 Good morning everyone and welcome to the 14th meeting of the Health and Sport Committee in 2017. I begin by expressing on behalf of the committee our deep condolences to the family and friends of those who lost their lives in last night's evil attack on Manchester. We wish always injured a speedy recovery and offered our thoughts and prayers to everyone. We also expressed our solidarity with the people of the great city of Manchester at this time. Later in the agenda, we will have a session with representatives from the Scottish Ambulance Service, and I think that it is only right that at this time we put on record our appreciation and admiration for the work of the emergency services staff here and indeed across the world. The first item on our agenda is subordinate at legislation, we have two negative instruments to consider. The first instrument is the national assistance assessment of resources amendment Scotland regulations 2017. There has been no motion to annul any delegated powers and law reform committee has not made any comment on the instrument. Could I invite comments from members? If I may, I note in the papers that there has been some delay in these changes being implemented that normally they would be implemented from April, and that has been delayed until the summer. Could I propose that the committee writes to the Scottish Government to seek some clarification round about that and also some clarification round about the changes to the payments as well as be backdated, et cetera? The second instrument is the national assistance sum for personal requirements Scotland regulations 2017. Again, there has been no motion to annul and the delegated powers and law reform committee has not made any comment on the instrument. Again, could I ask any comments from members? Sorry, convener, again, can I suggest that we also write in this matter to the Scottish Government seeking the same sort of information? Okay, I assume we agreed on that as well. Thank you very much. Now we move on to agenda item 2, Scottish Ambulance Service, and we have an evidence session. I welcome to the committee Pauline Howe, chief executive, Dr Dareth Clegg, associate medical director, Gerard O'Brien, director of finance and logistics, and Paul Bassett, general manager of the Scottish Ambulance Service. You are welcome to the committee. I can ask Pauline to make an opening statement. Thank you, convener. The Scottish Ambulance Service touches the lives of almost everyone in Scotland at one point and another. Every year, we receive around 2 million calls for help, and a very small proportion of those are for people who are in immediate need of our services, who, for example, are suffering from cardiac arrest. Increasingly, a number of unscheduled care presentations are increasing and we have a range of conditions and a range of different responses for patients in those circumstances. For example, elderly patients who have fallen, we have a range of different responses for those patients now. We also provide almost a million patients with help to and from their hospital appointments. We host the Scotstar specialist retrieval and transport service for the most acutely ill patients in Scotland that require transfer into specialist facilities. We host the Scottish Air Ambulance Service, and we have special operations teams who respond to tragic events like the one in Manchester last night. Like you, convener, we would like to place on record our thoughts for all those who were affected by the tragedy in Manchester last night and our thanks to our emergency services colleagues, particularly those in North West Ambulance Service. The Scottish Ambulance Service is also changing. Like the rest of the NHS, we operate in the context of increasing demand for healthcare services, public services reform, tight financial budgets, an increasingly elderly population and a workforce who is getting older. We have listened to our staff, to the public and to our partners, and we have embarked on a significant period of transformation of our service, taking care to the patient. The reform programme means basing our service on clinical evidence and staff and patient experience. The aim is to provide care for patients where and when they need it in the most appropriate setting that might not be in a hospital. Last year we treated more than 100,000 patients at their home or in a homely setting where they want to be treated and we also saved more lives from patients suffering from cardiac arrest. Our reform programme means investing in equipment and technology but fundamental to all is investing in our staff. We are developing our workforce through further education, development, enhancement and addition of new roles and clinical skills for staff. We are training 1,000 new paramedics by 2020. As we continue to introduce our new programme in the next phase of our clinical-based response model, we know that we still have a lot to do. We are only part way through the reform programme. We also know how valuable it is for members to see our service first hand and it was great to see so many of the committee members out in our ambulance stations and ambulance control rooms recently. Of course we would welcome other committee members joining us to listen to staff and to hear and see for themselves first hand the work that they do and the ideas that our staff have for further development of our services. We are pleased to come to committee today to answer your questions and we look for your support and further improvements in our service. We need to develop new models of care within four communities that are sustainable particularly in remote and rural locations. We need alternative transport options for those patients that do not require the skills of ambulance staff and we need to continue to develop performance standards that matter to people and people tell us that the things that matter to them are improved positive outcomes and being treated with care and compassion. Thank you convener. Thanks very much for that. I wonder if I could ask you to reflect on the performance of the service in general. How do you think the service is performing? As I mentioned, we are part way through a significant period of reform of our service and that reform is based on the best clinical evidence that we've got available to us. As I mentioned in my introduction, we are saving more lives and we are developing our staff so that they can perform care in different settings. The experience of our staff and our patients is that for people who phone 999, a different range of responses are required. Sometimes that's not an ambulance at all, sometimes it's referral to other parts of the health and social care system and that's why we're investing in our ambulance control centres and upskilling the staff in there and developing URLs within the ambulance control centres and investing in the staff that you see driving about our cities and our towns as well so that they can take more care to patients. There's almost always more to do and we've got a very detailed corporate plan this year that will see us continuing to invest in the staff and to develop new care models and new care pathways with our partners. Gareth, do you want to say a little bit more about the evidence based for the changes? I think there are two things that would be good to say at this point about performance of the service and one is to pick up what Pauline mentioned about out-of-hospital cardiac arrest. Cardiac arrest is a good condition to use as an indicator because it really is at the top of the acuity pyramid after someone's heart stops in the community. There are only a few minutes in which we can intervene to do something to save the life before someone dies. It came to our attention over the last few years that actually Scotland doesn't do terribly well in the league table internationally in terms of survival after out-of-hospital cardiac arrest. Only one in 20 of the 3,000 or so resuscitations that are performed every year in Scotland will result in a survivor going home to their family. That's in contrast with other countries like parts of Scandinavia where as many as one in four people will go home. In recognition of that, more in what last year launched Scotland's strategy for out-of-hospital cardiac arrest. The Scottish Ambulance Service have been at the centre of this strategy, chairing the committee with all the other emergency services, third sector organisations, academia and so on, that have put together a programme including aims and pledges and undertakings to improve things over the next four years now, five years then, up to 2020. We hope to improve survival to the extent that we're saving an additional 300 lives a year after cardiac arrest. This highlights some important things about the Ambulance Service. Firstly, that we are keen to be proactive and at the centre of changes which will result in positive patient outcomes. That we're willing to engage with all the partners in the community that want to do this. So these are community groups, other emergency services, third sector organisations and academia and so on. We're willing to collect the data and the resource in order to push things forward. As things stand, as Pauline alluded to, we have seen an increase in the number of patients who get back a pulse before arrival in hospital since the launch of the strategy. Paul, if I would welcome the changes that improve the outcomes for patients. Looking at the measurements on the heat targets, we see that we have reached 80 per cent of cardiac patients within eight minutes and 9 per cent below target. Your category A instance is 10 per cent below target. Category B is 14 per cent. Stroke is 10 per cent. We do see other areas where there has been significant improvement above target. I didn't hear you commenting on those areas. I'll hand back to Pauline in a sec, but just to comment that whilst time targets are important, they're very important, we need to get to patients in a timely way, with the right resource that the patient needs. Clinical outcomes are perhaps more important. My submission from a medical perspective would be that we need to get patients what they need. As Pauline said, this is the kind of experience they want from the ambulance service. They want things that are important to them, but they also want good clinical outcomes. We want livesave, we want stroke disability reduced, we want sepsis treated early. That doesn't always mean sending the fastest resource. Sometimes it means sending the best resource. An example of this, a clinical example, would be stroke. It's very easy sometimes to send the nearest resource to a stroke, a person who sent an acute stroke, if that resource is a car. But of course, almost certainly, this patient will need transport to hospital. So it's often better to send a slightly marginally slower response where that response is then able to convey the patient to hospital where they need to be rather than send an earlier response, a car, to stop the clock to improve the kind of time targets that you are talking about, but perhaps not improve the patient's clinical journey. So a lot of the thinking around the new clinical response model is not just about time, time is important, but it's about getting the best resource, the right resource to the patient, so that we can improve the longer-term outcomes. Any time element within that? Yeah, the time targets are important. Do they remain in the new model? They do. And what about in relation to the overall review of targets that's going on, Harry Burns and others, are you involved in that? Will that change things again? Yes, so as part of the introduction of the new response model in November last year, it's been introduced in phases. The second phase is introduced next month. We've developed more evidence-based performance standards and we want to continue to refine them as we go. So we've shared with Sir Harry Burns the work that we've done and the modelling that we've done in the evidence base. And as part of our new response model, that will be independently evaluated by the University of Stirling and that's what the chief medical officer asked us to do too. OK, Alex. Good morning to the panel. Thank you for coming to see us today. I'm very proud to have in my constituency two centres of the Scottish Ambulance Service, both the risk and resilience unit and the call handling centre. Just specifically, I wanted to pick up on something that came up in respect of cardiac arrest. I've got a couple of other questions as well, but specifically on your point on cardiac arrest and the disparity of survival rates in Scotland versus those in Scandinavia. As I understand it, in Norway in particular, the reason that cardiac arrest survival is so much better is because they have an educated population who know what to do in the event of a cardiac arrest in the general public, that they have actual training in schools and that's mandatory and even doesn't need to be on the risk, but it happens. I'm aware that the British Heart Foundation have a call and a campaign to see an hour's worth of training in first aid given to all secondary pupils at some time in their school career. That's something I've put a motion before Parliament in support of. Just wondered if you had a view as an organisation in support of that kind of shift to training in schools so that people are equipped with the knowledge and skills to deliver that first aid? That's a really helpful comment. Bystander CPR, so CPR performed by somebody who witnesses cardiac arrest is absolutely crucially important. Survival from cardiac arrest doesn't just depend on the ambulance service, but there's a whole chain of events that need to stack up. The first is call for help and then bystander CPR. Anything that increases the proportion of bystander CPR that occurs after cardiac arrest will improve outcomes. We know that in Scotland bystander CPR happens only about half the time, less than half the time, in fact. Whereas in the best centres, and it's not only places like Scandinavia, but the west coast of the United States or many other places that have really good outcomes, bystander CPR happens up to 85% of the time. So that's what we're going in for. We need to seriously overhaul the way we view cardiac arrest as a community. In places like Denmark, this has been done by making CPR training in schools mandatory, but that's not the only way to improve things. It's certainly something that we have looked at and discussed with the Scottish Government, but at the moment we're taking a different approach, which is to support a national organisation called Save a Life for Scotland, and that's a collaboration between all of the emergency services, third sector organisations like British Heart Foundation, Chest Heart and Stroke Scotland, British Red Cross, St Andrew's Ambulance, a whole range of organisations to do CPR training in communities and with communities, and that includes in a range of schools. So one of the targets for Save a Life for Scotland, of which we're a member, is to try and get all schools in Scotland, or give all schools in Scotland ready to learn CPR over the next five years. Thank you for that. May I continue with the other questions for me? Thank you. So as I mentioned, I've got the Risk and Resilience Unit in my constituency. I've visited it a couple of times, and I'm very proud to have it there and some absolutely heroes who work there. Given the events in Manchester, are we as a country prepared for a similar attack in Scotland in terms of the response of the emergency services, particularly as was necessary in Manchester last night, the emergency response of the ambulance services? We work very closely with other emergency services and, indeed, with the ambulance services across the UK. So we always take on board any learning that we can from the tragedies, such as the one experienced in Manchester last night, and, of course, we're already in touch with North West Ambulance Service this morning to take any immediate learning that we can. We have a whole programme of planning, preparation, testing and training of our staff, not just our colleagues within our Risk and Resilience Department, but across the whole service and emergency preparedness. Great. Thank you. Thank you. Good morning. Thank you, convener, and welcome to the panel. I just want to pick up on something that Pauline Howey said in her opening statement. You referenced the addition of new roles and skills. I wonder if you could outline to the committee what that will consist of. The development is across our whole workforce because we know that enhancing the clinical skills of our staff can not only save more lives, but can improve outcomes for patients. So we've talked a little bit about cardiac arrest, but the most common reason why people 499 is for an elderly person that's fallen, and we know that a lot of elderly people that have fallen are not injured and they don't want to go to hospital. So we've been developing different skills for staff to be able to assess and refer people to alternative pathways that are community-based. So, for example, we've been developing new roles called specialist paramedics that have enhanced skills and they can treat and refer and work as part of a community or primary-based team within communities. Paul, you might want to say a bit more about them. Yes, certainly. So we've got a number of specialist paramedics that are already trained with a commitment of 240 by 2020. One of the key areas where they can actually utilise their skills is through the integration agenda, an integration with primary care, and the convener would be pleased to know that there's a trial going on currently in Dean's and Elybone medical practice, where there is a specialist paramedic based in the practice for seven and a half hours a day, doing the mobile workforce, going visiting patients, working as part of that integrated health system to try and stem demand from coming to us and treat patients more appropriately at the right time in the right place. They do a lot more on minor illness and minor injuries, which aren't part of the co-paramedic curriculum and haven't been for a number of years, but as we transform in relation to education and pathways, that will become more mainstream in relation to the demand increases that we've seen. That's interesting. I want to ask to what extent the realistic medicine agenda is informing your approach, because there seem to be some echoes of that in talking about taking care to the patient and also reflected in the latest statistics from April, where in the reducing hospital attendancies you're actually exceeding your target quite significantly. Is the realistic medicine agenda informing your practice and approach? Absolutely, and it works both ways as well. We've been sharing our approach with the chief medical officer and her team as well. We know these models' work. We had our own evaluation of the model based on the small tests that we did a few years ago, and recently, the Nuffield Trust reported in March 2017 that the model of community-based paramedics helps in keeping people at home and shifting the balance of care. The final question I wanted to ask is ISD states that as of December last year, 1,385 AHPs, essentially paramedics, and understands the Scottish Government commitment to increase that number by 1,000. Will you discuss what impact that will have, and will that help to address some of the areas where you've fallen short of your targets? It's fantastic news to be able to train that number of new paramedics in the service and working in our communities as well. We are very much an unscheduled care service, part of the health service, and we're community and primary care based. I think that we can offer a huge amount to patients in communities going forward with that investment of 1,000 to more trained paramedics. You mentioned the Deans in Eiliburn practice. Is that the practice that effectively went bust recently? That sort of terminology. There's certainly struggling, and we're certainly helping out where we can. Were you folks brought in to assist in that because of the fallout from that, or were you in there prior to that happening? It happened about the same time, but it's part of our longer term strategy because we've also got similar models in Kelso, Hoik, and certainly in the north of the country where we've got integration to try to bring together all the different aspects of primary care and for us to integrate in their work streams to use the available resources to best effect for the person's need at home. OK. Alison. Thank you, convener. Good morning. I, too, have had the privilege of visiting my local ambulance centre. It was certainly heartening to see the skilled workforce in action and to listen in to some of the calls. I understand the training that has gone into making sure that calls are handled as appropriately as possible, but Pauline Howe highlighted the number of calls that are related to old people and falls. Do you liaise with Government departments that might assist in preventing falls in the first place? Do you have any input there? We've been working with the assisted living programme at Scottish Government to try to prevent falls because we know that if people do become dependent on health services, then they very quickly lose their independence and the return to independent living for them can be an uphill struggle. We've been able to identify through some of the work that we've been doing, for example, in identifying alternative models of care for people who have fallen, those that are more at risk now of falling and put in place preventative measures, such as housing adaptations or it might be changes in terms of medicines management for those patients. We're working very much as part of a multiagency team now to share our learning and to try to put in place much more sustainable services but not just respond but can anticipate and ultimately prevent. Are you seeing any improvement because of the work that's happening already? The data that we collect is in terms of those people who have fallen at home that aren't injured and whether we're able to keep those people into community settings and we're seeing a significant improvement in terms of our contribution. I think it's too early to say yet in terms of that wider prevention agenda. You spoke about the Public Health Minister's commitment to 1,000 new paramedics by 2020. Is that going to be possible? We've taken a great deal of evidence with regards to recruitment and retention across medical professions. Who is it that you hope to attract to those roles? We train a lot of people ourselves so people can join the ambulance service and be trained as an ambulance technician. That takes about 18 months and then there's a period of consolidation of the practice and then they can go on and train to become paramedics. We're also introducing a degree course at Glasgow Caledonian University in September this year as a Trial 2. We've seen that across the country. The Scottish Ambulance Service remains an attractive employer. Last year, as part of the first phase of investing in new staff and new roles in the service, we attracted over 5,000 applications for roles within our service. There are some pockets in remote and rural areas where it is harder to attract staff. We developed a new model last year that was specifically looking at people that already worked and lived in those communities to try to encourage them to consider a career with our service because we know that they're more likely to stay in those communities once they're trained with us. Can I ask a further question, convener? This is specifically around the area of neonatal transport. You'll be aware that the maternity and neonatal services review recommended reducing the number of units from 15 to 5 and potentially 3, which will, of course, mean that more travel is required. How involved are you in those sorts of decisions and also there'll be implications in staff training there, too? We were a member of the Maternity and Neonatal Programme Board that reviewed the existing arrangements and we will continue to work with the areas as we move towards the new model that that review set out at the very early stages. We have the Scottish Star, the specialist chief of transport service that includes the neonatal service and that carries out a fantastic service every year. Thank you, convener. Thanks, panel, for coming along this morning. I wanted to just drill down a wee bit in terms of some of the measures that you've got and understand how that fits together. I suppose I'll just take a step back. I'm looking at the data. If I'm reading this right, you're doing about 600,000 plus incidents a year and nearly 900,000 journeys. You mentioned that there's 3,000 of those that are cardiac. I know that there will be other serious issues in there, but I reckon that you can confirm that the vast majority will be less serious, perhaps. When you look at those numbers, the thing that comes to my mind is how effective is your call screening process is at the start to understand what's actually in front of you and what the best resource to deploy is, because clearly you don't want to deploy resource to something where it could be better used somewhere else. I suppose that I'd be interested to know that you measure how effective that call screening is, because I thought that, to my mind, that would be probably the most important metric, because if you get that right, everything else flows from that. Secondly, I've fallen up on what Alison Johnstone talked about about preventative measures. Falls is a good example, but again, if you're working hand-in-glove with other parts of health service that are engaged in the preventative agenda, what you should see, obviously, is the total number of incidents going down as well. I wonder if you were tracking that and seeing any impact there as well. As part of the investment in our staff, we are significantly investing in our three ambulance control centres that work virtually as one ambulance control centre, and we've established clinical hubs within those centres. Those are staffed by nurses and paramedics and doctors who can help staff in terms of refining the triage and making sure that we direct the ambulances to the most appropriate calls, and where an ambulance isn't required, we then try to refer that to another part of the health and social care system. The modelling that we did in 2015 suggested that ultimately about 30 per cent of the demand that we were seeing at that time could potentially be better served by being served by another part of the health and social care delivery network. That's ultimately what we're aiming for over the five-year reform programme, and we've got milestones along that journey as we go. Paul looks after our ambulance control centres and will be able to explain in more detail. Certainly, in the call screening programme that we use or the process and protocols is internationally recognised, it's got a standards council and is constantly being updated. Our staff are currently undertaking training to move to the next version, version 13, which is geared towards identifying life-threatening patients much quicker. It's also changing the process in relation to, as Gareth alluded to earlier, improving cardiac arrest survival and recognition by getting hands on chest much quicker. Our call handlers are audited, and we have to do up to 3 per cent of audits on all the calls that come in, and we feed that back to the body with which we have the licence, and we are working towards what we call a centre of excellence accreditation, which means that we are robust in relation to our triage processes, and there's 20 standards that we have to meet and give evidence in relation to that to the licence and authority before we will be able to do that, and we hope to achieve that by March next year. Right, but I suppose the question was, do you have a measure on that? I would have thought if you take, I don't know, whatever it's a million calls, you would know at the point where the person takes the call and they make a decision as this A, B or C, and then when you go through that process and they decide, you call this a B, but it should have been an A or vice versa, do you have those numbers, is there that feedback loop and can you tell me what that per cent is? OK, Colin, is it like? OK, so obviously the codes that come out are generated by the system and are in direct response to questions that are scripted and answered by the patient. So a lot of it is reliant upon the interpretation of the person who's with the patient and occasionally, you know, that is wrong. In most cases, I'm pleased to say it's not, but what we do have is our crews when they arrive at scene and as part of the electronic patient report form, they have a box which they complete, which confirms that it was in the right category and the right protocol in relation to that. And we've got a high percentage, I haven't got an exact percentage, but we've got a high percentage that are accurate in relation to that. The codes can happen as the patient may improve or deteriorate whilst we're on route, but for patients that are considered to be at risk, we stay on the phone with them and we monitor that throughout and try to update the crews whilst they're on route. Yeah, I mean, again, coming back to out of thought, and you might want to get back on the number, but out of thought, that measure would have been absolutely critical to the health of the whole system and you should be tracking that week in, week out to see what your trend is going on because if you get that right, everything else kind of falls from that out of thought. And the second question round about the preventive agenda, are you seeing yet any impact in the number of calls coming down as a consequence of any preventive work that you're doing? So our call volumes continue to increase, but the proportion that we are seeing is hearing and treating and referring is increasing so we're sending of that total proportion we're sending more to other parts of the health and social care system and as the most recent figures show, the proportion then that we take care to patients in their own homes is also increasing. So that's the two areas that we see that we can shift the balance of care and keep people into community settings and out of hospital where they don't require to be. So ultimately we think about 40% of our activity requires to get to hospital, some not immediately. Some patients might, for example, be preferential to wait to the next day to the clinic as open. And that's what we're doing in terms of that differentiation and refining the triage arrangements. Gareth might want to say a little bit more about the evidence base for that. Yeah, I think it's interesting. A couple of things. First, just in terms of prevention affecting the number of calls, I guess there are lots of drivers that affect the number of calls they have in the service care every year. And it's not like there's a static body of people who are going to call in any given 12-month period and by preventing some of those calls to reduce the numbers, because the general trend is for an ever-increasing number of emergency calls. And that reflects, I think, the change in the way that, or the number of options that patients perceive or potential patients perceive that they have pre-hospital when something goes wrong. So the tendency is for our numbers to increase. It's partly demographics, but it's partly a shift in the pattern of care or options of care that people have in the community. While we do our best to reduce that by preventative measures, I'm not sure that we would expect to see that directly threading through into numbers of calls. So is there an issue there where people don't understand what they should do and call on an ambulance when in many cases they shouldn't? Is that part of the issue? I think that's part of the issue, but it's complex. So it's a change in the way that other out-of-house services are run. Partly it's to do with those changing perceptions of health care and their ability to manage their own health, expectations of the health service. I work in the emergency department here in Edinburgh and we see the same pattern. The kinds of cases that are coming are shifting. Actually we're getting older people, but we're also getting lots of younger people too. So we've seen a spike in the 16-35 age group as well as the older age group. That's not because they're getting sicker, it's because they're coming in with things that they would have gone to other places with. Right, and apart from it not being in a proper place that they go, it's also not an effective use of resources across the whole health service. It's a problem. The other thing I wanted to mention, just in terms of drilling down onto the accuracy of diagnosis using the protocols and ambulance control, I just wanted to give an example of what we're doing around, again, cardiac arrest to help illustrate the fact that we're very proactive in this and take it very seriously. You've correctly identified that actually that triage point at ambulance control is the pivot for the whole system. If that doesn't work then all sorts of other things don't work as well as they could do. So we've spent as a service a lot of time even listening to individual cardiac arrest calls to say what are the barriers that get in the way and what are the linguistic barriers, what are the misunderstandings that get in the way between the call coming in and the ambulance being sent or somebody being persuaded to do bystander CPR and we have some published work on that we've done in collaboration with the University of Edinburgh. In addition, of course, the other big triage challenge is around major trauma. Again, if there's a big smash, if there's a big accident, correctly discerning what resource needs to be sent and what kind of timescale is really important, not only for saving lives but also for saving money. So we are right at the centre of the process examining how we best triage trauma across the whole country as part of the trauma reconfiguration exercise. So we take this area of ambulance control and triage very seriously. Okay, Clare. Thank you, convener, and thank you panel for coming along this morning. From what I've been reading and what I'm hearing this is quite a significant change. This new model is very different to how the ambulance service was working before and you're asking ambulance service staff to do the job differently in terms of the activity, the judgement and particularly in terms of risk assessment as well. So what training have you put in place as an organisation for your current staffing? So we have on-going annual training for our staff and that's refreshed each year based on their feedback. So, for example, last year, based on staff feedback, we said that we wanted more around obstetrics and pediatrics. So we put that into the annual programme of training for them. As part of the introduction of the new response model, we've been engaging with staff around what else they would like to see in terms of their training and development. And we also, as I said, in terms of the 1,000 new paramedics and enhancing the skills of the new staff coming into the service or indeed those staff that were previously ambulance technicians that are now being trained as ambulance paramedics. So it's very holistic the training programme. It's for all staff and the new model, as you rightly say, is a significant difference from what we've previously operated and requires all staff to work differently. So we've significantly invested in our practice placement educators that work within our ambulance divisions and ambulance locations, as well as the people that work for us at Glasgow Caledonian University in terms of training new staff or upskilling existing staff. So you mentioned there's some very specific areas of healthcare at Obsingen, for example, but how do those skills that people are learning, which is fair enough, they get that through providing training through the feedback they've been giving you, but how does that feed into the new model, which sounds like it's a very different way of working? As you've not got a huge staffing turnover, you've got a lot of staff who've been with you for quite some period of time. How are you supporting them in that? So the most significant change in practices within the ambulance control rooms and Paul might want to say a little bit more about the intensive support that we've been giving for staff within them. Yes, certainly. When we're looking at clinical advisers, there's quite an in-depth process that's ongoing around the triage system that we use and how we safely discharge patients or transfer them to other pathways of care and also in the field there's documentation and there is a patient safety manager who's been looking at safe referral and discharge and what we need to do to ensure that patients do meet those requirements. And again, when we've been down in certainly in the Scottish Borders in Kelson and Hoyke, we've been trialling those models. In Hoyke, we had specialist paramedics again embedded with GP practices and we used all the paramedics at Hoyke station to do that test to change and that's been very successful and they've safely left at home a significant number of patients all referred and back into the GP community locally for appropriate care and support and also into avenues in social care and bringing other people on board. So it's about now rolling that out across the country and as Pauline's explained, we have the learning and practice programmes which we run every year committing this year to two days and these will all be part of the agenda items as well as any educational sessions via learning or any other portals that people want to undertake. So that's a continuous process that we do and it's also learning from good experiences and bad experiences in relation to compliance concerns and as well as compliments to try and hone what is best practice. So these new roles that have been developed within the Ambulance Service I'm hearing you talk about practice education facilitators and what's patient safety facilitators? So the patient safety manager sits within our clinical directorate centrally and does the horizon scanning to make sure across the Scottish Ambulance Service. I don't understand what that term means can you please explain what horizon scanning is? Right okay so what they do is they look at the national picture and they look at everything that's going on looking for best practice and we undertake the improvement methodology through doing test to change and that's a central repository to look at that to look at what works and what we need to revise and improve on. The other thing is with the delivering future leaders and managers we've got team leaders and local managers who through the staff engagement processes are also doing local roadshaws and local training which they're well capable of doing and in Edinburgh just recently we had a good example where a local team identified an issue and they got the training trailer to come in and spent time with all their staff going through that at a local level. So we encourage all these different models of training and certainly well aware of that ongoing on some of the islands as well where the team leaders take that responsibility feed into the syllabus that's delivered centrally and make sure that as far as possible it's divested locally to staff. That leads me on to my next question about the initial training that paramedics and ambulance technicians receive. You were saying that there's a course being developed at Caledonia University so how are you inputting into that to make sure that the paramedics that are being trained now are going to be trained in the new model of working? So it's our trainers and educators that are based at Glasgow Caledonia University they design the course and it's accredited too by other healthcare professionals that are based in Glasgow Caledonia as it's necessary. We've also seen that there's benefits in terms of that collaboration with other healthcare professionals too by being based at GCU and that's been helpful in terms of being able to learn from other professions as we develop paramedics within the Scottish Ambulance Service. Can I ask one final question? Have you had any feedback from the service users or service providers about the new model about the new model roll-out how well it's working where the issues are where the difficulties are with it? We've been engaging with patient groups across the country first of all to reassure them based on the clinical evidence and to get their feedback as to what they would like to see going forward and the issues for patients and to get the best ambulance response for them and what it means in terms of being able to safely safety net those patients that don't perhaps need that immediacy of response but it's more appropriate to get the conveying resource there in time. We work with patient and public forums across the whole country they help us in terms of the design of our services for example they've helped us to design new needs assessment models vehicle designs etc and that's an ongoing engagement programme so our service is very much based on patient experience and staff experience. Could I ask if you could provide us with performance information based on the new system because I think the committee clerks wrote to yourselves in what we've got was updated time information rather than information based on the new model and provide that for us that would be very welcome. Marie? I represent the Highlands and Islands so I'm particularly interested to hear about provision of ambulance services in remote and rural areas. I visited the ambulance centre in Isle and I was very impressed by the team there. I just wondered if you could tell us a little bit more about the different type of service available in remote and rural areas? You'll be aware that for example the model in Isle very much is a partnership type model. We work very closely with the hospital and the GPs based in Isle as well as the other responders there too. We have a range of different types of responders so we've got over a thousand community first responder schemes in Scotland that operate out of about 130 schemes and they provide a really valuable service whilst the ambulance is on its way. We've recently introduced in Grampian for example a new model called Wildcat where people are members of the community or nurses or doctors are trained to offer an immediate response to cardiac arrest as well. We very much work with communities to design models that suit their local circumstances and as you'll be aware, every rural community and every island community is very different in terms of the resources and the assets that are there in those communities. I wonder if you could tell me a little bit more about hospital transfers. For example not necessarily the urgent transfers like the cardiac arrest but perhaps the less urgent transfers from an island for example. I've heard anecdotally from people who have talked about the difficulties of the number of ambulances that can go on a ferry or transferring people from an ambulance on a ferry into an ambulance on the other side because they don't want the island ambulance to be away for a long time. I wonder if you could tell me a little bit more about the logistics of those particular challenges. Well it's challenging in terms of all the different ferry arrangements across across the country. We obviously have the Scottish Air Ambulance Service for those cases that need to be removed by air transport. Some of those patients will be emergencies others will be more planned journeys or urgent journeys too and we work very closely with the community based hospitals the GPs and the ferry companies to try to make sure that we can retrieve patients as smoothly as we possibly can based on their presenting aid at that particular point in time. Often in the island communities keep the island ambulance on the island and we will send a mainland based ambulance over to retrieve the patient and bring them into the specialised care in the mainland. Miles Thank you convener and good morning to the panel. The weekend before last the Scottish Ambulance Service along with I think all of the health boards apart from NHS Lothian experienced a cyber attack with ransomware and I wondered if you could update the committee on what changes you've put in place since then and any additional capacity needs you've identified which will have to be brought forward around IT. I will do. For a handover to my colleague Jerry O'Brien I'd just like to comment that there was no operational impact in terms of service delivery from the malware attack a couple of weeks ago. Okay, thank you Pauline. Yes, the service was made aware of this malware attack, ransomware attack 1545 on that Friday afternoon and by half past four that afternoon we had identified there was 15 or 14 PCs in a laptop that had actually been infected by that ransomware attack. The majority of those PCs were actually located within our Aberdeen network so we took immediate steps to isolate our Aberdeen network from the rest of the national network as purely as a precautionary item and by half past five we had actually updated our monitoring software and our software to actually effectively fight against any future ransomware attack as Pauline has said I'm actually very pleased to go there was no patient data impacted at all in the ransomware attack the 15 PCs which we identified being replaced were all providing admin and back office functions we were a little bit puzzled as to why we actually had 15 PCs that were affected out of our 1500 estate of PCs and we've identified that down to a patching issue we take a very robust approach to patching of PCs and we always insist that we've got the most up-to-date versions of software to do the same with our major business critical systems we work very closely with Paul's team in relation to bringing systems down and moving back to analogue and paper to ensure that we've got the most up-to-date software in there the remedial action for us we're just reviewing our patching arrangements just to make sure that we are up-to-date we have everything set to automatically update every two hours we're just working through why these 15 were not picked up through that but pleased to report to committee that there was no impact at all on patient data Thank you for that update my second question relates to pressures on maternity units because within NHS Lothian certainly I've had a number of cases where expectant mothers have presented at a maternity unit and being sent home to then go into birth and have to call out for an emergency ambulance to attend are you seeing these sorts of incidents increasing because certainly it's becoming sadly quite a regular incident I'm being told of happening within NHS Lothian and we've met as a committee with a number of maternity nurses under the Chatham house surroundings and they've highlighted this specific problem as well We haven't seen any particular spikes in terms of our patient-related data around maternity cases as you describe Colleagues, have you got any further intelligence around that? Sorry, and we know only a proportion of expectant mothers do travel with the ambulance service to hospital so we wouldn't see the true effect of those sorts of situations, the ones that we are more likely to be called to are imminent births complications or where there is no transport available in certain areas and as Pauline said certainly from looking at the data that we've seen a significant increase in those sorts of areas in any part of the country In relation to the malware attack there was no missed appointments or delayed appointments or anything like that Jenny Pauline Howey commented that the ambulance service remains an attractive employer but if we look at the 2015 NHS staff survey a couple of worrying things come out in terms of the statement that your staff were kept informed about what is happening on the board only 39 per cent agreed with that and my line manager communicates effectively with me only 42 per cent agreed with that that's the lowest for all national bodies in the NHS Can you account for why that might be the case? What a very unique service compared to other bodies within the NHS a distributed workforce that's mobile and works in communities Further to the staff survey we have been implementing the iMatter staff experience tool and I'm pleased to say that that's now fully rolled out across the ambulance service and our employee engagement scores which is a measure of how engaged people are within their workplace is 67 per cent which is much better than we were expecting and the participation rates are 70 per cent so much higher participation in iMatter staff survey but we're never complacent we have a range of channels where we engage with staff and that communication is two ways for example a couple of weeks ago I undertook a quarterly webcast where anyone in the service can ask any questions at all of me or the senior manager team I have a weekly bulletin which is three hot topics of the week and always we highlight the fantastic examples of good practice that goes on in the service so that we can share that learning as well we have station meetings across the service we have social media and a range of different opportunities for staff to engage and we've been enhancing and developing our front line leaders and managers through our developing our future leaders programme and we're giving them more dedicated time so that they can help to develop them in the areas that are important to them If I could just pick out another couple of points from the staff survey only 20 per cent of your staff agreed with the statement that when changes are made at work I'm clear about how they will work in practice and only 53 per cent had had a knowledge and skills framework development review in the past 12 months so nearly half of your staff haven't had a staff review in the past year and I appreciate that you've put in place changes on the back of that staff review and that again doesn't match up to other NHS boards nationally so I just wonder why again that might be the case and did you involve staff in the move to the new clinical response model were they part of that process because it seems like there's a disconnect between her staff are feeling on the ground and what's happening at a kind of corporate level in terms of the board? I think that some of the key differences are because we are a mobile workforce so we need to use different channels for engaging staff in terms of the new response model it was very much based on staff feedback staff were concerned that they were blue lighting themselves to incidents that potentially didn't require that level of response and we're frequently being stood down once we get more intelligence from the caller about the nature of the presenting condition of patients so this has been co-designed with our staff and we continue to adapt the model based on staff feedback ok, thank you so just to follow up on that I kind of get the impression that there's a bit of no want to face up to difficult things here because if we look at that section on staff satisfaction and absence only 13% saying they're feel consulted only 34% would recommend that their workplace is a good place to work 39% saying they're kept informed 15% saying they're not enough staff to do a job 29% saying they can meet all conflict and demands if you look at that compared to the staff survey in Wales it's significantly different significantly different and we've already looked at the performance data where I don't think you really mentioned too much about the issues where there was a failing in performance and there's been no mention of sickness absence or anything like that I just wonder there seems to be a disconnect between what your staff are saying on the ground and what you're giving us an impression of that everything in the service is really going along swimmingly as I said we're part way through a significant reform of our services and there's much more that we want to do we want to continue to develop staff we want to continue to put in place opportunities for them to be further engaged in the development of our service and listen to their ideas and take on board their ideas and that's why we've invested in those front line leaders and managers we're a very distributed service we can't do all from the centre we really want to empower local staff to develop services with and for local communities as they see within a governance framework that is safe and effective based on the work that our clinical governance team do so we're absolutely not complacent we've been looking at our health and wellbeing strategy for our staff you will be aware that our staff put themselves into very challenging circumstances and see sometimes the most horrific of scenes and so we have support mechanisms in place for our staff we've recently conducted a stress audit and we've got individual stress assessment tools now that we're training our staff in as well so there's a whole range of opportunities for further support mechanisms for staff and that's part of our health and wellbeing strategy that our staff partners have been designing with us can I go back to the issue that was mentioned earlier about the proposal to recruit an additional 1,000 new paramedics over the next five years which is obviously a very substantial increase in the current workforce given the points that were raised earlier about the staff survey which showed 15 per cent of staff believed they didn't have enough people to do the job which is half the level of the rest of the NHS and given the high level of staff absences that the conveners just mentioned at what point has it noticed that the service was so understaffed as we developed the new model and the proposals for the new model in 2015 we underpinned that with a five-year workforce plan and a five-year financial plan and it was based on that new model and the benefits that we could demonstrate for patients that we have secured the Scottish Government's commitment to invest in the service over the coming five years Jeremy, do you want to say a bit more about that investment? Yeah, we worked very hard over the last couple of years with Scottish Government colleagues in terms of developing that financial plan which is entirely driven by our workforce model and the significant I think as members of the committee have noticed the significant increases in staffing levels that will be coming into the service but not only that, so the significant increase in staffing levels in the control room but the investment which my colleagues have spoken about this morning in additional training but also the what we've also tried to address budget setting rounds that we've got there now is making sure that front-line resources are adequately resourced in terms of what we call relief cover so that's actually making sure that the staff are covered for when the annual leave, sick leave etc etc so I think it's part of that overall workforce plan in terms of saying this is where we are today this is where we want to move to based on appropriate utilisation levels appropriate time of the road for training CPD etc etc and then building towards that and that's what leads into this overall investment portfolio that's required over a whole range of headings over already recruited over as Pauline I think indicated recruited a significant number last year this year and moving towards the balance by 2020 when we will have implemented the full strategy so I think we've got all the elements Pauline says that all commends with the design of the new clinical response model back in 2014 moving into 2015 but it's a substantial change to the current levels of staffing so how can we be reassured that the workforce planning is going to work because it clearly didn't work up until now because you're significantly understaffed with high levels of stress, high levels of absence rates and a plan to substantially increase the number so clearly the workforce planning didn't work up until now so how can we be reassured that what you're putting in place is going to work in the future in terms of workforce planning because the NHS doesn't seem to be particularly good at planning workforce levels so we undertook a resource modelling exercise to understand all the variables that impact in terms of the staffing requirements not just in terms of numbers but skills mix based on the new clinical model and we continue to refine that as we progress towards 2020 we have been successful in recruiting the staff that we've needed up to now but they're not all doing the things that we need them to do yet because there's a period of induction and training and development of those staff so as we move through to 2020 we will start to see more of the benefits coming through in terms of the performance measures that we mentioned that have been saved from cardiac arrest more patients have been safely and appropriately cared for in their community settings and improving outcomes for other patients so far of the thousand paramedics and technicians that have been recruited how many were recruited in the last year so we recruited over 200 paramedics and over 200 technicians last year and we're on track to deliver and recruit the same levels in the current year now some of those technicians backfill the people then that become trained as paramedics and so on some of those paramedics then go on to become trained as specialist paramedics so it's a clear pathway that people embark on and of course some people want to step off the pathway at different points to The report recently that obviously indicated that some of the paramedics are current technicians that are being trained up to be paramedics but it was reported recently that technicians are being replaced by technicians on a lower band on a lower skill level I think it was at level 3 technician so a lot of the existing technicians are being replaced by technicians that have a lower skill level than the current ones that are being trained up to be paramedics is that the case? No so we have different types of ambulance response depending on the clinical acuity of the patient so what you might be referring to is that we introduced lower acuity ambulances to deal with those patients that don't require the skills of paramedics and those are being staffed by ambulance care assistants but we've continued to invest in the double crewed accident and emergency vehicles and the skill mix there is paramedics and ambulance technicians but the technicians that are being trained up he talked about being backfilled the technicians that are being trained up to be paramedics are they being basically backfilled at the same level of skills as technicians and indeed we're enhancing the skills of our technicians as well and obviously there will be a gap between the time it takes to train people up to the level that's required so what plans are being put in place to mitigate the current pressures on staff as you're training up these new technicians and new paramedics because obviously there's a substantial gap between them starting and being fully qualified so it's a constant balance across the country and at a local ambulance station level to make sure that we can balance out people's desire for further career development and training and the need to maintain services as we go through that career pathway that I spoke about so it's a comprehensive workforce plan that covers the whole country local divisions the ambulance services is split into five operational divisions and they determine what they need at a local level based on their expected turnover and progression towards the workforce model that we've set out in the 2020 strategy and we host different training opportunities in different locations across the country on an annual basis Donald Can I add to the issue of cybersecurity and in so doing I'd like to refer to my register of interests in the fact that I'm on the board of two companies in technology As has been discussed the Scottish Ambulance Service was one of the health boards hit and I think you said that there was no operational impact and further that there had been no patient data impacted can you tell us categorically that no patient data was either lost or compromised following the cyber attack within the Scottish Ambulance Service? Absolutely, there was no patient data lost or compromised as a result of the cyber attack on the 12 February Can I turn then to the well documented issues that have occurred in the north east of the country and in Murray and in the north these have become evidence in the last six months and they encompass a number of different problems some of which have been reflected in what we've discussed already this morning there have been for instance reports of insufficient numbers of paramedics in Aberdeen leading to a shortfall in staff there have been reports of too many long distance journeys for non-emergency patients there is also issues of staff fatigue caused by overwork and staff having to take time off and the effects that has on the service and lastly I think it right to say that the union unite had a ballot and 95 per cent of its members placed a vote of no confidence in the management of the north division of the Scottish Ambulance Service Can I ask simply what have you done to address these serious issues? So there's no doubt that our staff are working harder than ever before as we said right at the beginning emergency and unscheduled care demand is increasing and the nature is changing so we're working very closely with health board partners to understand the changes and to put in place safe and effective models of service delivery so you'll be aware for example that we've announced an investment in Caithness in terms of additional transfer resources we're working very closely with NHS Grampian around changes in service provision in Murray 2 and we've also established a staff partners request chaired by our employee director who's a member of the United Union established an on-call working group so that we can look at issues of fatigue and remote and rural working to try to wherever possible minimise on-call working in those areas Can you point to any concrete changes on the ground that have occurred? So we've introduced a new urgent tier what we call urgent tier in the Murray area in the last year we've introduced hospital ambulance liaison officers to make sure that all the transfers are appropriate and we can task the most appropriate ambulance resource that we have available that meets the presenting conditions of the patient at that particular point in time and we've also introduced specialist paramedics in the Murray area as well and as we demonstrated earlier on those specialist paramedics are able to see and treat and keep people in their communities in less need for transfer to hospital or transfer from hospital to another hospital There's also, I think, a logistics coordinator Could you explain the role of a logistics coordinator? Yeah, so these are based within divisions and the help in terms of making sure that consumables and vehicles and other equipment that people need to do their job are in the best place that they can Paul, I don't know if you've got anything you want to add to that Yeah, certainly, in relation to things like restocking systems for stations, what we try to do is make sure that to minimise costs that supplies are ordered in bulk and are delivered centrally and then cascaded out in each division to those points so Edinburgh is the central point for Lothian and we've got a logistics man in a van who then takes orders from the various stations and goes round and delivers that to the doctor in place, the cleaning facilities are in place medical gases and all those sorts of things and obviously if there's anything that needs to be taken away he does that as well so rather than having ambulances travelling from here to be with paramedics and technicians on board doing these admin type roles we have logistics personnel underpinning the system and supporting it to maximise availability of our ambulance resources Can I ask about a few specific things? The patient transport service and that there's a paper that the board has in terms of discussing the future of the patient transport service could you make that available to us? Yes and maybe briefly describe what plans you do have for the patient transport service The patient transport service is skilled by ambulance care assistants who are able to care for patients on route to and from their hospital appointments We've been refining that service over the last five years as part of a significant change programme and we've been identifying alternative providers for those patients that don't need the skills of ambulance care assistants and working very closely with transport authorities such as Strathlau passenger transport for example We continue to refine the model as we go forward because as you'll be aware the modern outpatients programme anticipates different models of outpatient appointments in the future so we're working very closely with health boards to understand what that will mean for the patient transport service and that's the key thrust of the paper What is it that we need to deliver going forward? We've also introduced more discharge ambulances and that will help patients to get back from hospital where they've been admitted for a stay and services are changing and we need to make sure that we continue to develop it as we anticipate those future changes You'll provide us with that The issue of the long run in the saga of meal breaks has that been resolved? We introduced a new Scottish system of ensuring that staff could respond to meal breaks several years ago now and as we've introduced a new model the arrangements for people to be disturbed during their meal breaks obviously it's really important that staff do get their meal breaks and that when they are on a meal break we minimise the disturbances so that people can be appropriately rested so we've been working with our trade union partners and with staff over the last few weeks to try to refine those arrangements as we've introduced the new model That sounds to me like it's not resolved It's working and everyone understands the need to ensure that we can respond to those immediate life-threatening patients when those calls come in Two final things You mentioned the skills mix It's my understanding that according to your skills mix there should be a paramedic in each ambulance call Does that happen? The skills mix will develop as we've introduced the new clinical model so within our strategy you'll see that there's different levels of skill depending on the nature of the call and I mentioned the low acuity vehicles for example who often respond to GP requests for people to be admitted into hospital so that will continue to develop where it's for whatever short notice call-off we can't get a paramedic on a particular vehicle then we would make sure that that vehicle is tasked to appropriate calls that meet the skills of that particular crew and we've got paramedics within the ambulance control centres that are able to offer advice and ensure that those resources would be appropriately backed up so there's safety netting in place At the moment, according to your the way you operate is it supposed to be that there's a paramedic on each call? We've introduced the first phase of the new ambulance response model Or was that the previous situation? That was the previous situation So we're now in a different situation and that may not be the case depending on the call It will depend on the presenting conditions and as Gareth said at the beginning it's absolutely based on the best evidence that we've got The final thing is, we saw in the media highlighted where ambulances were forced to stay off the road where ambulance crews were saying they were stranded at hospitals because there was no staff to receive them into the hospital No emergency staff there and the ambulance was in effect stuck with people in it or with patients there and nowhere for them to go Has that situation been resolved or was that a one-off or was it a regular occurrence? Hospital ambulance turnaround times are very closely monitored because it is really important that we can get patients handed over to clinical staff within hospitals and back out to respond to emergency calls when they come in I mentioned earlier on that we had invested in hospital ambulance liaison officers These are ambulance staff that work very closely with the site management team to try to pull patients through into the hospital and discharge patients as effectively as we possibly can Those hospital ambulance liaison officers operate in a number of the larger sites across Scotland There are different models where we are seeing real improvements in hospital turnaround times such as work here in Edinburgh through the Lothian Flow Centre which is a multiagency hub where we can make sure that we can get patients to the right place as effectively as possible Paul, do you want to say a bit more about the Lothian Flow Centre? Certainly, it's been a number of years in its making and it started off looking at the integrated transport agenda doing some really good work and certainly from an NHS law the in perspective they save ambulance resources only for patients who absolutely need them As we've now moved forward in relation to the Flow Centre we have paramedic embedded in the Flow Centre to make sure that we've got the multiagency approach and what that does is it gives us the early heads up on reports of where patient flow needs to be but equally the pull through from A&E means that the local if you like focus in relation to ambulance to delays is not to delay ambulances as it is to offload ambulances as soon as possible and we're seeing the benefits of that in Edinburgh Colleagues from other health board have been to visit the Flow Centre we are working in different areas with the local management teams to replicate that and to see what we can do in relation to continue to improve on turnaround times where it's required I think it would be helpful if there's data to back that up and if you could again provide that to us as well Any final comments Miles? I just wanted to in terms of Donald Cameron's question on my own I'd written down your response to the cyber attack and in both you said following the attack was lost Can you just clarify that during it no patient data was lost or compromised? Yes, during and following there was no patient data lost Sorry Thank you very much for your evidence this morning and as agreed we will now move into private session