doing to make progress on recovery?

As I said on Friday, the long Covid pathway is about signposting people with long Covid towards the right care, because they will have a variety of needs. We do not run a long Covid clinic; instead, we signpost people into the right service for them as individuals.

The council and the health and social care partnership have been putting quite a focus on reablement. For me, it is about reducing the need for social care over time, which will release additional social care capacity. If we can support people over the initial period when they are discharged from hospital and then adjust their social care packages to meet their on-going needs, that will help to create capacity in the system. The output that we have seen from the initial work that has been done is that that has been successful. I see it helping in the future with the issues that we referenced earlier, such as delayed discharge. In itself, that work will be important for creating capacity in hospitals so as to allow us to address the backlog issues.

Now we have questions from Gillian Mackay on the escalation framework.

According to the submissions, all the boards that are represented have been escalated to higher levels of the framework, and they all have higher turnover than the national average. Is the high level of turnover linked to poor culture in your board areas?

As regards NHS Borders, I do not think so. We need to be honest with ourselves that, in an organisation the size of the health service and in one that is the size of mine, there will be issues in individual services and, at times, issues between individuals. We need to have appropriate mechanisms in place to support people by understanding and addressing what is behind those issues.

When I joined NHS Borders four years ago, leadership was one issue that we had been escalated on. We were de-escalated for that part way through the pandemic. We have put a lot of work into how we lead the organisation and engage with our staff, and we are trying to shift our approach. We often talk now about having a compassionate leadership approach and we have just started a programme on that for staff across the organisation. We have introduced what we are calling our quality management approach, which sounds like management speak but simply focuses on how we engage with the public and our staff. We are making progress on that, but it would be incredibly naive of me to sit here and say that we should be complacent about it. We need to continue to work on that at all times, because it is important.

I do not particularly think that that relates directly to the turnover issue. In our circumstances, that issue is more directly related to the age profile of our workforce and in particular to the issues that people have experienced over the pandemic. There is no doubt that that has had an impact on people making different choices.

Absolutely—my response is very similar to Ralph Roberts’s. I know that nobody underestimates the pressures that have been on the workforce during the pandemic. We continually say a huge thank you to our staff for that. During the pandemic, which we have not yet come out of, and as we have moved forward, a number of staff have made work-life balance choices.

A number of people—particularly in nursing—have taken retirement, a number of people have gone into new employment and a number of people were on fixed-term contracts as a result of the pandemic, whether that was in test and protect or whatever. Like Ralph Roberts, I do not think that turnover has a correlation to culture, but like him, we are not complacent. We have, equally, put in a compassionate leadership programme, which Professor Michael West is supporting us in.

If committee members follow the boards, they will have seen that I brought in an external review of our emergency department way back in 2020-21 because of poor culture, so we are not shy of that. We will absolutely take appropriate action because we want people to come to work, have a good day, enjoy their work and be supported in the workplace, whether that is with training, development or good leadership. We have significantly committed to that.

I deal with similar themes to those of my colleagues—[Interruption.] I am sorry; I have a cough. The culture plan is predicated on our commitment to retention, attainment, professional development and recruitment. People have definitely made some life choices, as described by Cathie Cowan—we have many more people reducing the hours that they are offering, and our medical workforce has many contracts that are much smaller now than they were two or three years ago. We have 500 nursing vacancies and we are constantly on a recruitment cycle.

It would be fair to share that, nationally, the NHS has a reputation challenge in that the view in the media is that it is not a great place to work in and people are under constant pressure. However, our experience as chief executives is that we have exceptionally dedicated staff who genuinely love their jobs, and we do not get the opportunity to speak to that. Individually, we work hard on social media to raise the profile of the dedicated people who are holding things together for us, but that gets lost in the other national things that are going on.

As health boards, we give weight to the importance of the training and retention components because—particularly in rural boards—we desperately need to keep people in our patch. We are absolutely wedded to people having lifelong careers, but we are mindful of the backdrop of people not choosing the NHS and being greatly influenced by the media.

If we as a leadership body have a concern, it is that this is the first year in which nursing courses have gone to clearing. The idea that we are not filling all our university places for our future nurses is something that we need to tackle for Scotland. We need people genuinely to choose healthcare because it provides a profession that is lifelong and rewarding. If there is a piece of work that we are keen to work on, it is the national bit. We understand that we are in recovery and that there are pockets of exceptional stress that we work through every day, but a lot is going into supporting our workforce.

The age profile is a big thing for all of us, as is the national position of primary care. We know that turnover in that will be extraordinary in the next decade, so the retention and recruitment arena is equally as important as the internal culture and our visible leadership commitments.

I will be first every time to stand up and say that those are good careers and that that is not the reality in every single department in every single hospital. However, I think that when staff are telling us about the conditions we must address them and ensure that workplaces are supportive for absolutely everyone.

For my supplementary, I want to go back to Cathie Cowan, given that NHS Forth Valley was escalated on the basis of its culture. I spoke to a number of staff members before escalation; they all told me that senior management were remote from the workforce and were rarely seen. When five respiratory consultants resigned, they all cited the toxic culture as a reason. Since the escalation, psychological therapy staff have been in touch and have said that because of the two-year waits they are so worried about patients that they are working unpaid hours. What is being done to acknowledge the culture that staff have been working under, and how will the situation be sorted? We seem to be talking about three or four departments in NHS Forth Valley alone.

With regard to the escalation, we acknowledge that there are issues, but we are tackling them. We have been able to recruit additional staff in psychological therapies, in which we previously had below the national average. The fact is that being below the national average has an impact on performance.

I am very close to staff and have high visibility. The areas that have been referred to are on the acute hospital site, in particular, and people who have been following what has been happening there will have seen that a number of staff were, for a variety of reasons, not working in their substantive posts but were acting in posts. In order to fill the space, we decided to bring in an acting manager while we looked to recruit to other posts, which has enabled people—for example, our chief nurse on the acute site—to go back to their substantive posts and has allowed us to bring in an additional doctor for our front door. If you were to ask staff just now, as I regularly do, they would say that things feel better.

For me, the litmus test is not just what the staff say, but what our staff side representatives—our trade unions—say. We have very close working relationships with them, and they have said that stability at the acute site feels much better with the additional management capacity and leadership.

For context, I point out that it was just in the past 24 hours that the psychological therapy staff member to whom I referred was in touch about staff having to work unpaid hours because they are so concerned about patients.

I am slightly concerned about what we will do until the new staff who have been recruited are actually in post, given the lag that often comes with recruitment. I think that your submission mentioned 12 weeks, in that regard.

We have been able to change things in that respect with our union colleagues,; NHS Forth Valley had been an outlier in respect of allowing people to give only a month’s notice and recruiting to those terms. The trade unions were keen to have three months’ notice, which gave us a huge gap for redistributing case loads while we filled vacancies. Our staff side has worked with us to resolve the situation, so we are now in the same place as other NHS boards, which will certainly help us.

As for the member of staff who spoke to Gillian Mackay, I will absolutely follow that up. We would not expect anyone to work unpaid hours in order to address waiting times. In fact, you will see from our submission that we have worked hard to address long waits. As far as performance is concerned, we have continually sat in the 70 per cent area, even with the backdrop of our not having staff in post.

Ralph, did you want to come in briefly?

No.

That is great, because we do not have an awful lot of time and we need to talk about staffing more generally.

From the evidence that has been submitted, I think that there is a huge issue not just with recruitment of new staff but with staff retention. For example, 30 per cent of leavers from NHS Ayrshire and Arran were retiring, and that sort of turnover in your boards is higher than the national average.

First, is retention in the system the significant issue? Secondly, what action is being taken to encourage staff to stay to ensure that we are not facing the twin challenges of having to recruit new staff while trying to keep staff in the system? Perhaps we can hear first the perspective of NHS Ayrshire and Arran.

10:15  

[Inaudible.]—the programme there is multifaceted, as you can probably imagine. Training staff and getting people to a position from which they can see a way out of the current operating processes will make a genuine difference.

Over the past three years, single-disease management has stifled careers; Covid, by its nature, has meant that people have not specialised or had the opportunity to specialise. In the current climate, releasing people to specialise is a challenge. Our recruitment and retainment commitment therefore includes release of people to training.

Would you like me to cover anything else, Paul?

You said that people have not had the chance to specialise. Do you acknowledge, however, that the major issue is stress and burnout?

There is a lot of anxiety: anxiety and stress are key drivers of staff absences, because the current climate is tough. Staff are looking after people and working with the equivalent of a five-year backlog and the system remains under pressure. The wellbeing programme, on how we keep people fit for work, is without a doubt equally as important as ensuring that people are able to find careers and can see themselves progressing beyond their current position.

The commitment to get people into training in order that they can see a future that is different from what they see now is an important part of the retention programme. If you and I were to walk around any part of the health system we would hear, first, requests for more staff. The second request would be that staff need more time together and more opportunities to train.

Our health professional’ professional development has been stalled for three years, which will have ramifications for a long time. As we get into recovery and get back to working at a rate at which we genuinely start to chip away at the pressures in the elective programme, we will be able to support more training for our staff.

We are doing a lot of work with NHS Education for Scotland on development of new roles and finding new career pathways for people. For people who are retiring early or who choose to take a break, there is always retention and callback, but there is also an appetite to come back and do slightly different things. A person who has been working in the acute sector might have the opportunity to do something different in the community with a different skill set. Our staff welcome that, so we will continue to work with NES on how we generate new posts to give people new avenues through which to pursue caregiving and intervention.

We talked earlier about prevention. People are leaving the NHS by choice and are taking retirement at 55 and beyond, given the pension options that we are all living with. We believe that if we can create posts that are genuinely different, however, we will see people return.

I will go to Ralph Roberts then Cathie Cowan. I will not be able to go back to Paul O’Kane for a supplementary question, I am afraid. I apologise for that, but we have another panel waiting to come in, so I cannot let this session overrun.

My comments will probably complement what Claire Burden said.

It is important that we do not jump to some single-issue assumptions. For any member of staff, the choice to leave, move on, retire or whatever will be multifactorial.

From my point of view, the issue is partly about the working age of our population in rural areas, and the choices people make around that. Some of it is to do with people’s experience over the pandemic. We moved a number of staff at that time because we had to, which was more or less popular, depending on the individual.

I turn back to culture. There is no doubt that what I hear most from staff is their frustration about not being able to do the job that they came to do, because they do not feel that they are delivering the quality of care that they previously delivered. That is a big driver of the pressure in the system.

We must accept that the issue is multifactorial. We need to support people through it with professional development, as Claire Burden outlined, and we need to focus on retire and return so that, after they have retired, we support people back into part-time roles and build on their skills.

Fundamentally, if we get recruitment right, it will support retention, because it will take some of the pressure off staff. We have done masses of work over the past year on international recruitment and have been very successful in bringing international recruits into the organisation. That has been challenging, but it is paying dividends. If we can do that and it reduces pressure on our staff, that will improve retention.

To some extent, that goes back to the point that I made much earlier about one of the reasons why our staff experience pressure—in particular, in the acute hospital, although there are different circumstances in the various parts of the system. We have additional beds open and have therefore had to spread staff more thinly, which puts pressure on them. If we get to the point at which we can close down the extra beds that we made available during the pandemic, that will allow us to improve staffing levels and retention.

However, we have to recognise that we need to work hard at that, and that in the medium term the working-age population is shrinking, so we will have to look differently at how we staff our services.

I will be very quick. As Ralph Roberts and Claire Burden said, there are significant pressures in the system, but we have been fortunate. I will give you an idea of our recruitment and retention. Of the 127 new nurses whom we have recruited over the past couple of years, we still have 118 in our system. That is a good measure for us. To go back to culture, our iMatter scores are up there among those of the rest of the boards in Scotland.

We also try to give staff space to do things. Our mental health staff have been awarded the Royal College of Nursing accreditation—which is a unique accreditation—because we gave them time to do that. That lets them shine and feel proud about what they are doing and how they are doing it.

As I said, we have invested in bands 2 and 3, which demonstrates a culture of inclusiveness and commitment to development, and those staff are staying with us. Similar to what Ralph described, we have been able to secure colleagues from other countries. Our international recruitment is focused not only on employment but on welfare and the bringing of people and their families to Scotland, and it has been hugely successful.

We have also done work on our anchor institution concept, which is about how we create local jobs for local people. We think about how to do that with local authorities, and we recently secured a unique partnership with our college and university. We are working in that space to bring school leavers into the health service and social care, but it is a tough gig that I would never underestimate.

To go back to Gillian Mackay’s question, I note that the acute site in NHS Forth Valley is a particularly tough place to work, because it is primary care, given the demand that comes through our systems. We must respect our staff and acknowledge the circumstances that they work in. That is what they want to hear from us as leaders, so that they get reassurance that we know about the pressures that they work under. Training and development, and a commitment to protected time so that people have a bit of downtime are things that we are working on, and we are doing a bit of work on reconnecting, reskilling and so on. Our focus is very much on recruiting and retaining staff, and doing different things with our staff so that their skill sets increase.

I have two questions. The first is for NHS Borders. Mr Roberts, in advance of the meeting, we asked for a four-page document. You have provided a document that has no fewer than eight embedded papers and did not provide what we asked for. So that we have a written response from you that is similar to the other boards, could you please provide us with what we asked for?

I am sorry if what I sent did not meet your expectation; I am certainly happy to review that. We tried to give you as much information as possible. We will reflect on that.

Thank you. If you could just deliver exactly what we asked for, that would be appreciated.

My second question is for NHS Forth Valley. Sickness continues to be an issue across the boards. What percentage of sickness among nurses and midwives is physical sickness and what percentage is mental illness, such as burnout or depression?

We have a breakdown of that, but I do not have it in front of me. As Claire Burden said, stress will figure highly in the absence rate—there is no doubt about that. We do significant deep dives into that, so we can say that stress is not all about work, although it plays a part. The cost of living and other factors in people’s lives are also parts of that.

I am sorry, but that does not answer the question. What percentage of absences among nurses and midwives is because of physical illness and what percentage is because of mental illness?

I do not have that figure in front of me, although we have a figure and a breakdown of causes within it.

If you can provide that, it would be appreciated.

Certainly.

We have talked about stress and burnout, but what are you putting in place for the wellbeing of your staff? I do not mean anything related to profession and careers, but what is in place for the wellbeing of your staff so that they continue—

Can that question go around to all three witnesses?

Yes.

We have an extensive wellbeing programme and we have a very positive spiritual team to lead it. There is dedicated space and time, and we have a wide range of resources that provide access to financial advice, occupational health and therapy. A legacy of the pandemic is that we have, for the first time, psychiatric and psychological support. It is rather sad that we need that to be at the level that we have. Between them, the spiritual team and our professional support services have a steady flow of people.

The staff response to the wellbeing areas that have been created has been very positive. There are also timeout sessions, which goes back to the cultural commitments of the team management structure. Making time for teams to make use of those facilities is a core part of our commitment to professional development.

Now that we have, over the past 12 months, entered an era in which distancing and so forth have diminished, we are in a better position to offer break-out support, and we have invested independently as teams have needed that support. Sadly, bad events happen in the NHS. That is the nature of the beast, but we have commissioned specific support programmes following specific incidents or for teams that have experienced a serious incident. We also have wider-stream more generic processes and services available through our cultural plan and our human resource teams, through which teams can commission time out.

What we provide is wide ranging—from highly specialised support when it is needed, to wellbeing spaces that people can access 24/7, to team development programmes.

Thank you. I ask the next witness to be brief, please.

We offer a range of support. There is very targeted support for individual teams in relation to individual incidents or issues when they happen. More generally, we have staff counselling services, the occupational health and safety service, psychological support for staff, and a wellbeing group that has looked at issues around meals and the space that staff have, for example.

We explicitly ran a workforce conference in the autumn to try to focus on our workforce issues. That was attended by probably close to 100 staff, and it was really successful. We are working up to a wellbeing week in June this year to try to maintain a focus on wellbeing.

10:30  

I have heard that the thing that staff want most of all, in addition to individual targeted support where that is necessary, is fundamentally the sense that they are doing the job that they came in to do. That is about us supporting them, supporting staffing levels and, as Claire Burden said earlier, trying to get back to the point at which the health service is seen as providing good careers. To be frank, staff have found very difficult the transition from being clapped on the doorsteps at the beginning of the pandemic to the point at which they now feel that they are under endless pressure from the public, politicians and others. There has been a really difficult shift in mindset for them. We all have to recognise that and support them through that.

There are the media headlines, as well. To go back to what you said about the national conversation that we need to have, I note that what makes the headlines are not nuanced stories about things going well; the headlines are always about waiting times.

Our staff say to me a lot that they are looking for the acknowledgement that is needed to radically change the health service, and that we need to change the dynamic and the conversation that we have about that and recognise that the health service needs to continue to evolve. Probably more than anything, they are looking for recognition that we cannot simply go on flogging the service as it currently is, and we need to change it.

I will let in Cathie Cowan. We must then move on.

I will be brief.

Ditto, what Ralph Roberts and Claire Burden said. We are thinking about the health service at the local level and what needs to change. Mobilising our clinical teams to be part of that is really important. We have produced a wellbeing plan or strategy that outlines all the things that we have been doing and all the things that we continue to commit to do, which are targeted or generic. I can provide the plan, or people can access it to see its significance in respect of the investment that we have put in.

We must move on. We have two other themes—mental health services and reform—but I might not be able to call all members who have asked to ask questions. I apologise. I am afraid that Evelyn Tweed can ask only one question on mental health services.

I will roll my questions up together then. Thanks, convener.

I direct my question to Cathie Cowan, whose board covers the Stirling area. Constituents at the end of their tether have contacted me regarding child and adolescent mental health services. I know that things are getting better and that your numbers are getting better, but what have you done to enhance those services, how quickly will we see more progress and, crucially, what is being done to help people in the period in which they cannot be seen—in the 18-week waiting time—when they are in a crisis mental health situation?

I will start with primary care. We have worked with council colleagues and the Government on investment in counselling. We are taking a prevention and early intervention approach so that we are not seeing escalation into the tier services in CAMHS, and we start where kids are engaging.

In primary care, we have invested in staff CAMHS workers so that general practitioners have access to that service. Most important is that we have laid out a proposal about referring people into primary care and subsequently into services.

You are right to point out that we have made progress. Coming out of the pandemic, our focus was on dealing with our long waits. You will see that they were significant. I am pleased to say that we have addressed those long waits, and I think that staff feel really good about that, because they impact on staff with children and families whom they feel they are not supporting.

Tackling of long waits is now enabling us to deal with the front of the waiting list, so you will very quickly see us moving from a really poor position of having 18-week waits to achieving the standard by the first quarter of this year, in April to June.

Thank you for that. I apologise because I cannot bring you back in, Evelyn.

Two more members—Stephanie Callaghan first, then Sandesh Gulhane—wish to ask questions on reform. I ask for succinct questions. Please direct your questions to specific witnesses, as much as possible.

I had thought that someone was going to add this point to their question, so I apologise.

Are there specific recommendations that you would like the committee to make on early intervention, in order to ensure that it is a priority for the future?

Let us go round everyone quickly.

I return to a point that I made earlier about prioritising early intervention. That will mean that we will need to examine our performance framework and how we prioritise it. There is certainly work that we can do to focus on early intervention, but that requires us to consider the whole scope of our resource and to make judgments about how and where we prioritise it across the organisation.

I would say something very similar. I spoke earlier, in relation to the performance framework, about the incentive of having standards to work towards. That would help us to refocus our energies in that area.

On our diagnostic work and technical infrastructures, unifying of our ICT will genuinely help us with reconnaissance of our population, as we work to national models to improve access to diagnostics and get into the prevention agenda by adding to and building on Ralph Roberts’s and Claire Burden’s platforms. That would be my ask: diagnostics and technology.

Thank you—that was very helpful. We will have one last question from Sandesh Gulhane.

I will say, as a doctor, that being in healthcare is a great career. I want to acknowledge clearly that I and all of us on the Health, Social Care and Sport Committee acknowledge and thank our NHS staff for all their hard work.

As far as questions go, I have been disappointed by some of the answers that I got. I am sure that we have other questions, so perhaps we could write with them.

We will write and pick up on things that we have not had time to get to.

I have a question to put directly to Claire Burden about information technology infrastructure. I was very interested to hear about how you are trying to develop an all-in IT infrastructure. Could you tell us—very quickly, as we are running over time—how close you are to implementing that?

[Inaudible.]—work going on for the platform—the network. We have quite a lot of remedial work to do before our colleagues will start to see that.

The technical infrastructure—the platform from which we can unify our system—is the work that we are doing first, and the two pieces of software are TrakCare for hospitals, which allows us to unify three pieces of kit in one, and the electronic patient record, to which we are committed and which is “once for Scotland” compliant. We have support from our health and social care partners, and they will ensure that we are all able to share that.

I thank all three of you for your time this morning. We will write to you with questions that we have not managed to ask. As you are aware, there are a great many things that we wanted to ask you and that you wanted to tell us.

10:38 Meeting suspended.  

10:46 On resuming—