 Welcome to the sixth meeting of the Health and Sport Committee of 2018. I want to ensure that mobile phones are on silent and note that we are filming and recording the proceedings so that there is no need for anyone else to do likewise. We have received apologies this morning from David Stewart MSP and we start the morning's formal proceedings with our round table evidence session on NHS corporate governance. I would like to welcome all our guests who have joined us for this round table and reflect on the responses that we received to our survey and our call for evidence to the inquiry. I think that the best way to start is for me to introduce myself. I'm Lewis MacDonald, MSP, the convener of the committee and an MSP for North East Scotland. If I could ask everyone to introduce themselves around the table. Good morning. I'm Ash Denham. I'm the deputy convener and I am the MSP for Edinburgh Eastern. Morning. I'm Kenrick Lloyd-Jones and I'm here representing the Allied Health Professions Federation Scotland and I'm employed by the Charter Society of Physiotherapy in Scotland. Good morning. I'm Miles Briggs. I'm a Conservative MSP for Lothian region and a Conservative spokesman for health and sport. Morning. I'm Bill Scott, director of policy for Inclusion Scotland. We are a disabled people's organisation. Good morning everyone. I'm Alex Cole-Hamilton, Lib Dem MSP for Edinburgh Western and my party's health spokesperson. Good morning. I'm Brian Montgomery. I'm currently an independent healthcare consultant but I'm here by dint of a number of previous roles I've held, including being general practitioner, trust and divisional medical director in NHS Lothian, board medical director in NHS Fife. I'm actually a spell that's interim chief executive in NHS Fife. Good morning. I'm Jenny Gilruth, the MSP for Mid Fife England Office. Good morning. I'm Emma Harper. I'm South Scotland MSP. Hello. My name is Rachel Cackett and I'm the policy adviser for the Royal College of Nursing in Scotland. I'm Alison Johnston, MSP for Lothian. Good morning. I'm Ivan McKee, MSP for Glasgow Proven. Good morning. I'm Claire Sweeney, associate director, old at Scotland. Good morning. I'm Brian Whittle, south of Scotland MSP. Good morning. I'm Sandra White, MSP for Glasgow Kelvin. My name is Richard Shaw, head of the policy and research department at the Scottish Council for Voluntary Organisations. Thank you very much. I also say that we issued a survey to members of NHS boards when we issued our call for evidence in January. We'll hear more from some of those board members at a future meeting, but I'd like to thank all the people who responded. 47 per cent of board members responded, which was a very good level of response and which we really appreciate. Clearly, there are a number of issues on which our witnesses today have a high level of expertise. I wonder if I could ask Brian Whittle to put the first question in relation to the boards of the panel. Thank you, convener. Good morning to the panel. Is there a need for a greater role for patients in the public and the third sector in NHS governance? Is there a distance between the boards and the general public that needs to be closed? Excellent. We produce an overview report of the NHS in Scotland each year, and we produced the last report in October last year. In that report, we mentioned that there was a need for a very different conversation with the public about the way that the health system is operating and some of the difficult decisions that now have to be made given the financial pressures and the integration of health and social care. It is a very changed landscape, so we would say that there is a need for a more open and honest conversation with the public about the direction of travel for health and social care services in Scotland. We firmly believe that the findings and recommendations of the Christy commission that service users have to be involved in the management and governance of the services that they receive. That is the only way to bring about the transformation in those services to make sure that they meet the needs of the people that use them on a day-to-day basis. People with long-term health conditions and disabilities rely on health services on a more frequent basis than general members of the population. They have to be involved in service planning and commissioning, as well as the other aspects of the NHS governance. I would further extend it and make the distinction between those who are active service users, if you like, but the wider population. That relates to the point that Claire-Made is looking forward. We are currently in an environment that is only going to get greater, where the number of opportunities that are open to us is far greater than those that we can afford. There are some very difficult choices and discussions that lie ahead, and I do not think that it is for the professions or the boards to make those decisions. Those decisions have to be made collaboratively with the wider public. On Brian's point, some of you may remember that the Royal College of Nursing did some work a couple of years ago on performance management and how to measure success in the health service. In that, it similarly made the point that both Claire-Made and Brian have made about the difficult decisions that are required and the need to come to those decisions in partnership between those who are using the services and those who may need to use the services in the future and those who are delivering them, which would include the members of the Royal College of Nursing. I would absolutely underline that. I think that the heart of the response that we gave in writing went to the point that we now have a number of different systems at play. I think that comes across as well when we are talking about how we are engaging third sector organisations and how we are engaging the public. If you look across the integration landscape and the legislation that was put in for integration, there are now colleagues in the third sector who can say better than I can whether they think that it is working well or not, but there are legislative frameworks around that engagement at an integration level for those functions that have been delegated down to a local level. We then have a different system within NHS boards and we now have emerging regional agendas, where maybe some of that engagement is still far less clear because we are at such an early stage of what that regional system might look like. I think that we have quite a mixed market, if you like, in how people can engage. I do not think that that always makes it the easiest thing to do. I think that the key thing that we need to be looking throughout this issue on governance and how we do that well and how we engage people has to come down to the point of transparency and clarity, because decision making and accountability for decision making, particularly when we are dealing with issues that are around clinical safety, for example, or the quality of care, we have to be absolutely clear from the very beginning where those decisions are sitting and who is responsible for them. I think that there possibly needs to be some distinction between when we are talking about the inclusion of the public. At the one level, there are service user organisations, there are then service users and then there are the general public who are potential service users and how you engage and involve those may depend on the kinds of decision making you are looking for, so that, for example, a consultation to the public might be on particular proposals, whereas when you are looking at the design and delivery of services, you may be involving service user organisations who may bring the degree of expertise required to speak on behalf of service users in that field. We are picking up a lot of frustrations in the third sector and when the people in the third sector support when they have brought issues to the governance of NHS that those issues are not followed up, they are not treated with the same level of respect and equity that other decisions makers might be afforded. The overall context is that we are now in a situation in Scotland where we have an ambition towards a much more open government culture. Indeed, Scottish Government has made commitments in that as part of the international open government partnership. The international spotlight is on Scotland at the moment as a pioneer in open government around those kinds of issues. The issues are participation, accountability and transparency. One of the things that we have picked up is in the field of participatory budgeting, where things have been working quite well. When the general public, including service users and organisations, are given a genuine say and they can see how their say influences the decisions that are made and how those decisions are then made, even if the people who put in their views and put in their perspectives don't get the outcome that they want, they are happy with the process. If you talk about very stark decisions such as shutting a hospital, that is politically a very difficult decision to make, but if people can see how that decision is made, what the trade-offs were, and they can genuinely feel that their views were heard not just individually but the discussions that they have had with each other are heard publicly, then they are much happier with that and that is the evidence that will be found from participatory budgeting around the UK. I think that that is something that certainly can apply here. Just a quick follow-up to that. We have this ambition to be more open and more transparent and to allow more people into the decision-making process, but do we have a practical system in place that will allow that to happen, or where do we have to change? Yes, again, please. We do. We have a practical system in place. It is the open government partnership action plan and this is a mechanism that has to be designed jointly with citizens and civil society and government in each country. Scotland at the moment is coming to the end of a pioneer action plan where it made five commitments, including financial transparency around participation, around opening up the way in which the national performance framework is being developed and so on. This action plan is very much a first step, but there is now a mechanism for moving on to a two-year action plan from August onwards. The opportunity that we have now is quite a clear mechanism with international guidelines that can improve participation, transparency and accountability in how decisions are made that affect people, with a lot of tools, techniques and resources that are available internationally to use on that. That is certainly something that, at SCBO, we are supporting. We are helping to mobilise citizens and civil society around, so we have got the resources available for that internationally. There is a potential disconnect sometimes between the overall policy ambition and how that is being realised on the ground. We look across the public sector in Scotland, so we see differences in terms of how some of those policies are being applied. There are some interesting challenges thrown up with things like participatory budgeting and self-directed support and what that looks like in a health context. There is an easier fit for local authorities, you could argue, in an IJB world. That fits reasonably well. I think that there are still questions about how that is being applied in a health context, so it is certainly something that we are going to pay a bit of attention to over the next little while. We have published reports on self-directed support in the past that have highlighted some of those tensions, so I absolutely think that it is something that we need to keep looking at. We are doing a little bit of work around community empowerment with other scrutiny partners. What that is revealing to us is that the areas that do this really well have spent a long time and have invested in having a really good relationship with the local community. When times are difficult and difficult decisions need to be made, it does not necessarily make that easy, but it means that there is an environment where that engagement is expected. There are people who are willing to participate in that discussion and there is a level of trust that is being built up. That is not the case in all areas. Thank you very much. Jenny. I thank you and good morning to the panel. Clare Swinney, you spoke about that disconnect between the policy ambition and what actually happens in reality. Picking up on Bill Scott's point with regard to service users needing to be involved from the beginning in service delivery. When we drill down into the statistics and look at the demographics of board membership at the moment, a majority of respondents, 64 per cent, were aged 55 and over. A third were aged between 35 and 54. One respondent was aged between 25 and 34. There was no one in the 18 to 24 category. How do we reach out to other age groups and how do we get a greater diversity on our boards to make sure that all the public is involved in that process, not just a very small section of society that might be involved in other things? Who would like to start with Bill? There is a desperate underrepresentation of disabled people on all public boards, including NHS boards. We need to do far more. Again, when conveners of boards were asked whether diversity and equality were primary considerations when they were recruiting new board members, it was not uppermost in their minds. We need to have boards that represent everyone in society. There is always going to be finding some people who come forward in some groups. When we talk about community empowerment, it should be about developing the potential of individuals to represent groups within boards, etc. Because lived experience can take you so far. You know what affects you, but you need to know how it affects the group that you are there to represent. That can affect people in different ways—different empowerment groups, etc. Particularly young people who are under represented. Again, it is not that young people do not care about the health service, it is that they probably use it less frequently than older people. Maybe it is somebody else who is going to do that for me. However, when you take issues to young people, they often become very politically engaged and are willing to serve and do their bit. Again, there is a bit there about how much have we done as a society to reach out to young people. How do we get them interested in being involved in health boards? I am sure that it is not just who was recruited, it is also who applied that you will have to look at. If you want to broaden out the applications to be on boards, if there are public places available, you will have to target certain groups in society that are under represented. Make sure that they feel that their service will be valued and that their voice will be heard in the process. Otherwise, they are walking in their room with a group of people that they have never seen before. I have no idea what their police are, but they know that they are all older than them. If you are the young person in the room, it must be a very difficult situation. I think that there is an important distinction between being on boards and being actively and meaningfully involved in board-led mechanisms. One of the dangers is that we run the risk if we try to make boards as representative as possible. We end up with cumbersome bodies, but not only that, bodies where many of the people around the table are only interested in a fraction of the agenda. That has been a problem in my own experience on boards over a number of years. I think that the real challenge is less about who is around the board table, important though that is in terms of the general representation, certainly for a territorial board, but it is about what sits underneath that board and how that board empowers and responds to those substructures. I think that that is where you need the very specific, very focused, very knowledgeable input from a whole variety of stakeholders. The question of the balance of diversion representative, as opposed to perhaps your saying skills and experiences, is that essential? While I think that a board has to have a good cross-representation, I think that it would be unreasonable and unrealistic to expect to have everything represented around the board's table, what for me is more important is what happens beyond the board table and how the board table responds to that. Ritchell? One of the things that I would notice is that those people who have responded to your survey and who currently take the role of non-exec directors are doing an enormous public service. I think that it is an enormous job. The work that we have been doing recently looking across the papers that go out to boards and then to IJBs, remembering now many of these non-execs, will have a dual role on two different governance functions. The papers run to hundreds and hundreds of pages. It is an enormous task that we ask people when they are doing this public service. I think that it is important to acknowledge that, whether it is the right mix or not at the moment. Work that we did going back to what I was talking about previously on measuring success, we commissioned a number of fairly eminent people in Scotland to write some articles for us. One of them was looking at major service failures. One of the issues that was brought up for us there was the importance of diversity in boards to ensure that there is sufficient challenge to decisions as they are going across. Too much of the same tends to result in decisions that may be not challenged well enough. I would go back to what Bill was saying, and this reminds me of conversations we had many years ago in the Parliament about NHS boards and how they should be configured, which is the importance of making sure that there is, on the one hand, lots of opportunities for people to have genuine participation and engagement in decision making, which may not mean a board seat, but where we develop that, we are developing, if you like, the grass roots to be able to move into those roles at other points. That diversity will hopefully come through, but I think that we have to acknowledge the task that we now set people who take non-exec roles. We do not yet even know where that will sit with the regional planning agenda as it emerges. That is clear. Just to echo Rachel's points, I think that that is really important. The size of the ask is significant. I think that we have got a job to do to make that seem doable for people, that it is possible for younger folk to actually be involved in those, for different groups that are not represented in the way we would like them to be, to actually say that this is something you can do. It is a possible job. I think that sometimes some of the pressures that sit around the health system particularly can put people off. The task can seem impossible. We see that we have got quite an important role. The auditors, particularly, have every single public body in Scotland to be there to help to support. If there are questions from non-execs around finances, we can offer training. We can help to support people's development in the areas where they feel a little bit weaker. It is possible to do this, because it is a huge public service. It needs to be made as easy as possible for people. I fully recognise some of the limitations around a representative model. I am here, and I am representing the allied health professions, which brings together 13 different professions within health and social care. I understand the limitations, but at the same time I think that there is a way in which you can include the various interests to ensure that you are making good decisions. We certainly, for the last decade, have said that there ought to be allied health professional representation and inclusiveness in decision making because they cover every aspect of care from intensive care and accident emergency through to primary care and social care. They are also bringing something of a fresh perspective, particularly around the integration and biopsychosocial model of care. They have something to contribute, and we would like to see that included. We think that the best way of that happening is through better guidance to have those people included. However, it takes investment in that leadership, because no one person can know everything about every one of those individual professions without an investment in that leadership, so that whoever is in a representative role has a degree of accountability and the need to engage in the people in which they are there to support and promote. I appreciate what Dr Montgomery was saying, but I find it somewhat startling that there is nobody in the country in the 18 to 24 age bracket, particularly given that this is the year of Scotland's young people. We need to have those voices on the table, whether they accept that it is at board level or not. I think that, if you look at current board membership, they are not representative of the country more broadly. There is an overt emphasis on those in the retired section in terms of age brackets, and I think that that could be detrimental to service delivery, because going back to what Bill Scott said, if they are not at the table, how can they impact upon the decisions that are made? In terms of training, only 10 per cent of respondents that we heard from said that the recruitment process always led to the right people being appointed to the board, and some respondents called for a more national approach to training and induction in terms of a consistency approach. I suppose that that alludes to what Claire Sweeney spoke about with regard to the complexities that are involved in the process, which might put perhaps younger people off. I do not necessarily accept that myself, I think that it could be a struggle for any age group to get into grips with some of the technicalities involved in that role. Do you agree that we need a national programme in terms of training? I think that right now, in the charity sector, when we are thinking about governance quite closely, as you can imagine, there is a huge amount of scrutiny on governance, and with that comes training and awareness of how the skill set that you bring to it is not just the background, but it is also the awareness of what you do as somebody who is part of a governance of an organisation. While we are talking about having a balance in the boards, people need to know that the way of responsibility that is going to be on them once they are around the board. I do not think that we do enough around supporting people to understand their governance role and the implications that it can have for them as well. Way beyond giving people 100-page reports a day before a meeting, I am not saying that that is what is happening, but if that kind of thing happens, it does certainly happen in some sectors. People need to be able to give them the support and the awareness of what they are getting into. The trick here might be that, rather than expecting us to put all the weight of governance on the NHS boards, if we can somehow open up the role of governance of health services and NHS trusts through wider mechanisms that involve the public, so that less of the emphasis on decisions is solely put on who is around the table in the boards. I think that we might have a more balanced system overall in general, and then it makes things like training a lot easier. I think that more needs to be done to help to support all the age groups. I think that is absolutely true and clearly does not ask to get that from the survey responses. There is a demand there for that. One of the things that we would focus on around the financial skills, we often see that that is something that people worry about when they are joining a board, so I think that there is more to be done around that. There are some courses that are available to help to support people. One of the other things that we really look for is the respectful challenge that the non-exex need to give around some quite complex issues. Again, support for people with their confidence when they are joining a board and they are quite new to it to be able to take on that role. Sometimes we hear the feedback from new non-exex that being new in and being able to ask what might seem quite a silly, quite a basic question that has not been asked before is a really, really valuable thing, but giving people the confidence to be able to challenge in that way is a good thing. There is a whole set of technical skills, but also some softer skills that people need support with. I would definitely recognise that there is more to be done to support people for sure. I echo what everyone has said. It is important that, around the table, you have that variety and breadth of perspectives, but my sense is that non-exec colleagues in particular also need and value the ability to see the bigger picture and understand the bigger picture. There is a huge potential induction process that they need to go through to allow them to get that degree of confidence. I had the experience a few years ago in Fife as one of the two boards that had an elected board for a while. That was a fascinating process, not least because it almost felt like the pause button was pressed in that overnight, a significant number of non-executive directors who had, over the years, built up comfort and confidence and experience disappeared and were replaced by a number of individuals who were voted on by the local public. They, by their own admission, found it difficult because, while they understood their particular interests, their particular perspective, they found it very difficult to slot into the big picture. They found it very difficult to offer those challenges into areas that they were not comfortable with, for example. I think that the elected boards have obviously been paused and we have moved on without them, but I do think that there is a lot more about training and induction for board members. I think that the other thing that is very important is that it is not just about the board that they are appointed to. It is very important that they have an understanding of the NHS in Scotland, particularly as we are starting to look at things like regional issues much more closely. The training and induction has to be more than just their local geography. One of the things that the Scottish Government funded us to establish a Highland localisation and employment project, which was actually established to do the very things that we are talking about, which is to work with local disabled people and the groups that represent them, either organisations of disabled people or organisations for them, to develop the potential for disabled people to participate in decision making, both in community partnerships and in health governance. The idea is there, and I think that you have to start even before the training to actually build the confidence, which is what you said, Claire. You need to build the confidence of people to think that they are capable of doing it. That might mean that you start well before the board stage and try to get them involved in other activities where decision making is involved. We did a mapping exercise in Highland, and the hierarchy is the NHS board, the integrated joint monitoring committee, the health and social care partnership, the adult strategic commissioning groups and the improvement groups. The only groups that disabled people were represented on were the improvement groups. They have all been halted and become task-focused groups, which means that no new disabled people are being recruited to them, so there is very little opportunity to develop people to move on. It does not seem that they are moving into any of the other governance groups, and that limits people's ability to then have that bigger picture and build up the knowledge that they need. We would agree that they should not just be there to represent an interest group, they should be there to represent everyone, but with the specific knowledge of an interest group that they can bring to the table and say what they plan to do will not work for the group that I represent or a part of the group that I represent for those reasons. The lived experience is part of what they bring to the table, and it is an asset that can be used rather than a limitation on their ability to make decisions. We very much agree that a lot of development work is needed, but we need to prize open some of the other decision-making bodies within NHS boards to be able to promote people later to have a larger role as a non-executive director. Ivan McKee, I think that I have a question on the non-executive director. Thank you, convener, and thank you everybody for coming along and taking part this morning. It was just to follow up on a bit more detail on some of the specifics that Jenny Gilruth has been talking about, about the training aspect of this. Certainly, in my experience dealing with the health board, there is very often a situation where the execs have got their whip hand and the non-execs are not challenging to anything like the extent that they possibly should. Other members have probably had the same experience in their relations with their health boards, and it is something in my experience that you see in the private sector as well. There are lots of examples where a non-exec, for your told, execs account has led to some disasters occurring. I suppose that, to drill down into that a bit more, my question is to what extent do non-exec members understand what the job is that they are doing, because being a non-exec director is a job in itself, and to what extent do the health board execs understand that the job of the non-execs to hold them to account, and what specific induction and training is in place at the moment to facilitate that, or are we just going to throw in people and hoping that they sink us in? There is an induction programme for new non-execs. We contribute to that through talking about the financial position across the whole of Scotland, and it is an induction session for all public board members. It is not just for the health system. When we go around to boards, when we go around to audit committees, the thing that worries us when we see it is if there is not sufficient challenge there. I think absolutely that it is not as healthy as we would like it to be in all areas. There are some areas that need to work a bit harder to make sure that the non-execs are challenging, that they are given the right information, that they speak to Rachel's point about the sheer volume of information that people are expected to absorb, so that they can fulfil their role on the board. I would say that the local audit teams will challenge around that where they see it, so it is something that will be reported through the local audit reports. We are very keen in all of our work, but certain particular pieces of work such as our report on the role of boards to emphasise the importance of that scrutiny role. It needs to be respectful, but it needs to be a challenge role. We have also commented before about where there have been major feelings in the public sector. It does tend to be governance related at the heart of it. One of the healthy signs is a respectful but challenging relationship between the chief executive and the chair particularly, so that is something that the auditors will look at in detail. We see it in places, but it is by no means across the whole picture. That is true. I think that it is fair to say that the changing landscape that everyone finds themselves in at the moment around health and social care is also a challenge for the directors generally. One of the pieces of work that the RCN has been involved in for a number of years is supporting those nurses who have been appointed to integrated joint boards in a governance role. It is a brand new role. One of the things that we have to be aware of is that, although we may be very used, if you like, to the traditional NHS board governance processes that we have, the integrated joint boards are quite a different thing. We are bringing together two quite different cultures on how decisions are made and how decisions are reached. One of the pieces of work that we have been doing ourselves to support nursing leaders is to work with nurses who have been appointed to those seats to help them to work through what that difference is, because it is a real learning curve to how to go into that very new environment in a seat. For example, where an NHS board and an executive nurse director has a voting seat and an integrated joint board they do not, where the way in which decisions are being made is quite different and the way in which the expectations that are set on that clinical expertise. I think that we keep coming back whether we are talking from Bill's point about ensuring that the expertise of people who are experiencing a disability is heard on a board, similarly from our perspective. The clinical quality and assurance role that a nurse has in that leadership role is also expertise that has to be heard and taken on board in the right way. I think that we are all finding our feet slightly differently here. I think that non-exex is a very particular point, but I do not think that it is limited to the non-exex on the boards. The other thing that I would like to highlight is that, as an executive director, I expected and welcomed the challenge and found it incredibly useful. Much of that challenge took place long before it got to the board table, despite the fact that it came from non-exex and others. In many ways, it echoes my earlier point about the success of a board in many ways relates to its committee structure and the various activities that feed into and inform that board. I would expect, as an executive director, that that challenge would be taking place through the committee structures, but development sessions are set up. The advantage of the development sessions is that they tend to be more unis subject. You can then engage a wider degree of stakeholder. For example, we would get clinicians along to meet with board non-exex and others. If it was helpful to them, we would bring local politicians in, so that part of the discussion would take place before it got to the board table. The challenge would be there, and the challenge would be responded to. I would argue that the quality of discussion was probably better than you would have been able to achieve around a board table simply because you had that flexibility in being able to augment the participants. I want a quick follow-up on that. I have not had my time on the Audit Committee when we were looking at various boards, particularly in the colleagues sector. There were lots of things coming up and it was actually quite concerning. I just want to drill down perhaps slightly. People have accused boards of just moving insiders from one board to another. From my experience on the Audit Committee, people tended to be the same people and they knew each other. Is that a problem? In particular, when you are looking at rural areas—this is one of the ones that I wanted to pick up on as well—the number of members in each board does not equate to the population of each area. If you are living up in the islands, for instance, you have 41 members in that respect, including 14 from the Orkney, Shetland and the western isles—quite a small area, so that people would assume that they would know each other. However, when you go down to NHS Lanarkshire, for instance, there are 14 members on a board, but there is a population of 652,000. Is it a small pocket of people who are being used in health boards and set the areas and should they equate to the population of the areas that they cover? The recent induction process for all non-execs in Scotland—the last session—was quite interesting. It felt a little bit different because there were more representatives from particularly rural areas—the islands in particular—something we are really interested in—the extent to which some of these issues are not an NHS issue or an urban issue. Some of them are about real connections to and understanding all of the needs of the local population. It is a small anecdotal example, but I can definitely start to see more of that coming through, particularly in some of the more rural areas. I think the islands bill will have an impact here as well at something that we are watching quite carefully. I think that sense of needing to be closer and have that connection to the population is starting to come through. I cannot speak particularly for the NHS context, but we are certainly seeing that through the induction sessions, I would say. Thank you, convener. Good morning, everybody. I am interested in the allied health professionals, board membership and engagement. I guess that it looks like there are only 9 out of 32 of the integrated joint boards that have an AHP director at the table. I mean that it remains quite barren in the numbers that AHPs are underrepresented. I wonder if that would impact the ability to set forward some of the national COPD guidance for implementing pulmonary rehab, for instance, because those ideas are not getting shared or put forward across boards. How would you then move forward AHPs in the boards? I think that you phrased that perfectly well. I think that the allied health professions are in a position to recognise where a whole range of services can be improved through their involvement, whether it is through falls prevention, whether it is through COPD and respiratory care, whether it is around keeping people out of hospital, whether it is about getting people out of hospital quicker, all the major problems that are being faced by the NHS, and what there is, I believe, is that people do not know what they do not know. Therefore, there is a potential there, but that potential is not recognised. I think that it is the recognition of the potential is where the allied health professions feel frustrated, because they know that they have potential solutions to so many aspects of care. Because we are talking about 13 different professions here, we are talking about a whole range of areas in which they are involved in very much the same thing around the assessment diagnosis and treatment of people, but that they are coming at it from a perspective that is non-medical and therefore something different that they can bring to the table to improve services. They believe that that message is not well understood because their potential is not well understood by those people who are outside of their professions. I should mention that I am the cross-party group convener for the long health cross-party group, so I am interested in physiotherapy and allied health professionals. The Government wants the HPs to be central to change. If the HPs are going to be central to change, and the fact that you are describing that there are 13 different types of allied health professionals, does that make it more difficult then when everybody is doing something really quite different? It is always going to be a challenge for any individual, because there is no such thing as an allied health profession. If you like, each of the professions are educated separately, but they are grouped together as the allied health professions. Often, it is a term meaning that they are not doctors and they are not nurses, but they have some clinical role. In that context, it is always a challenge for anybody to know every single potential of each one of them. The importance, I think, of the onus, is on anybody taking on any kind of representative role in that or being a mouthpiece or sitting at a table where services are being designed is to ask their colleagues how they may have a role, in, for example, whether it is respiratory care or getting people out of hospital or whether it is about preventative care in the community, whatever it happens to be. It is then going back to the networks and facilitating those networks and investing in those networks and creating that collaborative culture, which is something that the allied health professions are very good at, but I think that it actually needs a great deal more investment to get the right leadership to shift services forward. Kenricks, more or less, made the point that I was about to make, which was that, while I accept the added value of having someone with a broad understanding of AHPs around the board table, that is of little consequence if you do not have the correct mechanisms down at the groups that are really making the decisions, the recommendations, making it happen. It is a bit like my earlier point that a lot of this is really about what happens beyond the board and how the board responds to that. As a medical director, I had exactly the same issue. As one doctor, I could not hope to represent the entire breadth of the medical profession, but I took my advice from an assortment ofologists and made sure that I had my arguments sorted out by the time they got to the board. Indeed, I took my advice not just from the doctors but the whole clinical community. I think that that is the important thing, is that, by the time the board is getting involved in the discussion, that breadth is there, that quality is there. I think that it comes back to the point that we were making in our written submission, which is when we are talking about corporate governance, we need to make sure that we have all parts of corporate governance on the table equally. I think that the clinical governance part of that is absolutely key. I would say that looking at papers across different governance groups, there is a tendency at the moment in the climate that we are in to very much focus on the financial governance and the extraordinary pressure that boards and IJBs and others are under to try to make ends meet in the face of the current demand that they have to meet. Actually, if we do not make sure that the clinical governance elements are up there alongside where the views of clinicians are being really clearly heard and that advice is then influencing those financial decisions, that is when we get into things being out of kilter. How we ensure that those voices are heard and I think it goes back to the points we were making earlier around the involvement of people who are service users or representatives of service users as well. We have to make sure that those mechanisms are really, really strong. To Brian's point, the clinical governance committee is a really important part of any governance group, whether that is at an integrated joint board level or an NHS board level or at the future at a regional level, because we have to make sure that diversity of voice is heard. However, that governance then is set up in terms of the ultimate accountability. That is the area where I think we could probably do more. I know that in our submission we were asking to come back again to the guidance that has been written for clinical guidance for integrated joint boards. We are a couple of years now, two, three years now, into actually seeing what that looks like on the ground. We have moved from theory into practice. There are things that we need to learn and I think they are the areas that we could really make things much, much stronger in terms of ensuring that our entire corporate governance works well. I think that the Health and Sport Committee's report last year actually pointed out that we need to invest in the very people that we want to be involved with. You made the same point that if we expect people to represent a wide group of allied health professionals, disabled people, whoever, then you need to have some investment in those people to be able to do that job properly at any level of governance, but particularly at corporate governance level on a board. Some people face barriers to even making those first steps. Disabled people and carers face barriers to being involved at all, because there might be physical barriers, there might be sensory barriers. There could be confidence barriers based on mental health issues that have to be overcome before they can take that first step. They need support, so in some instances they will need advocacy support to be able to take part in decision making that affects their lives. For others, it will be developmental support to take that first step and first in confidence that they are going to be supported to take part in decision making, and then they can move on. That means that we have to think about what are the barriers to people being involved. I worked in an area of multiple deprivation for several years. There were many strong activists in that area who could have played a role in decision making within health boards, not always at the health board level but in the locality, etc. However, they needed to be developed to have that confidence. I think that there is some about recruitment processes for public bodies, etc. That is a barrier because we expect certain levels of experience running a business, etc. You are not going to have that experience, but you might have run a local charity. Is that any less valuable than running a business? If you have that experience, you can bring it to the table. I think that we need to think through how we recruit public bodies so that we fully represent all the society. That includes a lot of people living in deprived areas who have little or no opportunity to participate in governance. A number of witnesses have commented on levels or areas of representation or activity other than the boards themselves. For example, there are public partnership forums, equivalent forums for staff and service users. Do witnesses have a view on how effective and useful those forums are in terms of providing a means for people to engage further at a later step or in serving the function that they are there to fulfil as it stands? We are still at the moment in a consultation focused model, so you will have NHS boards and other major public sector institutions. They will issue consultations to individuals. Individuals will be asked to fill in their responses in those consultations, then it goes back into a black box and decisions get made. They may or may not feel as though they have been heard. We absolutely need to change the model. It needs to be less about many to one consultations and it needs to be much more about deliberative decisions and discussions. That is why participation is quite key. We have seen some really good ideas coming out from, for example, the idea of having the panel around social security. However, those things need to be developed to where they genuinely involve conversations between people. That is why I raised the point about participatory budgeting earlier, because that is an area where there is practice being piloted right now. We can apply the same kind of principles where people do not just speak and fill in forums and respond directly to an institution, but they actually speak to each other and they deliberate and they share and they build their confidence. As a result of that, many of them will then be inspired to go and participate in more formal structures, but the listening needs to happen, not just that the formal structure needs to be happening right in the forums that are set up for people to engage in. Thank you very much, Keir. One of the starkest comments in the survey responses was around boards feeling that they are powerless to make the decisions that need to be made. I think that everything that we have heard is about a need for a more open and honest conversation, more engaging. Yes, the structures and systems that we have in place now, the clinical governance committees, the ordered committees for us, we would see those as really key committees, but there is still something that is getting in the way of organisations feeling that they are able to then take on some of the really tricky stuff. It is for some of the reasons that we have talked about, you know, a challenging new environment that everyone is operating in, the integration of health and social care, bringing together two very, very different cultures with different skills and experience, so there is definitely a period of working through some of those challenges, but I was just struck by the fact that some of the respondents have mentioned that they still find it very difficult to get over that line, to take some of those challenging decisions, so I think that there is something there about what is it that they need to help them to do that, some of it that we have talked about today. I think that there are some very good examples of where there has been very good patient and public engagement. In the main, though, this has tended to be very much focused around specific conditions, diseases, whatever. One thinks of some of the work that has gone on within the wider cancer field, diabetes, some of the heart disease issues as well, and I think that, within each local board, they will have their own specific examples. Part of the difficulty is that it is all very ad hoc and reactive. There is no standard methodology. That may not necessarily be all bad, but the difficulty that it gives you is that it makes it very difficult to evaluate it later on in the process, and it certainly makes it very difficult to compare and contrast what happens in one board area with another. I think that the other thing that I would highlight from that experience certainly that I have had among those disease areas is that many of the very important decisions that are made are made without input from the board. In many instances, the decisions that are made by, for example, a diabetes-managed clinical network with patient and public input may well be reported to the board, but the board's permission will not be sought. The board will not be a major part of the decision-making process, and the boards tend to get involved in the more difficult, more contentious areas, but the vast majority of clinical processes, clinical services, the decisions that are made with whoever is getting to the board particularly, I think that as we are getting increasingly into health and social care, though, that is changing, and the IJBs clearly want to have much more of a hands-on role in that, which I think is only right and proper given the complexity. Yet again, I think that we are in danger of perhaps investing more in the boards than they actually deliver or need to deliver. Before I get to my question, I just wanted to put a marker down in support of what Emma Harper said about allied health professionals. I think that we in this committee hear a lot about recruitment crisis, retention crisis and particularly the GP profession, the nursing profession, but we often, I think, do not pay as much attention to what is going on in the HP sector. I think that when we bring the safe staffing bill, things like it, through this committee, it is important that we reflect that, those considerations. My question was in particular about failure of demand and how that is met by the boards. Obviously, we have had a great deal about targets and missed targets and the response or lack thereof to individual boards across the country. It repeatedly strikes me that there is a siloed approach to this. There is not a sense of learning. When one health board adopts an approach to a missed target and that succeeds, it does not seem readily then to be repeated in other health boards. Why is this? What is the problem with sharing best practice across the health boards and how do we get better at that cross-fertilisation? Thank you for that, Alex. I think that particularly around when we are looking at improving systems, it is a collaborative approach that we are gesturing towards, a collaborative approach that seems to be delivering results. If, for example, you look at targets, if we looked, for example, at A&E services and we decide that we are not hitting the targets for seeing people within four hours, you could therefore have an investigation into everything that is going on behind the hospital door. In other words, how many staff do you have on at evenings and weekends and are we responding at the right time and the demand? Actually, what is really required is that we discussed COPD earlier. Respiratory problems can be one of the main reasons that people are blue-lighted to A&E. A respiratory flare-up can happen over a weekend, and if we can just get somebody the antibiotics on the Friday, they will not be blue-lighted to A&E on Sunday, and we need to be thinking therefore about a whole-service approach. This is very much what the allied health professions are talking about, and there is too much temptation still to use a model that looks at where the symptom of the problem is, which is A&E, that we do not have enough staff to hit the four-hour target, rather than a whole-system approach that looks at why people are coming into A&E and is there anything that we can do to prevent that, if that helps? I mean, picking up the specific of your question and also Kendrick's key use of the word collaboration there, I would suggest that the current governance arrangements, board-level governance arrangements, mitigate against collaboration. If you look at the way that boards are held to account both in terms of performance, performance management, targets, resource allocation, collaboration is really driven by crisis, it's not driven by let's rely some opportunities here, and there's actually a disincentive, I think, for boards to meaningfully collaborate on the front food. The collaboration usually happens too late in the day because much of the, particularly the performance management arrangement, is about the delivery of short-term targets, rather than consolidating services and developing robustness and sustainability going forward. Your point, I think, being that a different governance approach might produce a more collaborative culture between boards, is that really what you're saying? Indeed, so again, if I take some of the examples again, which are real in my own recent experience, when board A is perhaps struggling to deliver a service and goes to board B saying, if we pooled resources, could we do this differently together? Board B's reaction tends to be, well yes, that's very interesting, but where we to do that, it could compromise my performance, and therefore it mitigates against constructive collaboration, because the boards have each held to account for what happens in the short term on their patch. So, I think that there is something interesting happening in terms of the systemic issues facing the health system in Scotland now, which we highlighted in our overview report in October last year, where boards are more inclined, I think, to look to each other now because of the difficulties that people are facing in terms of coming in on financial balance and trying to hit targets at the same time. So, we've had quite a lot to say about the way that the targets influence the way that the health boards particularly operate, and I know that there's work underway to review how that's happening. But I do think that integration, coupled with some of the pressures around the system at the moment, means that the time is right, it feels a little bit more fertile, if you like, for people to be sharing and learning from each other. I do think that there's something that needs to be thought through a little bit more clearly in terms of what needs to be delivered differently in different parts of Scotland versus the things that actually can be done once for Scotland, can be done on a regional basis, and we're starting to see some of that be a bit more clearer now, or certainly will become clearer over the next wee while. So, there's certainly something else that needs to be paid attention to there, I think, for sure. I absolutely think that the move towards regional planning and delivery is the right thing, but we still don't have a framework to hold regions to account, and the framework still holds individual boards to account functioning as regions that are virtual constructs. That's a very important point, Rachel. Picking up on the last two speakers, we've said before that we're in this great state of flux in how services are being both delivered and governed at the moment, and the point is that we have to have absolute clarity of accountability. You know, we're talking here about high-risk clinical interventions. We need to be really sure how decisions about resources, about what services look like, we have to be really clear where those decisions are being made and who can be held accountable. We have a lot, I think, some of the boundaries that we're used to are getting very blurred, and that's not necessarily a bad thing. It's just as long as we have the frameworks to go with them. So, with an integration, for example, you may have a health board with a number of integration authorities sitting beneath it where one of those integration authorities is hosting services for all of them. There are questions then about how those decisions are made for the entire population. You take it the other way you get to the regional planning issues that are beginning to emerge, and you're back into a similar issue. Who holds the accountability for the decisions of what those regional services will be within the structures that we currently have, and what might we need to change to make those structures transparent and robust for the future? I mean, I'm fascinated to hear that the construct is such that it's counterproductive to any efforts to collaborate and the idea is, one, not any efforts, but the idea that if we help you in this way, we might impede ourselves in another. We were struck by the example that I was coming back to. The health board, which is doing best in terms of cancer waiting time targets, is systematically logging all the reasons for missed appointments or delays in waiting times and then mitigates against them and builds on a strategy for how that's not going to happen again. It's working, and it just seems such a simple thing to do. Why is this not being picked up by other health boards? It's just one example. I accept the point about the structural problem and the potential for help and collaboration to be impeding the work of another authority. On simple advice and simple sharing of good ideas, are we really that far behind? I don't think that there is really the correct impetus, again, that the correct framework, if you like, that really allows people to say, let's all pursue the best of everything. If you like, that is just part of a much bigger picture that has to be taken account of locally. This is one of the things that is proving quite interesting at regional level, is that more and more services are being deemed appropriate for a regional approach. What you're seeing is bits of service potentially being taken out of an individual board's control, having to be then dealt with on a different level. Whereas previously we've tended to have almost like 14 independent fiefdoms as territorial boards, this collaboration around certain issues is actually creating some quite significant challenges, I think it is the way forward. It has to be because we are increasingly lacking critical mass, particularly around certain hospital services, if we continue with the 14 board model. However, what we haven't done yet is get clever enough to develop the framework that promotes that, and that's the framework around governance, around performance management and around resource allocation. Thank you very much. During the course of this inquiry, we've had a number of submissions that pointed to concerns that the public or stakeholders have had with the level of openness and transparency of boards. I wanted to ask the panel if they think that that is justifiable. Is there a problem there with openness and transparency? Who would like to take on that one? We have a network of around 300 people who have an active interest in openness and open approaches to governance in Scotland. We put the call for this committee, for evidence, in that forum for the network. We certainly got a lot of comments back, but I have to say that all of the comments were negative in terms of transparency and openness of NHS boards. I noted that, in the research that is part of the papers from SPICE, it suggested that the boards themselves feel as though they are operating fairly openly, but that their perception as the wide public may not think so. There is a recognition and understanding, even within NHS boards, that there is a concern among the wider public about how open and transparent NHS boards are. Given that everybody recognises it, I think that clearly there is an opportunity to do something about it. I am not quite sure how much more research we probably need to do before we should just start cracking on and tackling the issues of openness and transparency. We have signalled that in our recent report on the NHS that there is a need to be more open and transparent and have better levels of engagement with the public, absolutely. We are seeing with integration that that is starting to shine a bit of a different light on some of those issues. The very way that integration joint boards have been established, the Public Body's Joint Working Act means that there are duties that they need to be more open and transparent. That is having an effect in terms of the NHS boards for sure, but there is more to be done. Obviously, Audit Scotland's recent overview report put forward a number of recommendations of things that boards could do. I will just read out a couple of them. Public attention of all boards and committee papers and minutes, public attendances at meetings, filling gaps in data and key areas, etc. SCEVO is currently working on the open government partnership action plan. At this point, where do we feel that boards are with regard to those recommendations? How far on do we think that they are with the action plan? Where do we see that going in the short term? The action plan is currently... The pilot action plan, which has just come to an end now, did not drill into that level of detail. However, the two-year action plan, which I understand that the Government has committed to, and now there is a process behind that, there are certainly a number of individuals in the networks, certainly on the civil society side, who have an interest in specifically tackling openness and transparency around health in general, not just NHS boards but all the decisions that affect health and care as part of the openness and transparency agenda and the action plan agenda for Scotland. There is certainly a willingness and an interest on the civil society side. I sense that there is potentially an interest on the Government side as well, but over the next two or three months we will be within a process where those actions are put together. I hope that this will come through as part of that. We will follow up on the recommendations that we made in that report. It is something that our local auditors in all of the NHS boards and integrated joint boards across Scotland will be also paying attention to a report and on through their annual audit reports. We are just kicking off the second of three pieces of work looking at integration in Scotland and it is something we will want to look at in more detail as part of that piece of work particularly to do a little bit of a drill down in certain areas in Scotland to understand how partnerships are working in terms of their openness and if there are lessons to be learnt for elsewhere. We are hoping that that will see some really good examples and we will be able to highlight some of the things that are not working so well. I think that transparency and accountability go pretty much hand-in-hand. It is where the ability to be represented at any level or at very few levels within boards is that I think that you will find a public feel that the board is not being open and accountable because the only people that are sitting round the table are board representatives or the usual suspects, which we heard about before, that quite often public appointees are the same people on different boards or different public bodies. It is a closed club rather than an open one. Having been quite critical with Highland, I would like to say that in the mid-ros community partnership area, they have set up a very innovative community learning and development peer opportunity for disabled people to participate. A local NHS Highland board member, the community planning partnership, etc., have co-produced with disabled people in the groups an opportunity for somebody to go on to the local community partnership and to support them in that and that they want to see that broadened out to all the community partnerships throughout Highland area. However, that is going back to the investment that is needed. If you identify groups that are underrepresented, you need to actively do something to make sure that they are represented in the future. You cannot just hope that somebody will come forward. You have to go out and work with those groups to find out what their interests are, what they feel is not being represented within the local decision making and then work with them to make sure that those issues are properly represented at local level first and then build up. I think that it is looking to transform things from the grass-root to the top rather than from the top down. I am interested in the transparency and communication to members of the public. I know that the IJBs are pretty much new in its two years, but yesterday I visited Stranraer with the CABSEC and the people at Galloway community hospital feel as if the services are deteriorating or reducing when the services are being expanded locally to mirror what is happening in Dumfries and Galloway, Royal Infirmary. I am interested in how information should be disseminated. Is it the board's job to do that? How would we make sure that people understand what models of care are, what new care is and all those words and language that is being used? I am interested in how we would support that. It reminds me of a piece of work that we did a few years ago on the role of the advanced nurse practitioner. We did a number of case studies that I would be happy to share with the committee looking at how communities had taken on the role of advanced nurse practitioners in their area. One of the ones in my mind, as you are talking, is one of our island communities where the advanced nurse practitioner service was going to be taking over out of hours care. There was a great deal of opposition to that as it started. There was a huge amount of work done by that health board, taking them to another health board picking up from the point about learning. They took them off to another health board where a similar service model on an island had actually had a really good impact on the local community and took the community leaders along to meet people to talk them through what this redesign of a service could look like for them and what it would actually mean. When we interviewed community leaders a couple of years down the line from that change having happened, they were incredibly supportive of the change but it had required the effort to go and actually talk about why this actually could be an improvement to the service they had before rather than a reduction. I do not know that we are always as good as we could be at actually talking about when services are changing how they can necessarily potentially improve things for communities rather than feeling like you are losing something that maybe you valued for some time and there is probably more that we could do but I think that it goes back to that point that Alex Cole-Hamilton was making about learning from other areas. There is much more that we could do there than we currently do and I think that is a helpful example which I am happy to share further. One thing that we have certainly been picking up is the importance of being proactive rather than waiting for people to FOI decisions and information that has been made available and there is a very strong feeling now about that that we are picking up. There is a really good example actually that in the work that Scottish Government is doing around identity assurance at the moment and they are making use of various structures within that but as part of it they are using the Scottish Government's new website for blogging about the discussions that take place on the various programme boards and stakeholder groups but not just blogging about what they are doing but opening it up for comments from the public so that people can put questions in which everyone can see. Of course it is all moderated but people can see what other people are asking and I think that in terms of transparency being able to see what others are asking so that you do not feel too afraid to ask that question yourself is really important as well and that encourages the openness and transparency. It is not just a one-way process. I think that there are two very important strands to the question about communication. One is as you experienced down in the Freeson Galloway there is something about how do you keep the local population informed about what is going on and why. One of the things that has been quite striking for me particularly as we have looked at bringing together resources around integration is how little the average health board invests in communications. The communications departments are rudimentary quite frankly even compared to the local authorities and if one looked at what the public sector would be investing in there. I am not sure the answer is necessary to then create a communication industry in each health board but it may be links to the second point that I was going to make which is I think that there is also the need for communication at a superboard level possibly even a national level about where health and social care is going and the benefits of it going in that particular direction because as you know there is a huge degree of suspicion about any changes being synonymous purely driven by financial reasons cuts rather than because they represent a more effective more sustainable better model of care. When it is left to a health board to lead that discussion at the point of implementing a local change quite frankly it is too late in the day we do need to have a much earlier conversation about what we want from our health and social care service over the coming years. That takes us back around to the earlier conversation about skills and experience because what we are expecting here is that it is a very different skill set than perhaps traditionally you would expect to be getting in many of the professions we are talking about. It is about an openness and a willingness to be challenged and to be more transparent and get things wrong sometimes and that is okay and I think we are expecting a different tone of engagement from our professions now and perhaps we haven't done enough to support people with that or even to talk about that because it can work very well but it is quite tricky to do particularly around some really difficult decisions that need to be made so I think it is worth recognising that when we are talking about the skills on boards and the skills in the various organisations actually some of this is fairly recent fairly new territory for some of those folk. I think we all start to remember the pressure that the boards are under at the moment so on the one hand what we are asking is for boards to be at the heart of an enormous transformation agenda which will result in services looking radically different over a number of years if boards are to meet the sorts of gawn that have been thrown down by the Scottish Government and by Parliament to allow our services to change to meet demand. At the same time we have been talking about targets, we have been talking about lack of resource, we have been talking previously in other committee discussions around annual budgeting, the need to break even at the end of every single year and a huge political pressure around meeting targets and I think we have to bear in mind we are asking our board governors to do two things at the same time which are not always easily compatible and that doesn't always leave them in an easy position when it comes to then having that open and honest conversation and I think if we don't acknowledge that here then actually the culture that sets around the sorts of decisions and the way in which boards are being asked to make decisions sets them really between a rock and a hard place. I think it's interesting the word that you used earlier Brian about informing people because I think that's not enough. I think that's how consultation has largely taken place up until now. Boards have informed people this is what's going to be happening and asked them to understand why that's happening. What you need to do is involve them from the outset in asking them what do you want from the health service and how do we collectively deliver what you want. You have to limit their expectations in that, you have to tell them what the situation is, what you have to deliver at the moment, what your resources are. It's a big question but without co-producing, trusting people with the information and then trusting them to make meaningful choices about options that are presented to them you're not going to develop the health service in a way that properly meets the needs of a modern 21st century society because you have to trust them that once they're informed they will begin to own the choices that are made rather than be told about the choices that have been made for them because if they own the choices they understand the limitations that are then there whereas before all they can see is my local hospital closed or that service that I relied on has moved 20 miles away. Why? Because they were just told that it's a good thing for you. They need to believe that it was the right choice and to believe that it's the right choice they have to be involved from the outset and so do the representatives in arriving at what the choices were that were offered to them rather than just being told that it's this or nothing. I thank you very much for moving towards the end of the session but we have a question from Alison Johnstone. Yes, thank you convener and I think it's picking up on earlier points that have been made. I think that Rachel Cackett pointed out that boards are under pressure to meet both targets, clinical targets, which written submissions have suggested can often feel unrealistic and can even demoralise staff and at the same time they have to meet those targets on reduced budgets. Some of the submissions that we've received have expressed a lack of trust that boards make decisions in the best interests of the public and one of the submissions there's a real frustration there. There's some recognition that decisions were constrained by finances and in relation to openness and transparency one respondent wrote, we are terrible at admitting that we're financially constrained and pretend that decisions are based on clinical grounds when in most cases they're based on clinical staffing and financial elements. The debate with the public is therefore fundamentally dishonest and it says that the public are not stupid. I think that openness and transparency would help if people understood why a decision had been reached at. I think that the openness and transparency question comes into that very much but how can those competing pressures, scarce resources and the wishes of the public be balanced to result in decisions that are acceptable to all or is it simply too big an ask? Ryan. I would further complicate the way you've described it by saying that it feels more like a triangle and that at the three corners of the triangle you've got quality of care which is paramount in my view. You have performance which is basically about targets and the third one you have resources which is about money, people, buildings all the rest and the real challenge currently is can you keep that triangle level, can you balance across these three and there's a fair degree of compromise going on. I think there is probably a degree of naked emperor in there as well in terms of the reality of the financial situation but what we are increasingly seeing is that in the attempt to maintain and enhance the quality of care within a finite budget the thing that is currently most likely to suffer is the ongoing delivery of the current targets and I think to do that does need the kind of conversation we've been talking about through the whole of this morning which is about we're in a new world now. Are there different ways that we could actually seek to challenge this problem? I think a lot of it comes back to the point I made earlier on which is that we're actually in the very fortunate position currently of we've got so much that we can offer within the confines of health and social care that it's now exceeding that the budget that's available to deliver it and that's where the difficult choices start to come in. Rachel. I think it touches on a number of things that we've discussed this morning. I think the importance of making sure that the different arms of governance have equal weighting is really really important because if the discussion becomes so heavily weighted towards the financial savings targets that boards are finding themselves having to make as our IJBs then actually what we end up with is a skewed discussion which the issue of quality of care which I would agree with Brian has to be up there in the services that we're talking about can easily get lost and we can't allow that to happen so we have to make sure that the boards are giving equal weight across the system to both of those discussions so I think that really matters. The issue of targets and what we describe as good performance I think we still need to come back to because I agree the pressure on those does mean that it's not always easy to have the sorts of conversations that you might want to have about long-term transformation and that's really the ballgame that we have to be in now is what does long-term transformation mean? You asked are we going to satisfy everyone? Almost certainly not, but that's where the openness and transparency and the sorts of discussions that Rishi has been having around how you involve people and it's not that everyone's going to have to agree but at least there's a sense of actual proper participation and I would put that for staff as well as for the public that participation of the people who were both receiving and delivering services is really key and that's the only way that we're going to be able to go forward and we do have to set this within the political context. The NHS politically will always be at the heart of so many people and we have to be aware of some of the political pressures that will be there in terms of what this might mean for the future. It's you know that's the landscape that we also work in which now includes local government through IGBs of course so I think there are a number of things that we can do but making sure that we are looking at how we're talking about performance, understanding what we mean success is ensuring that there is genuine participation. Brian brought up the issue of managed clinical networks previously and the way in which they are transforming and have transformed services without even necessarily having to go through the formal governance processes when we were doing our work around how we might rethink what success looks like for health and social care services. One of the models that we were interested in was what managed clinical networks have done by collaborating and using participation to come up with ways to improve the sorts of services that are being delivered for people. So I think there are ideas out there, there are things that we could do but we are working with huge constraint on resources and the political pressure that comes with an NHS. I think part of the answer here has to be if we look to try and continue to do what we've always done with the current resources and the staff we can get because some of the posts we know can't be filled then it's not going to work so we do need a different model and health and social care integration must be part of the answer to that I think. One of the things we've maybe not talked about today and is worth mentioning is the focus on outcomes so what difference any of this is actually making to people and we're seeing some really healthy conversations starting to happen now I think between clinicians who are unable to have an open conversation with folk about you know do you really want to continue that treatment is that right for you now that brings all sorts of tensions in terms of hitting certain waiting times targets and what performance actually means in that context when your care might be very different to the care that works for you so it's opening up a whole range of different variables there that we've not really had to deal with before so I think a focus on outcomes and also an acknowledgement that at the heart of this some of this is not for the health system to fix you know some of this is about access to the right housing to issues to do with education to do with welfare issues so that sense of broadening that out that again integration is starting to open up some of those conversations it's not just about how the acute hospitals are operating it's is the shift to prevention happening fast enough and how do we make a little bit more space for that to happen. Yes perhaps if Kenrick was going to address this next I'd be interested in the written submission from the AHPs it points out that the average adaptation costs £2,800 and if you don't make that adaptation you can end up spending £7,500 as a result of all sorts of other things so it's about that shift to prevention too but I'd just like to understand where in the governance process are we looking at whether or not that kind of saving is happening. I would just absolutely reflect on the discussion we have what we have is a system which is under pressure to make short-term decision making on declining budgets very often in which they're looking at a very restricted aspect of where that budget is spent and how it can be shaved and in fact what the system needs is long-term future planning to transform services so that we're reducing the demand where we can and we're supporting the population to get the right outcomes and in order to achieve all that we do need this whole system thinking and yes we have continually seen examples where the investment in a preventative service would save money but it saves money off somebody else's budget and for that reason there's never the incentive to instigate it now we have as as allied health professions continually pointed at this and said well look this is where if you could just provide us with this budget we could save all this money but there's never the incentive to deliver on that when we get pilot schemes that demonstrate the clinical and cost effectiveness of these they're often done with centralised money from the Scottish Government to fund initiatives and the minute that that initiative funding ends with the expectation that it'll become embedded in a service the services dropped not because it hasn't worked not because it hasn't proved itself to be effective clinically and cost effective but because it was extra money that is now no longer in the budget and these kinds of decision making need to be changed and there needs to be challenged and where are the AHPs in this well what we're seeking I think as as allied health professions is just a parity of esteem around let's get the right professionals around the table to make the right decisions in the interests of the people we're serving and not thinking about things in terms of the budget or the short term but in fact how we can deliver lasting improvements by getting sometimes different people to offer a slightly different service but achieve a better outcome for all involved we've talked a lot understandably about resources here but I would make the fairly bold comment that the long-term answer is not more money the resources that we currently have or the resource challenges that we currently have are as much to do with people and facilities as they are to do with money and in fact we in some instances are unable to buy the things we need we can't find the people we need to employ we cannot use the money that's there but I think the other money challenge that we have just now is that we're spending a lot of it very inefficiently very ineffectively we are not achieving good value for that expenditure as an example you know the number of people that we are keeping in acute hospital beds who don't need to be there where for a fraction of the cost we could be providing home care packages or nursing home beds the amount of money that we're spending on staff, locum staff for example to sustain services that really are yesterday's model so I think it really is the transformational change that Claire and others have been referenced to all morning and I think I hope the discussions like this one will give us the another platform to really get into that territory about how we need a different sustainable model for health and social care going forward. A brief final supplementary from Brian Whittle. Yeah, thank you. It's just to add to the chemistry submission there around. It seems to me that we come across this all the time there's these little pilot schemes that come along prove that we can spend less money and get better outcomes and the whole holistic if you like that the big budget and yet when it comes to end the pilot scheme it ends up on a shelf which I've got to say for person I find that massively frustrating there's a very good one in the the crosshouse hospital in the stroke rehabilitation where you have six weeks of stroke rehabilitation usually and then they take that into the community and that's the proven that the recurrence of stroke and the re-emission of stroke is far reduced with that process and yet that ends up back on the shelf. That just doesn't seem logical to me. How do we get to a point where those kinds of initiatives are adopted much more across the board when it's proven to work? What we actually need is a whole system buy-in to change because very often pilot schemes are initiated with a particular service looking at a particular model wanting to change to a better model will get that investment from a third party source but if we're going to be saving so for example in the example you use I mean those rehabilitation in the community what that can be saving is a fortune for on-going social care if you can get somebody to rehabilitate to the point where they can remain independent in their own home for longer because that is a major drag on resource is going to be an aging population that is lacking independence and if we can provide people with that independence then that's the first priority but to do that means spending money before they require social care and therefore how do you get the whole system to recognise that cost saving when the service that's providing that is going to actually spend more money to save everybody else from intervening? Thank you very much. We've had a good session this morning on accountability and scrutiny and we've acknowledged I think that there's an increasing focus of services at the regional level and no mechanisms yet in place for achieving that at the regional level. As a final question is there anything we should be thinking about or saying to government about improving accountability and scrutiny in existing territorial boards? Yes, but with an application to the regional level as that develops clear. So the Scottish Government is currently developing a financial framework to underpin the 2020 vision. We think that's really important part of the answer. The connection between the policy aspiration and what that actually means for local areas has been the thing that has been missing in this I think. So people understand everybody's signed up to the overall vision but trying to realise that in practical terms has been very very difficult for all of the reasons we've talked about so we are really interested to see what that financial framework looks like because it should set out the steps that need to be taken to get to realising the vision that's been set out. So it speaks to that term you mentioned long term financial planning, long term planning in the round. We think that's part of the missing picture. I totally agree about the systems change approach to this, looking at the wider system, but you know what to do that we're going to need to change our frame of reference at the ice level. Fortunately we do have a new frame of reference that we can use and that is the sustainable development goals. At the moment the Scottish Government is working on the national performance framework that's going to be laid in front of Parliament shortly and as part of that they're integrating the national performance framework with the sustainable development goals. Now what the sustainable development goals allows us to do is to start looking at this from a more preventative lens, from a system-wide lens. How does tackling improved health outcomes relate to tackling poverty, tackling climate change, gender equality and a whole range of other things, so by looking at it from that lens we can start to not just talk about systems which will put a lot of people off but actually have a very concrete frame of reference that's internationally recognised that the Scottish Government committed to that national performance framework is being integrated with and that can provide a wider context for tackling health. Thank you very much and can I thank all the witnesses who have attended this morning has been a very useful and wide ranging session and will certainly inform our on-going inquiries. Thank you very much we'll now move into private session.