Meeting of the Parliament

Meeting date: Wednesday, November 23, 2022

Official Report 1245KB pdf

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NHS Forth Valley

The next item of business is a statement by Humza Yousaf, who will give an update on NHS Forth Valley. The cabinet secretary will take questions at the end of his statement, so there should be no interventions or interruptions.

17:32  

There is no doubt whatsoever that the past two and a half years have, in the face of a global pandemic, been easily the most difficult that the national health service has ever faced. It is my belief that the vast majority of the public are understanding about the difficulties but, equally, they quite rightly expect their health board to provide the required leadership to navigate through these really difficult waters.

Over the past year, a number of elected members from across the chamber have raised a variety of concerns relating to the services that are being provided by Forth Valley NHS Board. Today, I am providing an update on the actions that we have been taking, and will continue to take, to address those concerns.

I confirm that the Scottish Government has taken the decision to escalate NHS Forth Valley to stage 4 of the NHS Scotland performance escalation framework. We are doing so for reasons relating to governance, leadership and culture.

The Scottish Government has been engaging with NHS Forth Valley for some time on a range of performance-related issues. Members might be aware of recent reports that were published by Healthcare Improvement Scotland in relation to safe delivery of care in Forth Valley royal hospital. This year, HIS has carried out several unannounced safe delivery of care inspections due to on-going concerns about safe delivery of care. HIS has escalated its concerns to the Scottish Government because it has not seen the required improvement in NHS Forth Valley since the initial inspection that it undertook. HIS is expected to publish its most recent report in the coming few weeks.

There are also concerns about the sustainability and integration of general practice out-of-hours services in the region; indeed, we have had a members’ business debate on that very issue. In accident and emergency departments, there has been consistently poor performance against the four-hour standard, and there are issues related to integration of social care services.

Although poor performance in any of those discrete areas is of concern, I expect effective governance, strong leadership and improved culture to deliver sustainable change. Unfortunately, I have not seen the leadership that is required to drive improvement in those areas of concern, which is why the focus of the escalation is on governance, leadership and culture.

Stage 4 escalation comes into effect from today, Wednesday 23 November, and brings direct formal oversight and co-ordinated engagement from the Scottish Government in the form of an assurance board, which Christine McLaughlin, who is the director of population health, will chair. The purpose of the assurance board is, first, to support NHS Forth Valley in determining what steps are necessary to ensure delivery of high-quality governance, leadership and culture, and in doing so to support improvements in a range of performance and quality-related issues.

Secondly, the assurance board is to advise the director general for health and social care, through agreed governance routes, that such steps have been taken. The DG will update me regularly.

Through delivery of that work, the assurance board will seek to ensure that appropriate governance is in place—in particular, with regard to providing scrutiny of performance, leadership style and practice.

The assurance board will scrutinise the NHS Forth Valley improvement plan and hold the leadership to account for effective delivery of improvement actions in the agreed timescales. In doing so, we will work to ensure that the leadership is operating effectively and inclusively—particularly in respect of understanding and managing performance issues—and that a positive and inclusive culture exists in NHS Forth Valley.

The group will also consider any lessons learned that could be shared across NHS Scotland, and it will provide advice on the future escalation status of NHS Forth Valley, including criteria for de-escalation.

The first meeting of the assurance board will take place next week to ensure that improvements are delivered as quickly as possible. I have asked Professor Hazel Borland, who is the former nurse director and interim chief executive of NHS Ayrshire and Arran, and Dr John Harden, who is the deputy national clinical director, to lead the senior-level external support for the board. HIS will provide tailored support, too, in order to deliver on the actions that it set out following recent inspections.

Professor Borland brings a wealth of experience. She will work jointly with Dr Harden, Scottish Government directors, HIS and other delivery partners to support the senior leadership team in its delivery of the required improvements. That work includes supporting NHS Forth Valley in the development, agreement and delivery of a co-ordinated improvement plan across the affected service areas.

As I have already set out, the Scottish Government has been engaging with NHS Forth Valley for an extended period across a range of issues, as part of standard board sponsorship work and in response to on-going concerns. That engagement and on-going support have been crucial in providing the board’s leadership with the time and space to take responsibility for change in its own organisation.

Escalation is a last resort. We have not taken the decision lightly, and we have had to take it following consistent demonstration that the NHS Forth Valley leadership team is unable to follow through with the required transformational change without additional formal support and monitoring.

To that effect, John Burns, who is the chief operating officer for NHS Scotland, and Caroline Lamb, who is the director general for health and social care, met the chair and chief executive of NHS Forth Valley. I, too, have spoken to the chief executive and the chair today to convey my concern, and to articulate clearly my expectations for immediate and sustained improvement in the period ahead. They have agreed that the assurance board will review and scrutinise the improvement plan that the NHS Forth Valley leadership team will develop, which will set out short-term, medium-term and longer-term actions.

I expect the improvement plan to be developed and presented to the assurance board for scrutiny at its first meeting next week, with a focus on completion of immediate actions in a matter of weeks, as opposed to months. Although lasting change will take time, it is crucial that we see urgent and tangible improvement in the coming weeks and months.

NHS Forth Valley already has a number of clear actions and recommendations against which we expect it to deliver, which include work to strengthen the integration of health and social care and out-of-hours services, and to make improvements in unscheduled care and mental health services.

I expect NHS Forth Valley’s leadership to work collaboratively with its council and integration joint board partners to deliver the necessary changes, including the development of a shared narrative that expresses its ambition for integration of health and social care services in the territory. I also expect NHS Forth Valley to take the findings of the Healthcare Improvement Scotland inspections extremely seriously. It is imperative that the leadership team delivers immediate improvements against the recommendations and requirements that are set out in those reports. Of course, I will closely monitor progress in that regard.

NHS Forth Valley is also one of the poorest-performing boards with regard to psychological therapies and child and adolescent mental health services, and there has been less progress than we had hoped for in those services, compared with other areas. We have been providing tailored support, to help to meet the standard, as well providing access to professional advice. We have also been ensuring that the board has robust improvement plans in place. Again, those are all being closely monitored.

The actions that I have described today are not exhaustive, but they provide an insight into the type of change that is required in the health board, and they will support NHS Forth Valley to remove the barriers that are impacting on its operational performance and pandemic recovery.

I put on record my thanks to, and appreciation of, the staff who are working tirelessly across NHS Scotland and, indeed, in NHS Forth Valley, to deliver the high-quality care that we expect. The stage 4 escalation that I have announced today is not a reflection on staff, who are working tirelessly to provide care for the population of Forth Valley. However, we must recognise that there are continuing concerns about the ability of the leadership in NHS Forth Valley to respond effectively to those issues when they are raised.

Although it will take time for NHS Forth Valley to assure the public and the Scottish Government that sustained improvement has been made, I hope that this statement provides some assurance that significant work is already under way to address the legitimate concerns that have been raised. I will continue to update Parliament as progress is made. I am happy to continue to engage with elected members across the chamber.

Thank you. The cabinet secretary will now take questions on the issues that were raised in his statement. I will allow around 20 minutes for questions, after which we will move to the next item of business. I will be grateful if members who wish to ask a question press their request-to-speak buttons now.

I welcome the announcement, and I fully support the bullied, broken and burnt-out front-line staff of NHS Forth Valley, but I also urge patients to continue to attend when required, because the staff are still excellent.

As shocking as the allegations at Forth Valley royal hospital are, this is only one example of how the health service under the Scottish National Party simply is not working. Five consultants quitting in NHS Forth Valley admits to a culture of bullying; £2.8 million paid out in compensation in NHS Highland admits to a culture of bullying; and complaints of harassment in NHS Tayside tripling over five years is due to a culture of bullying. Yet a freedom of information request that I submitted to NHS Forth Valley revealed that no NHS Forth Valley managers have faced any sanctions.

A bullying culture seems to be widespread throughout our NHS. Insiders at Forth Valley royal hospital have called it “unsafe”, “toxic” and a “war zone” and said that staff are working in “intolerable conditions”. However, what struck me the most was a quotation claiming that there has been an

“irretrievable breakdown of necessary working relationships”

between staff and leaders. Therefore, my question to the cabinet secretary is whether, given that allegations of a toxic culture date back to July last year, he will guarantee that action will be taken against those responsible and whether he can commit to a root-and-branch investigation of that toxic culture in NHS Forth Valley but also across Scotland.

I thank Sandesh Gulhane for his question and I associate myself with his remarks. I also reiterate my remarks at the end of my statement, namely that this process is not a reflection on the hard-working, exceptional staff right across NHS Forth Valley. Regardless of what job they have in NHS Forth Valley, they are an integral part of that health service and that health board.

I included culture in the escalation framework because of many of the concerns that the member is right to raise and which other members have raised in the chamber. Therefore, immediate improvement and sustained improvement—it is important that I emphasise the word “sustained”—in the culture in NHS Forth Valley are key.

I do not agree with the member’s assertion that there is a widespread bullying culture in the NHS. In an organisation the size of the NHS, which is the largest employer in the country, unfortunately, there will be issues around culture. It is important that we address those and, therefore, I am absolutely committed to doing that.

Having met every whistleblowing champion across the boards in Scotland, I say categorically that I not only support whistleblowing as an important mechanism to raise concerns but hope that every member of the NHS feels confident in the whistleblowing processes. Their complaints will be taken with the utmost seriousness.

I will start on a point of consensus with the cabinet secretary. Today’s decision is not a reflection of the dedication and hard work of staff, who are working day and night to care for patients. Instead, it demonstrates beyond doubt that the cabinet secretary has let down the staff and patients in Forth Valley.

The facts speak for themselves: the health board is repeatedly the worst performing for A and E waiting times, despite the valiant efforts of A and E consultants and nurses. The most recent figures show that, in September, only 58.8 per cent of patients were seen within four hours. The Royal College of Emergency Medicine is clear: it has warned that long waits result in poorer patient outcomes and risk lives. In June this year, Healthcare Improvement Scotland published its inspection report, which flagged up serious concerns about patient safety due to a lack of nurses.

This is not a health board problem; it is a system-wide NHS problem over which the cabinet secretary presides. Will he explain why, given the clear risk of harm to patients, it has taken six months for him to act?

The concerns about A and E that Jackie Baillie expresses are not only ones that I share but ones that, I suspect, are shared across the chamber and the population of Forth Valley. That is one of the reasons why I have asked Dr John Harden, who, as well as being the deputy national clinical director, works as an A and E consultant in NHS Lanarkshire, to assist. He will bring specific expertise in that regard.

It is reasonable for Jackie Baillie to ask why it is taking so long. Being in the midst of a global pandemic, our A and E departments across the country are challenged. Escalation is genuinely a last resort, so we have been working with the board to see where improvement can be made. There have been weeks where there have been fluctuations and we have seen some improvement but that has not been sustained. That word is incredibly important. We want to see not just immediate improvement but sustained improvement.

The reason why we have got to this point and why it has taken some time is that we do not take the decision to escalate lightly. It is an absolute last resort, particularly when we are escalating to level 4. I am happy to keep Jackie Baillie updated, particularly on A and E services.

I thank the cabinet secretary for his statement. The situation that he outlines is serious. I know from my previous career, including managing large transformational change programmes, that organisational culture is set from the top.

I understand that the chair of the board is very experienced and I am sure that she is aware of how serious the situation is. Will the cabinet secretary confirm that the board, and the chair in particular, understands the relationship between its overarching governance, leadership and culture? Is the board ready to demonstrate that it has what it takes to turn the situation around?

Michelle Thomson is right in what she says. Leadership comes from the top and people take a view from the leadership in relation to the culture that permeates throughout the board.

In my discussions today with the chair and chief executive, I made my expectations very clear. We have many strategies and documents, but they are only as good as their implementation. That is why I have asked the assurance board, which will be chaired by Christine McLaughlin, to ensure that we are not just hearing words of comfort and reassurance but seeing tangible improvements from the top—from the leadership—that permeate throughout the organisation.

However, the proof of the pudding will be in the eating. Therefore, we will wait to see what the improvement plan says and the timescales that are involved. As Michelle Thomson would expect, I will personally monitor that. I will be absolutely clear: I expect to see some immediate improvements and those improvements to be sustained over a period.

NHS Forth Valley moving into level 4 is a damning indictment of the board, which is required to ensure that facilities across NHS Forth Valley are safe and fit for purpose.

In his statement, the cabinet secretary said that he will ensure that leadership operate in an effective and inclusive manner, particularly when understanding and managing performance issues. Numerous whistleblowers have contacted me to express concern that they are not being listened to by management and are experiencing workplace bullying and poor working conditions. They complain of a toxic environment. How will the cabinet secretary address whistleblowers’ concerns and ensure that that toxic culture is stamped out, once and for all?

I thank Alexander Stewart, who has often raised with me concerns about NHS Forth Valley—most recently, just last week—in a very constructive manner. As I said to his colleague Sandesh Gulhane, the issues that they raised are why the escalation framework relates to leadership and culture.

On the back of what Alexander Stewart said, I will meet the whistleblowing champion and some of the people who are involved in whistleblowing at NHS Forth Valley, to see whether there is further support that we can offer.

I will also speak to Christine McLaughlin, who will head the assurance board. She already knows my thoughts on this, but I will reiterate the importance that we place on effective whistleblowing in NHS Forth Valley.

There is much interest in the statement. I would like to get all members in, and I would be grateful if speakers would bear that in mind.

Patient safety is key in all this, so Healthcare Improvement Scotland’s independent inspections of Forth Valley royal hospital are welcome. Will the cabinet secretary provide an update on the next steps that we can expect, following the inspections?

I agree whole-heartedly with Stephanie Callaghan that HIS’s inspections and unannounced inspections provide a great source of information and, at times—including these circumstances—cause for great alarm, particularly when improvements have not been made between inspections. When a number of inspections have taken place but we have not seen the requisite improvements, that gives me great concern, and that is one of the significant reasons why we decided to escalate to level 4.

I understand that HIS will publish an update in relation to its most recent inspection at the beginning of next month.

I refer members to my entry in the register of members’ interests.

While we all await the outcome of a follow-up inspection by Healthcare Improvement Scotland, patients are still being nursed in overcrowded wards, consultants are leaving in droves and workers are not being paid properly, because of management interference in a job evaluation scheme. Why has the health secretary not acted before, given that state of affairs and that level of risk?

I do not agree with the premise of Richard Leonard’s question. This Government stands on a good record in relation to staffing of the NHS. There are areas where that has been challenged, but we have record high levels of staffing, including record high levels of nursing staffing.

On fair pay, our nurses and agenda for change staff are the best paid in comparison with anywhere else in the UK. We are still in the midst of those negotiations, as I suspect Richard Leonard knows very well. I am grateful to trade unions for directly raising with me concerns about staffing, and I hope that we will get to a positive outcome.

I am sure that members agree that it is vital that we ensure that plans for improvement include a focus on reducing pressures on the valued staff of NHS Forth Valley, as we would wish for NHS staff anywhere in Scotland. Can the cabinet secretary say more about the steps that are being taken to engage with front-line staff and their unions, to address their concerns and support the delivery of care in the current circumstances?

Emma Roddick is absolutely accurate in mentioning the workload pressures on staff in NHS Forth Valley and right across NHS Scotland, which is still dealing with the impact of the pandemic. We know that people are presenting at A and E departments and entering the acute sector with a higher level of acuity, for example. That is why I will continue my engagement with trade unions in that regard.

We will also do what we can to increase staffing. As the member knows, in my most recent winter update, I announced further funding to recruit 750 nurses, midwives and allied health professionals from overseas. We will continue to invest in staffing to help our NHS during what will probably be one of the most difficult winters that it has ever faced.

The issues that have been brought to the Parliament by the cabinet secretary this evening are deeply alarming, and I know that staff and patients will want a positive outcome from the steps that he outlined in his statement.

One of his most concerning points was that Forth Valley is one of the poorest performing boards on child and adolescent mental health services and psychological therapies. That will undoubtedly impact on the children and young people who live there and are waiting for treatment. Will any specific steps will be taken to improve Forth Valley’s performance in that area, and is the cabinet secretary still confident that the target of 90 per cent of patients being seen within 18 weeks will be met in March 2023?

That remains the target, and we will do everything that we can to try to meet it for March 2023. I will not pre-empt the improvement plan, but we would absolutely expect there to be specific and detailed action, alongside timelines and timescales, in relation to psychological therapies and CAMHS.

I can ensure that I provide a written update to all members by the end of the calendar year, and I can also commit to regular updates if there are specific issues that members wish to raise with me.

Can the cabinet secretary expand on what help the Scottish Government can provide to support the health board to develop an action plan to deliver improvement?

I will be relatively brief. The assurance board will be critical to that improvement, and the external support that I referenced in my statement will also, I hope, be able to provide support. I want the assurance board to be a supportive yet critical friend that will challenge Forth Valley’s leadership to make sure that it is ambitious but also realistic in its timescales for improvement. I have mentioned Professor Hazel Borland, the former nurse director and interim chief executive of NHS Ayrshire and Arran, and Dr John Harden, the deputy national clinical director, who will also provide that support. Tailored support from HIS will also be very helpful in that regard.

I recently met with the Royal College of Nursing to discuss its concerns about the leadership and culture of NHS Forth Valley, which is in my region, and I thank the RCN for its open and honest discussion.

A and E has rightly been noted in many questions. Can the cabinet secretary assure me that the improvement will be sustainable and that the input of staff from all sites, not only the acute site at Forth Valley royal hospital, will be taken into account when discussing improvement?

This is an NHS Forth Valley escalation; it does not relate only to Forth Valley royal hospital as the major acute site. I can give that categorical assurance in relation to Gillian Mackay’s latter point.

Gillian Mackay is also absolutely right that the improvement has to be sustained. One of the areas of concern is A and E performance, but social care integration is related to that. She has raised her concerns about Forth Valley very constructively with me over a number of months, and we know that improvements in social care will help with bed capacity and the flow through our hospitals. Ultimately, it is better for an individual whom it is clinically safe to discharge, for example, to be out in their home or in a care home as close to their home as possible. I give her the guarantee that a whole-system approach is being taken to the escalation framework.

The cabinet secretary will be aware of recent reports about strained relationships among managers at Forth Valley. Can he say any more about steps that could be taken to support culture change for leaders at all levels?

I will perhaps write to Siobhian Brown with a detailed written update, because we have a lot of programmes that help to foster positive, compassionate leadership. For example, leading to change is the Scottish Government’s national leadership development programme, which I was pleased to launch earlier this year, and we have a range of other initiatives.

I go back to the point that I made to another member, which is that we can have all the strategies and programmes in the world, but we want delivery and implementation on the ground. That is where the assurance board, headed by Christine McLaughlin, will hold NHS Forth Valley’s leadership’s feet to the fire in order to ensure that that leadership change is implemented in a timely and sustainable manner.

I will continue on a point that was made by Alex Cole-Hamilton.

On 22 September 2016, in the chamber, the First Minister said of child and adolescent mental health waiting times that

“The performance of NHS Forth Valley is unacceptable, and that has been made clear”.—[Official Report, 22 September 2016; c 21]

Today, on 23 November 2022, we have a statement that says:

“Forth Valley remains one of the poorest performing boards in terms of psychological therapies and child and adolescent mental health services”,

and that the Government has

“been providing tailored support”

and is monitoring closely. How has the Scottish Government allowed the situation to go on for so long, and does the cabinet secretary agree that our young people deserve way more than close monitoring?

There will be more than just close monitoring. As I have said in a number of answers, I expect to see tangible improvements on the ground. I will also say, absolutely candidly—I have said this on many occasions—that we know there were challenges in relation to the pressure on CAMHS pre-pandemic. Further, I do not think that there is any doubt from anybody here that that has been exacerbated by the global pandemic. Of course, we want to ensure that we meet the targets that we have set out in relation to psychological therapies and CAMHS, and we will also invest in pre-crisis interventions.

I give an absolute guarantee—as I have done to a number of members who have asked very important questions on mental health—that the improvement plan for NHS Forth Valley will include tangible steps for improvement in relation to CAMHS and psychological therapies.

On a point of order, Presiding Officer. My apologies. I would like to draw members’ attention to my entry in the register of members’ interests, as I am a practising national health service doctor.

Thank you, Mr Gulhane. Your comments are on the record.