 Morning, everyone, and welcome to the 15th meeting of the Health and Sport Committee in 2017. I could ask everyone to ensure that mobile phones are in silent. You can use them for social media, but don't photograph or film proceedings. The first item on the agenda is an oral evidence session on the draft budget is 2017-18. I welcome to the committee Keith Redbuff, chief officer of Western live in¿shar health and social care partnership, Vicky .irns chief officer Angus health and social care partnership and Katy Lewis, chief finance offerer Danfries and Galloway health and social care partnership. Via a video link, we have Carol Williamson, chief officer of Shetland health and social care partnership. I hope that you can see in here as okay, Carol. I can't yet, thanks. I'm chief financial officer rather as chief officer, sorry. Thank you for joining us. We will try and ensure that if we are bringing you in, Carol, that we direct questions to you so you know when to come in because this is not an easy format for you or the rest of the committee to work with, so we will try and be as helpful as possible to you. If there are any problems at your ends, please wave at us or wave your hands frantically or something like that to let us know. We move directly to first questions, Alison. Meeting papers from Westin Bartonshire notes that it will only be possible to release resources from acute services to sustain funding for community services if the number of inpatient beds is reduced. In the inquiry on preventative spend, the committee has heard some evidence that creating a split between acute and community sector creates a false dichotomy, which won't decrease demand on the acute sector and won't necessarily reduce costs because staffing and overhead costs won't be reduced. I'd appreciate if you could expand on that a little and if the panel could give us their views on whether or not you believe that the 2017-18 budget plans indicate the shift in the balance of care is such a shift achievable and can demand in the acute sector be reduced to allow resources to shift to community. There's a lot in there in terms of our report. I think that we're fairly clear having been at the integration process for some time. We're not uncomfortable with the system of care that we have, but with the pressures that are on every part of the system, if you're going to have a fundamental shift there, that needs to include resource shift as well. The reality is that in terms of a shift in the balance, that will mean fewer hospital-based beds, fewer acute beds, not trying to separate out to say that there's two systems. We are part of a single system, and all parts of that system need to be working efficiently in order to deliver that, but that will need to see a shift in a reduction in the costs and the resources that's consumed within acute and move to community. I think that notwithstanding the costs around there and staff, I think that we all feel that some of the new services that could be provided in the community could be provided by the staff that come out of acute. The resource would follow the service and the people, so we wouldn't be dependent on new resource from that, we'd be shifting that resource. From our point of view, we see our community assets and resources working very hard as well, so the capacity needs to come from somewhere, and I think that with the policy intent, that would always place that for that to come from, would be from acute. Do anyone else like to comment? I'm happy to come in from an Angus perspective. I think so far we have seen some small signs of shifts in resources. We certainly, as a result of the community services that we've put in place, have seen less reliance on the use of some of our inpatient facilities in Angus, but also the use of care homes has decreased to commensurate with some of the developments that we've seen providing more care at home. The important point to point out in terms of our local partnerships that look at the use of the acute sector and the cost of care in the acute sector is that we have to approach that in a round-table partnership approach to the planning for the future. It's clear for us that where the money might not be easy to shift, the change in practice is the thing that we can work on effectively together, so we're seeing more and more of those who provide specialist care in the acute sector now coming out to work with primary care professionals in Angus hand-in-hand around a multidisciplinary team approach, and that seems to be quite an effective way of changing the balance of care as opposed to shifting the financial resource through the budget settlements. Within Dumfries and Galloway we've got quite a different model to a number of other partnerships whereby we haven't created that divide in our integration scheme. Acute and primary care services are all delegated within that under the directorship of one chief officer, and what that's allowed us to do as a partnership is to see around the integration table the diversity of issues, both the pressures within community services and the pressures in acute. One of the things that we're keen to do though is that there has to be that investment within community services before you can see the shift coming out of acute, and one of the things that we've done quite effectively within Dumfries is shift our mental health service provision, so we've actually reduced a number of our beds, increased the services to the community closer to home, both in dementia care and the overall care of individuals. We're starting on the pathway of that model within our acute services with some of the investments that we've undertaken to date, particularly something that we're trying in the Dumfries and Galloway area, which is around the one team, and looking at very much that multidisciplinary team and getting that much more established within communities. We've seen good progress in shifting the balance of care up in Shetland through use and intermediate care team, but we're finding it more difficult to shift the costs because we've got a small hospital up here with high fixed costs, and we're really at the stage there's not a lot of scope for closing further sections of the hospital, so we're finding it quite difficult to shift the costs. Just picking up what Alison's saying, it seems to be a bit of a view emerging that there isn't going to be any shift in finance or it's going to be negligible, is that the case? Progress so far shows that there has been a shift, it's a reasonably small shift from... Can you quantify that? Yes, and this is all the period of the last three years, I believe, but I'll double check that. Previously, we were looking at resources around 39 per cent that has shifted to 41 per cent, so there is a small shift, but I think it's very clear from all parties concerned through the powers that we have, through the commissioning plans that we need to see further shifts where that applies, and I guess that goes back to my point about resources are really invested in people, so if we can change the way that people practice, then the resources will follow that through the new pathways of care that we're developing with acute sector colleagues. Sorry, Alison. Obviously, one group of people that we need to invest into are the staff, the social care staff, and when integration authorities responded to the committee's survey last year, the information that we got back suggested that the cost of implementing the living wage for all social care, adult social care workers exceeded the Scottish Government's estimate of £37 million, and the Scottish Government, and I'm quoting here, indicated that the £10 million included for sleepovers will be reviewed in-year to consider its adequacy with a commitment to discuss and agree how any shortfall would be addressed. What are your views with regards to whether or not the funding provided by the Scottish Government to allow the implementation of the living wage is sufficient, and, in particular, is the £10 million allocated for sleepovers, included to cover costs associated with sleepovers, is that sufficient? Thank you. I think that, personally, in West Dunbartonshire, because of the makeup of our market, we are still a direct provider of a significant number of services for older people, less so in terms of other adult services, but the amount provided for the living wage for us was certainly sufficient. We did not require everything that we had in the allocation in order to meet that. In terms of the sleepovers, we've had a second tranche of funding again for 17, 18. I think that all of us would probably prefer to have money invested in providing direct care rather than people who were sleeping, albeit that they are available when people need it, but that has given us the impetus to review the models of care that we have with various providers to make sure that we are getting the best use out of that funding. From the West Dunbartonshire perspective, we have been agreed because of that balance in our provision, and as our directly employed staff were already paid above the minimum wage level, the cost implications for us were less significant than there have been in other parts of Scotland. I recognise the risk that was highlighted from the period last year, and we had similar concerns raised, but we have not dissimilar to West Dunbartonshire work through all the implications and resolve those within the resources available. We were one of the first partnerships to implement the living wage, and we did that through a tender process, with a cap of £16.50 an hour for that tender process. The benchmarking means that we are sure that most of our big providers are now able to pay that living wage to staff, and we have seen some significant improvements in our ability to recruit and retain care staff. We did have to invest a significant amount of our social care fund that came through in 2015-16 into this as a specific issue because of the issues around rurality and travel time, particularly within a locality like Dumfries and Galloway. We thought that that was a worthwhile investment of our resource. In terms of the specific issue around sleepovers, we have invested around about £400,000 into increasing the rates, moving to an hourly rate, rather than a fixed price overnight. We think that we have an agreement that meets our legal obligations around that. We are the direct provider for the majority of services in Shetland, and we have already been paying the living wage, so the Scottish Government funding has been adequate for Shetland. Thank you. You said that there was a cap of £16.50 an hour. Tell me how that operates. We went out of the tender process where all of the providers were able to tender in an hourly rate that they required. Most of them came in within a few pence of the £16.50. Did you agree with them that £16.50 would be the hourly rate? That was a rate that we agreed locally as a team that we would use as an adequate benchmark for that tender process that we undertook. Did they know that when they tendered? Yes, they did. If they knew that £16.50 was the rate, that would be great. We have done a lot of work engaging with our providers locally around their cost of provision and particularly how that links in with the more rural packages, where travel time we were getting I suppose signs that that was a really big issue for some of the providers. Thanks, that's helpful. Colin. Thank you very much, convener. Can I refer to my register of interests, where I was a local councillor up until the 4th of May in Dumfries and Galloway, so I would have been involved in the council's budget setting process? Can I just ask the panel, first of all, good morning, and can I ask, have your budgets been set for the forth coming year in each of your IGB areas? Yes, ours have been set and agreed to. In West Dunbartonshire, we have an agreement on the council's contribution. We are still in discussion with the health board in terms of their contribution, but our last meeting, the variation in terms of the NHS budget, we did set the budget on the basis that we would have continued discussions and any pressure around that, which was somewhere about £1,500,000, we would cover from reserves as necessary. Okay, yes, we've got an agreed budget within Dumfries and Galloway. Is your budget agreed? Yes, we agreed the budget, but there is a deficit on the NHS side. Okay, good. Just on that process, the budget has been agreed in some areas, but not all areas. Has that included identifying all the savings that you require for the forth coming year, or do you have any gaps in those budgets? I'll start. From the council perspective in West Dunbartonshire, we had no savings. We used in terms of the amount that each council was allowed to reduce in terms of its allocation, in terms of the rules that were set out in Parliament. We meant that we had money left or that we hadn't implemented a rent used currently from the 16-17 allocations, which went to the bottom line, but we've actually not had to make any cuts from that perspective. On the NHS side, we're currently looking at a 2% turnover target to meet the requirements of the flat cash, and I said that there's about £1,500,000 that we're still in discussion with the health board around. Sorry, from an Angus perspective, we had a full set of efficiency plans considered by the IGB in April that were approved. We have a small shortfall in terms of the NHS Tayside budget agreement of around £49,000 in identifying efficiency savings, and a similar shortfall with the Angus Council settlement, but that's more in the region of £200,000 in terms of the efficiency plans that we need to identify. It's more significant to Angus and the Tayside partnerships across NHS Tayside is the shortfall that's estimated in the devolved budget around prescribing and Tayside currently, which for Angus at the moment currently has a shortfall of over £1 million. Within Dumfries and Galloway, we've currently got a £5 million gap on savings identified. We're working through what we agreed with our integration joint board, a business transformation programme, where we're setting up various programmes of service redesign that we're progressing to work through how we will bridge that gap. What I undertook as chief finance officer over the last six to nine months was a range of workshops with our integration board members, just setting out the scale of the challenge that we expected. Remembering that within Dumfries we've got the whole of acute services within there. Some of the pressures that sit primarily within NHS boards are now within the totality of the integration joint board in Dumfries and Galloway. We've still got progress to meet to close that gap and just recognising that there will be a range of difficult and challenging decisions that we'll need to make as a partnership moving forward. In Shetland, we've got a balance budget on the local authority side, but we've got a £2.5 million funding gap on the NHS side. That's about 6 per cent of the total IJB budget. We have identified safe and plans of £1.2 million, but we've still got £1.3 million unidentified, so it's still a very challenging position for us in Dumfries and Galloway. To the council side and the health board side, but isn't it supposed to be an integrated budget? My perception of the process is that, instead of the IJBs setting the budget and determining how much money you require, what is actually happening is that the council set aside how much they're allocating and the health board set aside how much they're allocating, but it sounds as if it actually even goes further than that and that the health board effectively decide what savings they're making and the council appeared to make judgments on what could be saved from their allocation. I thought that it was supposed to be an integrated budget. Why are you talking about the council allocation and the health board allocation and having different gaps between the two? The reality is that that's how the funding for integration authorities is set up. We have two sources of funding. It comes from the local authority and it comes from the health board. In previous evidence sessions, people have suggested that there should be a single process, perhaps directly from Parliament, but the reality is not that. All the due diligence and setting up partnerships to start with, the due diligence work looked at the amount of funding that had been previously used for that purpose from the council and from the health board and to satisfy themselves that the money allocated was fit for purpose. Once it comes to us, we're duty bound to lose its identity from that perspective, it's pooled, we're able to use it in a more flexible way, but in terms of the original allocations, they still come from councils and health boards. The Government will argue that you have the authority to determine how much you require to implement your strategic plan. Are you saying in practical terms that that's just a piece of theory that it's not being used, that you're not really, as an IGB, saying that we believe that we need X amount from the local authority and X amount from the health board to deliver our strategic plan, therefore that's our budget? The Government will argue that that's what the powers that they've given you allows you to do it, but what you're really saying is that you just wait to see what the health board and the council give you and then you decide how you're going to allocate that funding. Is that what's really happening in practical terms? When we get our allocations, we are then able to look at how we best meet our priorities for our strategic plan, but the initial allocations can only come from those two places. I'm certainly not aware of any place else who has done that. I suppose that that more initial needs element of saying, this is what we think our population needs. Please go back to our funders, to councils and boards and say, this is what we need. Please give us it. I'm happy to follow on again from an Angus perspective and I would endorse Keith's comments about once the money is devolved, then we certainly are using that with more flexibility locally and we're certainly investing quite significantly in social care from the totality of the resources that are delegated to us. I think one dynamic that exists in Angus, I'm not sure if it exists anywhere else, which requires us to retain, if you like, the description of a health resource and a local authority resource was the risk sharing agreement that we entered into through the integration scheme for the first two years. For the first two years at the IGBA's operational, we entered into an agreement with both the NHS board and the local authority that there would be a risk sharing agreement in terms of any overspends relating to the costs of health and social care. That does require us to maintain systems for being able to record and articulate the spend against health services and local authority services should we be required to draw on that risk sharing agreement. But there is recognition that moving forward, we want to move forward in the spirit of the guidance of establishing IGBA's and have more of an integrated approach to negotiation around budgets. The question around who sets the budget or who negotiates it, I guess, is an interesting one. From the experience of the past couple of years, I think that the due diligence process itself has been very helpful in identifying an adequate and fair budget and has been very helpful in those negotiations in terms of reaching budget settlement, but there is no denying that although we are an integration authority, we are partners with the local authority and the NHS board as well. We are therefore not immune to the efficiency programmes that they have to put into place to provide sustainable care, and we have to be part and parcel of those. They all, if you like, play out during the negotiations that we have had for the initial year and certainly for 2017-18 as well. Can I just come back on that point? In your evidence, your written evidence, you seem to imply, though, what you would prefer as a system of direct funding from government. You talk about the frustrations of having separate partners, where you imply in your written evidence that almost direct funding model might be better. I think that some of the information that we put forward has supported the approach that has been taken this year, which has been more national direction given in terms of the resources that will be directed towards IGBs. That has really helped local discussions because it has been fairly unequivocal. Our preference would be that there is more direction that enables us to have a fair starting position for those negotiations moving on in the future, if it is all possible, to direct allocations to IGBs. I do not want to sound like Jeremy Paxman, but I will come back to that point. How would you ensure that there was democratic local accountability if everything was funded directly by the Scottish Government, instead of through local authorities? I guess that we would have to consider that in terms of the make-up of the IGBs, but the preference at the moment, if there was one, would be to continue along the lines of experience last year of more national direction in terms of the allocation to flow through the two bodies to the IGBs. We also said in the evidence that, if you like, the precedent set this year of allocating funds through the NHS boards, but with clear directions is one that we would like to see continue. Is that the view of all the panel, that you would prefer the money to come directly to the Scottish Government? Maybe when you are answering that, if you personally come from the health side background or the local government background? My background is both. I have managed health and social work services across both local government and the health service for the last 30 years. I have had an experience of working both in councils, exclusively managing social work services, then moving to the health service and then finally into a joint position. My IGB has not come to a view about direct funding or not, so the view that I would give would be personal. I would share Vicky's view that for the new money that has been invested, having clarity around that about what it can and cannot be used for is incredibly helpful, particularly at a time of financial challenge for the whole of the public sector. In some respects, albeit that we are bodies corporate in substance from that point of view, but the reality is that the IGB directs councils and health boards in terms of what they want the money spent on. I think that there is some inevitability over time to potential for IGBs to become the direct employers of the staff to have that direct funding. That is one solution if people perceive the current method of allocating funding from both through local government and health boards as being problematic. That would be the most obvious one in my opinion. I think that those things can work. From an authority, we were running an integrated service since 2010, so the actual budget negotiation process that we have gone through in the last couple of years has not necessarily been any more difficult than it was previously. We have worked through a number of those issues and had the time to do that. There is always going to be a bit of negotiation around that, but if people have come to that with a common sense of understanding and said that coming from an area that has been broadly supportive of integration and what that is trying to achieve, that has not been a particularly difficult one for us. I will pick up. It is quite well documented that one of the things that we have asked for over the years is to try to get greater alignment between council and NHS budget setting processes, so there is no inevitable delays in the process. I am from a health background and I will declare an interest. I am also the NHS director of finance in Dumfries and Galloway, so I have a dual role. One of the things that we want to ensure is that those timelines are as early as possible in the year, because I think that we have seen later on later budget timelines for agreeing that, and that makes our jobs more difficult in terms of agreeing a financial planning piece. I suppose that the other thing that I would want to make a plea for is to try to get a longer-term financial direction, even if it is only indicative, because again, the ambition is that we do not plan on an annual cycle. Some of the service changes, some of the resource shifts are inevitably going to take a longer time to do that, and the greatest certainty that we have of resources over a three- to five-year timeline linking with the timeline for the strategic plan would be welcomed. Carol? I have also got a dual role. I am head of finance for the NHS and IJB, chief financial officer, so speaking from the IJB side, outside the direct funding is welcome because it safeguards the IJB budget and it drives to shifting the balance of care as well, but I say from the NHS side it is probably not so helpful because, as I said earlier, we have got the fixed costs in the acute hospital, so if we have got to protect the IJB budget, it puts the savings disproportionately on to the acute services, which are already almost at a minimum, so I would say that it is helpful from the IJB side, perhaps not so much from the NHS side. Picking up on what has been said, it seems almost that the aspiration with IJBs is that it should be a process rather than an event. I wonder within the current funding model what the limits are in achieving the autonomy and independence that we all recognise at IJBs require if they truly are to deliver on the aims. Okay, but yeah. Carol, would you like to go first? Good partnership working and being mindful of each organisation has also got their own efficiency targets to meet and I guess it's just about a good partnership working, I don't know if I can say any more at this point. Is it a quick? Partnership working and that's always going to come down to the individual partners involved, so there's likely to be that variance. I look at the experience that we've had in Dumfries and Galloway. The success of our partnership to date has been on the effective relationships between our local authority and NHS partners and how that works and that's not going to go away depending upon what happens with the sort of the arrangements within the IJBs. One of the things that I think we need to be clear is to look at where the integration board sits within the current climate, so one of the things that's happening within health is a much more greater shift towards regional planning and how that's going to work and I think we need to be quite clear where the decision making is happening and I suppose reflecting on one of the points that Colin made earlier around how do we ensure that the decision making is happening in a sort of a locally democratic kind of way. One of the things that we've tried to do in Dumfries is delegate as much of our budgets to our localities. We've reinforced our locality structure and getting that locality management, so that's one of the sort of themes that we see as really important is getting that ownership within the communities of some of the service changes that we're taking forward and I think that for me is one of the real important strands of what it is that we're trying to achieve. I'd certainly share your view around it's a process rather than an event. As I said earlier we've obeyed in 2015 with the new legislation, the governance and bits and pieces changed around that but for us we've been working on the integration for a long period of time. Formally, since 2010 we actually had integrated community care management arrangements since 2008 so we've been at this a long time and I think we've been able to work through a lot of those things so things like efficient management efficiencies. I was the CHP director in West Dunbartonshire from 2005 and I now have a smaller management team to manage the totality of the IGB's business all of what was health, community health, all of what was social work. We're making half a million pound savings and have been making half a million pound savings in management costs alone for the last seven years so I think there will be opportunities for others in there but for us that's been a process, time to work that through to establish that trust in those relationships that are vital to making that work and we would certainly advocate along the lines you're suggesting there that this is something that will evolve and develop as we go forward. On the idea of moving to a direct funding model of the issue of democratic accountability has already been raised, what other challenges would you envisage in moving to such a model? I suppose there's quite well established resource allocation formulas for how health boards and local authorities receive their funding so you would have to almost start again with that and there would be the whole equity and fairness and I suppose that would be incredibly challenging around that I would say. To build on I think it was a comment that Keith made earlier on and perhaps the comments around these becoming more independent bodies there are a whole range of other things that we would need to consider including the employment status of the people who work within the health and social care partnership. I guess at the risk of being slightly contradictory in nature I'd like to build on comments from Kateynton Precent Gallery in terms of where we focused our effort to date. Our effort has absolutely been invested in building good, strong local partnerships through the localities and building the relationships with the people that actually provide care and integrating that at the point of delivery and there's been less focus I guess on trying to create total independence of a new integration authority and I think that's as a result of a range of issues notwithstanding the fact that we are part of the local authority and also the NHS board locally and we have a series of interdependencies that are still as a result of that many of the corporate services that we use are provided by the parent bodies but moreover and again referring to the reference to regionalisation our experience over the first year of operation and moving into to this year has shown that we have interdependencies to create beyond our own boundaries and there is a larger requirement for us as IGBs to work regionally now on the pressure points that we have so I think the focus for us is build on the local partnerships and then create the wider regional partnerships that we need to sustain ourselves would it be fair to say then on that point that the potential for integration is only limited by the capacity for partnership between individual local authorities and health boards? Well, from my perspective if you like the effectiveness or the capability of the partnership is absolutely underpinned by really good local partnerships so I guess the flip side of that would say that you know if you like the potential is within the grasp of the quality of the relationships locally absolutely it's not necessary around the systems it's more around the relationships leadership and good local partnership in my view so we've ever been necessarily having to move to the direct funding model really the focus should just be on making sure we can get these partnerships working as effectively as possible I would agree with that yet Ivan thanks for coming along there was a couple of things I just wanted to get a bit more clarity on you may or may not be able to help. The first was around the overall level of the budgets so I'm looking at the total NHS Scotland health budgets 2016-17-17-18 and I'm looking at the comments in your submissions round about the health boards being instructed to give you an allocation in 2017-18 that was flat in terms of cash whereas if you look at the total NHS budget for Scotland it's up by in cash terms 270 million over that period 2.1 per cent and in real terms by 80 million or 0.6 per cent so the health boards in total are getting increases in cash terms and in real terms but from the comments I'm seeing they've been told to only give you the same level in cash terms are those two statements correct and if so where's the rest of the money going to the health boards hanging on to that for something else or what's the context of that? I suppose just in terms of the overall numbers around health there was obviously 100 million from the health budget that was directed as part of the settlement into social care so within Dumfries and Galloway 3 million of the funding that the health board received so part of that 270 million that you talked about has already gone across to the integration boards as part of the partnership that wasn't counted in the number that's talked about in terms of the cash flat settlement which really left NHS boards with a relatively small uplift around about 0.4 per cent in terms of their increases and that's part of the challenge around why we're seeing the level of savings. As you're getting the local authority money we've talked about you're getting the health board money flat cash terms plus you're getting this extra 100 million on top of that as well. So integration boards would have got the flat cash and the share of the 100 million which has come through the health boards or has it come direct to you? It's come through the health board. Right okay so I mean I'm looking at Dumfries and Galloway for example and your number's going up 6 million between 2016-17 to 17-18 and you're saying 3 million of that 6 million went through you as part of this 100 million to the IGME? It'll be a combination of the social care fund and the full year impact of that from 15-16 sorry the 3 million and any kind of other ring fence funding that we've had through the integrated care fund and how that's played into the budget position. Right so the model's even more complicated than it first appears. Okay so you've got money coming through the local authority, you've got money coming through the health boards and flat cash terms and you've got other pockets of money coming through the health boards that are allocated specifically for the IGBs on top of that. Okay fine as I mean just touching on the points that Tom and Colin made about where this evolves to and it's a process kind of sounds like it's something that's sort of already creaking under the complexity and the add-ons and the bits and pieces that are getting bolder on top of other bits and pieces that are there and I'm assuming that will kind of evolve as we go. Is there a danger that this thing just gets too complicated? Absolutely I don't think so. I think at first glance but suppose being in it we should at least understand how that works and I think as we've said earlier I think the clarity around in terms of specific additional allocations. My recollection although I may be wrong was that for example in 1617 the 250 million for social care my recollection was that was over and above any uplift that went to health boards whereas the 107 for 1718 is part of the health boards total uplift so that was a my colleague Kate you can keep me right on that so that was that has a slight additional complication but I said we understand that and I suppose that goes back to your original question of why it looks like there is so little what's happening in that extra money well as far as my health board by the time they flowed through the share of the 107 million for greater Glasgow and Clyde I think there was something in the single figures of millions left of the uplift to cover all inflationary pressures. Okay following on from that then if the concept is set aside I think we're talking about what you're calling large hospitals which I understand the definition of a large hospital is a hospital that covers more than one local authority or more than one IGB area if I'm correct is that is that how it's defined not necessarily not necessarily right okay so it could be just allocated for one or it could be across several right and from just reading through the notes here the the way that money seems to work again correct me if I'm wrong but the concept seems to be that the hospitals need money to run the hospitals are providing services that the IGBs need the IGBs aren't funding those through a transfer of resources but the health board has got that money to start with but rather than give it to the IGB to give back to the hospital the health board just keeps the money and gives it direct to the hospital and part of the hospital's funding is coming through that set aside process and part of it's coming directly from the health board is that how the process works. I suppose it's fair to say that the set aside piece for this first year of operation has almost been like a notional allocation so what what health boards have done in conjunction with their IGBs is worked out through their sort of costing mechanism the sort of the the amount of resource based on the services that are directed through the integration scheme that would be allocated to that partnership with a view to kind of looking at how that can impact on on you know kind of acute services what we've done in Dumfries is we don't have set aside budgets because we've got all of our acute hospital and budget within within that there's a piece of work that's going on through the with the policy team in government and the chief finance officers network to look at how we make that a bit more real because I mean it's probably fair to say for Paul Thickey and Keith it probably hasn't felt real in the first year in terms of how how that impacts on the overall resources that each of the integration joint boards have got but it is to give the IGBs an impact and an influence on on the delivery of acute services within their which obviously makes sense because the whole point as we started with is to move the resources from acute and to the social care side but obviously as you make that more real that throws up another problem which is if you're trying to manage a hospital and you're not sure where your money's coming from and you're having to negotiate with several IGBs I think it's even more complicated especially if you get big fixed costs as you're doing a hospital is there any thought when given as to how that's going to play out? In Shetland we put the set aside budget that was passed to the IGB at the start of the year as part of the delegated budget so because we've just got one local authority and one hospital then we just put in the full cost centres that relate to emergency care so we had A&E Ward 3 and the medical doctors and consultants that all went into the IGB and I guess our thoughts there is that allows the IGB to consider the whole system and if there was any funding decisions that impacted the hospital that would need to be carefully discussed between health board and IGB I mean that's where the partnership work comes in he wouldn't expect them to remove funding without the proper process to ensure that that is moving the balance of care in the correct manner. In the case of Shetland and Dumfries and Galloway where you've got that alignment a one-to-one alignment you can sit down with yourself and figure it out I'm more concerned about what it looks like in the case where the large hospital service and several IGBs and how that's supposed to work when you start having a real control over that budget and deciding what Yara aren't going to put in at the acute hospitals and how acute hospitals are supposed to manage themselves in that environment. From a Tayside perspective I would endorse comments again made around the reality in the first year and the first year has been more of an exercise to describe the large hospital set aside. I think we articulated in the information that we put forward we see a major area for this year for us to build the financial planning relationships regarding large hospitals. In Tayside we largely work with Ninewell's hospitals and that covers three of the Tayside IGBs but also has an impact on one of the IGBs in Fife because of the flow of patients so we're approaching that this year through a round table approach to planning so it's probably not dissimilar to what colleagues have articulated from Shetland and recent Galloway in terms of the whole system planning around the table for different components of care but then we'll have to obviously back up the jointly agreed plans with the financial mechanisms and the planning mechanisms that are set out with large hospital guidance. Major focus for us at the moment in Tayside is around unscheduled care and trying to change the pattern of demand there and the costs of care associated with that so that will flow through into our large hospital guidance and our strategic plans that are emerging over the next year. I'll just add to that briefly chair. I think that that's one part of the legislation certainly in areas where there are more than one IGB within a health board area the requirement for the chief officers and the partnerships to collaborate and cooperate together certainly in Glasgow that's something that we are doing have been doing and will continue to do so we're currently going through commission or developing our commissioning intentions so we've court we've worked collectively as a group of six to bring those together to make sure that what one's saying is absolutely consistent with what the rest of us are saying for example so we should and that should make that so it becomes a coordinated ask to the acute system rather than having to deal with six different arrangements six times over. Can I ask about staffing costs and the starting point for this question is to establish firstly who does who directly employs the various personnel who operate functions that the IJBs control is it the IJB is it the health board is it the local authority or is it a mixture I might go first if that's okay because in terms of the the background so the people who'd previously for the services that are delegated to us if you've been an NHS if you've been a health visitor or a district nurse or a physiotherapist employed by the health board you can that continues and the same way if you've been a home carer or a social worker within the local authority that continues so there remain two employers and I think that's in terms of my response to one of the earlier questions that's that you know the way the legislation is drafted we remain with two employers but it is open at some point in the future for that to change and for the IJB potentially to become the employer so a bit like they've done perhaps in Highland where for their single agency model they to be transferred all the previous health council staff for adult care into the board and vice versa I think for health visitors and specialist children services went to the council so same same sort of thing but I get it's been one of those areas and so for simple things like public holidays you know it helps to have coordination around those things there are very few admin staff we sometimes you know some inconsistencies sometimes within grades but in terms of professional employees I think occupational therapists as a professional group are the only group that historically have had employment in both NHS and councils but in reality they've done quite different jobs so but that's the reality where we are just now they are fundamentally one either with it and the only employees such as technically as us as chief officers where we are effectively seconded to the IJB for that purpose in terms of being their chief officer. Okay so thank you for clarifying that so if for instance an adult social care worker in Dumfrieson gallery galloway or you're a someone working in hospital in Dumfrieson gallery all under all delegated to the integration authority you will nevertheless be employed either by the council or by the health board in terms of the budget then who bears who who bears the staffing that staffing cost does it come into your budget notwithstanding you're not the employer yes okay and is that it's true of true of across the board okay thank you clear thank you convener and thank you panel for coming along this morning I want to ask a little bit about your annual financial statement I'm not quite sure when each of the IA's are expected to produce those so perhaps you could enlighten me I resist you to our IJB at the end of June okay I will go to the audit committee in the middle of June okay similarly we're preparing ours at the moment and it will go to our IJB at the end of June we're also preparing the annual report for the for the IJB as well Carol yeah in the tune of the draft account just going to IJB audit committee and IJB thank you for clarifying that I know here that the Scottish Government gave an advice note to IJBs about their annual financial statement reminding them that regulations require that the report includes financial information on the amount spent on achieving the national health and wellbeing outcomes and the amount spent on care groups localities and service type and I wonder if you could perhaps inform the committee how your annual financial statement is going to address those issues I suppose you picking up the fact of how we link financial numbers to to kind of outcomes I suppose on me we don't have the sophistication of our financial systems to provide that level of detail that that's required and the actual financial statement is a sort of a fairly indicative kind of cost book analysis splitting our costs across the various sort of parameters of care so acute care primary care and locality care one of the things that we've been having quite a big discussion about in our partnership is around how we move the focus away from some of the performance indicators that you can count you know some of the the sort of the national stuff around the TTG any week times to link very much more closely with the nine national outcomes so our kind of performance week that we've been pulling together actually sort of starts to set up how we're how we're going to do that with much more kind of longer term kind of qualitative indicators the work that we've been doing as a partnership indicates that it's probably going to take us sort of a three to five year kind of planning cycle before we get information that really starts to note how how that performance moves are happening and I think that's where one of the things that we really want to measure is particularly when we were talking earlier about the shifting the balance of care sort of ambition that we can really start to see over a period of time whether as a as an integration joint but we're making a real impact on on the outcomes to patients and that certainly is is our ambition I would say it's still very early days yet in terms of the first year of of operation so from an Angus perspective the national outcomes that were prescribed underpin the overall strategic plan that we've set out in the approach to our strategic plan which is actually then further rationalised into four different domains of change and development so the concentration locally has been for our financial plans to map the intentions that are set out in the strategic plan so they will follow those but they won't necessarily at this point be easily definable against each of the national outcomes and I think other areas also would find it quite difficult at the moment to map financial resources against each of the individual outcomes however the main thrust has been to align it to the strategic outcomes that have been set out for our iJB so the plan that you'll see put forward to our iJB in June will not only be a financial statement of the expenditure and the use of the budgets but it will also show you how investment of those budgets have achieved any change against our strategic plan. I'm sorry I'm a bit confused there so does the strategic plan include the national building outcomes? It does yes but beyond the original number within that we've got four different domains of development which we largely map the financial resources against so it does incorporate those but to drill down to match them identically against the nine national outcomes has proved quite difficult in terms of aligning the financial resources. I don't know if it's the same elsewhere but I gather that it's similar across Scotland. Carol, would you like to comment? The same is what Vicki is saying. We are going to try and combine the performance report along with the financial statements to see if we can begin to link the finances to the outcomes but as far as the detailed mapping between the finances and the national outcomes we still don't have that level of detail. It's a work in progress. I obviously share sentiments from my colleagues. I think our approach is maybe slightly different. I suppose our financial statement and the auditing accounts etc will be a piece that we need to do technically to do that and we'd look to do it in terms of the public report in terms of performance. We'd look to take information from that and to build it in in the same way as other people are talking about but I think it will be an evolutionary process that we will get better at the more we do and certainly something that the chief officer's network nationally will certainly be an area where we could all probably learn from each other in terms of how we develop that over time. It sounds to me here that you're very focused on numbers, on figures, on balancing the books, if you like, as opposed to matching that against the national outcomes. Is this because this is something new? Is it because you've not had adequate guidance? Can you explain to me why they haven't been linked up already and why we're looking at 35 years before we're going to see that information? Yes, it's new in terms of the legislation from that perspective. At the end of the first full year we'll be the first time that we've all had to do it so I suppose there's an inevitability that there'll be good and bad in that perspective. I think that we've explained and people have explained some of the difficulties in terms of matching that just purely against that or some expenditure might match a number of the outcomes, the nine national outcomes. But yes, there's no doubt that we've been focused on numbers, on balancing the books and making the most with the money. But at the end of the day, making the most with the money and doing the best with the money is actually not inconsistent at all with those national outcomes because that's effectively what integration is there to do. Apologies, I've used this anecdote in other places before but a long time ago when I worked on the other part of Scotland, when money was a bit tight, I spent three or four years defining well the social work department, we only do this and the health board said well we only do that and nobody cared about the person in the middle and I suppose that's the biggest difference for me about integration is it's all about the person in the middle and doing the best and the most we can with the totality of what we've got. So managing that money and those resources to the best that's best effect across the piece with its focus on individuals who need services is what we're about. So how do you evidence that then? Well the proof will be when we I do quarterly reporting to my IGB in terms of performance, in terms of some of the indicators around that would feed into some of those outcomes as well. So that's been an iterative process as well. Again, we just concluded our first full year but we had nine months in the previous year and again it's been an iterative process for us to that so that we are all about providing that evidence and for people to scrutinise that and to see whether or not we're making a difference. And from an Angus perspective, not dissimilarly, we also submit a quarterly performance report to the IGB and that does align the use of the financial resources against the strategic intent that's set out in the strategic plan and although it is still a work in progress, it's a major focus for us to ensure that we invest the money wisely to achieve the objectives that we've been set up to do. Is there work going on in terms of a standardised, auditable set of reporting mechanisms where we can compare you to you to you? That's certainly a national requirement on the annual report but I think that the interim reporting is at local discretion unless my colleagues know otherwise. So no is the answer or yes is the answer. There's a standardised approach to the annual report but not the interim reporting. I suppose all I was going to add was that inevitably with the nature of the national outcomes they are the things that you can't count as easily and by default in terms of the qualitative kind of measures like patient experience and things like that that there is a longer term nature to being able to evidence a shift in kind of cultures and changes in usage of services. So I think what we've sort of set out and I know I've talked about a three to five year timescale that links very much with the outcomes that we've set out as a partnership within our strategic plan and so at every kind of integration board meeting that we have we have both a financial update and a performance update so that we're focusing equally on both of those measures and linking our kind of resource allocation very much to where we want to see our performance improve within the outcome set out in the strategic plan. Finally, thank you convener, just to ask how readily available is that information, the quarterly information, how readily available will the annual information be? I mean all of our information is published on our local website and I'm happy to share our performance reporting with the committee if they want to see it. However, our performance reports are in our IGP papers which are public and available from our website. Same. Garll. Yes, the same, ours is published on the website and the quarterly performance report, we report against the nine national outcomes and what the same is what Katie was saying, we consider the performance report and the finance report together at each meeting so the performance report tells us how well we're performing against those outcomes and if we're staying within our financial plan then I guess that's the balance that we're implementing the strategic plan correctly. Do you then report that back to Scottish Government and they produce co-ordinated data or should they be doing that, comparative data? So do you report your outcomes back to Scottish Government and then do they produce anything saying this is what's happening across the piece? I mean they have set out within the health and social care delivery plan outcomes that we need to report but they're much more the kind of traditional outcomes that you would be used to seeing through the NHS. I mean we can take that back to them because I'm not quite sure what their intention is around that. Earlier on Keith spoke about cuts, Vicki and Carl spoke about savings and Katie spoke about efficiencies. If I was to get a copy of the dictionary into a source that's handed out to IGB managers and looked up cuts or efficiencies or savings, would I find the same explanations under those three words? Are cuts, efficiencies and savings the same things in the lexicon of IGB managers? Not always. Not always, not always. I can imagine that if your office uses 10 boxes of paperclips last year and you've got eight left, there's an efficiency to be made there, understand that. But in the big scheme of things and the big numbers, when you're asked to find very significant sums of money, are the cuts efficiencies or savings? Well I can only talk on behalf of our approach to efficiencies. So yours are efficiencies? Yeah, well because they're created to achieve both a reduction in spend but sometimes more efficient ways of working. So we've been through a major redesign programme this year with home care, health care that's provided to people at home that has involved different shift patterns and different ways of working that have actually increased the capacity of the existing workforce. So you would be doing that irrespective of the financial situation because it's a better thing for you to do, would you? And it's also an absolute requirement in terms of us keeping up with demand. That's that example. Which other examples do you have that are not driven by that need but that are driven by financial need? Well, I guess there are a range of, in your words, cost-cutting exercises which are literally about reducing the expenditure. Yeah, so would you describe those as cuts? They're more efficient ways of working. So we tend to use the language around the words cuts. Yeah, I'm very well aware of that but Keith did use the word cuts earlier and I think that was quite refreshing because it's the first time I've heard an IGB manager say it. So in your long experience, are you having to implement cuts? Well, having used the term I can't back down from it now but I think very often when it comes to it, we need to call it frankly what it is. Hallelujah. From my perspective, flat cash, for example, is a much better position and much more protected position than other parts of the public sector in Scotland but the reality is that flat cash across the period of the year means that and most of our control budget becomes into staff. Right, what from it? So the reality is if I have to maintain a flat cash because the pay bill goes up, the only way I can, as I said earlier, it's a 2% efficiency saving, a 2% slippage target in order to meet that. Ultimately that means I will probably have to employ fewer staff at the end of the year than I did at the start of the year. Now there may be some aspects of efficiency of doing things a bit better that might mitigate some of that but the reality is that most people would recognise that as a potential cut to the level of service and that's where I use the term. Thank you. I suppose that we will be doing a combination of things so we will be sort of buying things cheaper and doing things more efficiently, which is what you would classify as an efficiency. We'll be doing a range of service redesigns which will change the way that we currently deliver services to either meet a demand. Why would you not be buying things cheaper and more efficiently anyway? We do. We endeavour to do that. We will always be looking at that as a way to make savings as we move forward. As I said, we will undertake service redesigns to meet the demands of the service. The work that we've been doing around trying to reduce delayed discharges and working in our hospitals and things, we will change our services to meet those demands. There will be some things that we'll do that you might want to describe as cuts of budget reduction so we might stop doing things. We might stop prescribing something. We're looking at some of the things where we've got that balance of value for money. As a chief finance officer, we have to look at our resources across the whole piece and look at the population that we're providing the services to. There's no doubt that there will need to be some difficult decisions made within partnerships. We've not shied away from that. We're also trying to redesign services to do more with less, like more from residential beds and move the services into the community. I guess the difficulty is to convince the public that we are mentoring the level of services for reducing costs, but ultimately, as budgets keep getting reduced, we might get to the position that we need to make cuts and reduce services. In Shetland, that might mean moving more procedures to the mainland, moving towards more regional models, but at the moment that efficiencies we're trying to drive, but ultimately we could come to the stage that this is probably more classed as cuts, I guess. Thank you. In terms of the delay in green budgets and stuff like that, does that have any implications for day-to-day budgeting for people in the front line or is it largely that they just go on wet and let you guys worry about that? Yes, we might be in there. Good morning to the panel. I'd like to explore the convener's question a little further in terms of cuts and efficiencies. Having worked in the social care sector for the best part of 15 years, I understand that efficiencies don't always mean cuts. I remember being told to box clever in terms of travel and people to join meetings in the way that Carl is doing from Shetland a lot more frequently. That's an efficiency that reduces quite a significant burden on any organisation's budget, but then you move to the point where efficiencies mean that things that you used to do are no longer delivered and that's a cut. That's when the service user at the business end of what you're doing no longer gets the value of that process. I understand that and we can debate the semantics. What I'm really interested in exploring right now is the quiet death of services where it's nobody's fault. For example, the 20 per cent reduction to drug and alcohol partnerships that came through in the budget 18 months ago and is perpetuated in this year's budget, which was effectively a 20 per cent cut that was passed on to IJBs and effectively they were told to say, well please just find a way to continue doing what you were doing but with less money. Some authorities, some health boards and IJBs have to their credit managed to do that, but in Edinburgh for example we've seen a net reduction of £1.3 million a year in terms of funding for drug and alcohol services and some services have ended as a result of that. I just want to hear the views of the panel on what happens when why do some authorities manage to do that and others not and why is no fuss made about it when that happens because it seems to be that's the point at which it's nobody's fault and we lose services but nobody seems to be to blame for that. Perhaps I could come in first. I think my recollection of that last year was that there was a change in the way it was kind of for and there was as you say a significant reduction and with a desire to see that continue when my health board did. We did actually make it a local level some efficiencies. We discussed with our main voluntary sector providers and our own direct provision there and my recollection of our share would have been something like £300,000 hit on a £4 million or so budget. We made a number of changes that resulted in £100,000 being taken out in conjunction with our two major providers and I said cutting our own cloth a bit in terms of our own direct provision. It certainly wasn't as the chair of the ADP in my area. It was certainly not forgotten about or hidden. We did that in a very open and transparent way and people would have ideally not liked to do it but we were able to do it in a way that both the providers and ourselves were able to manage to continue to provide the most significant services. I'm grateful for that. I think my frustration with this entire issue, particularly around ADP funding, is that it's something that myself, the convener and others have raised successively in Parliament because we are not keen to give up on this without a fight, but it's felt like we've looked sometimes to health boards and IJBs for support in that fight and some health boards have managed to do as you have done and some have just thrown their hands up and said, well, there's nothing we can do, we're just going to have to reduce the funding. I think my frustration is that it seems to have just happened and we're just expected to accommodate that. We can see a correlation with a spike in HIV infection in Glasgow as a result of reductions in services, which is causal. We have yet to see exactly empirical evidence as to how causal that is, but nevertheless those services that we're keeping people safe are no longer doing so to the level that they want to do. I guess it's just a point that I'd like to have on record. Okay, I think we're going to finish there. We went a bit over time. I thank you all very much for your evidence. I also understand, Keith, that you're retiring at the summer, so I could put on record our thanks to you for your contribution to health and social care over. I think it's a quite a long period of time, so I thank you very much for that. I will suspend briefly. Second item on our agenda this morning is our first evidence session on NHS governance and we'll be looking at staff governance today. I welcome to the committee Donald Harley, Deputy Secretary of the BMA, Ross Shaw, Senior Officer of the Royal College of Nursing Scotland, Kenneth Lloyd-Jones, Public Affairs and Policy Manager for Scotland, Office of the Chartered Society of Physiotherapy and a representative of the Allied Health Professions Federation in Scotland, Matt McLaughlin, Secretary to the Health Committee of Unison and Claire Puller, National Officer Manager in the Partnership. We did seek a representative from United Union, but they were unable to put someone forward. First of all, I declare an interest as a member of United Union and just put that on the record. We'll move direct to first questions. Thanks, convener, and good morning to the panel. What role does staff governance play in delivering an effective workforce and how would you rate the NHS's performance on staff governance? I'd be happy to do so, I guess. I'd like to put on the record that we're fully committed to the staff governance arrangements in Scotland and the ideals that are underpinning them are very good indeed, but we would say that there are definitely areas, both functional areas and probably board areas as well, where there's marked difference between the practical reality on the ground and the ideals contained in the standard. I suppose there are three main areas that we would want to flag up. The first is all around engagement and involvement, whereas Scotland has a proud record with regard to that. A recent study by the University of Nottingham gave Scotland high marks indeed for the arrangements that it has, but oftentimes in practice it doesn't fulfil the function it ought to do because there's an element of rubber stamping around things in that fully formed ideas are brought to be validated rather than involving staff from the bottom up. In terms of medical staff who I'm representing today, they find it particularly hard to be released, to be engaged. It's not easy to provide cover for medical staff and this is a long-standing thing, but as finances become tighter in the NHS it becomes even harder to release medical staff and it requires a bit of planning and foresight. Six weeks notice typically to release a consultant and somebody there to cover for them. For GPs in particular, Mondays is the busiest day in practice. It's also the busiest day in clinics in hospitals as well and yet all too often we see joint arrangements being organised for a Monday, which effectively unintentionally or otherwise excludes medical involvement and engagement and thereby you're losing that practical front-line experience and the chance to improve services from that perspective. The second area I would like to highlight is that of raising concerns and there's a lot of stuff you'll have read in the evidence about how effective the arrangements are for raising concerns in general and I'll not rehearse that again just now, but just to flag up there's a particular unique situation with regards to junior doctors whose training programmes are controlled by NHS Education for Scotland and therefore the exercise considerable power over junior's access to... The issues around concerns being raised across the piece so you might be hold fire on that for now, is that okay? Okay, happy to do that. Thanks, convener. I think the first thing I would say as staff governance is a very clear ideology that was developed in partnership with trade unions and the employer and government of the day and I think that that has continued. I think that a lot of people invest a lot of time and effort to try and make sure that that continues. What I would say is that I think that that ideology, that principle is starting to feel the strain partly because some of the people who crafted it have retired, gone, left the service. I think that the continued budget pressure doesn't help. It's easy to do partnership working and staff governance when you're in a period of growth because you've got good things to say to people. It's much, much harder when you're doing that in a period of retraction and change and so I think that that is affecting the current performance as particularly middle managers feel squeezed to deliver and so we hear lots of stuff about ticking boxes and consuming your own smoke and all of that kind of mantra starts to feed through when in the past I think people were much more inclined to try to engage and talk positively and had time and energy and space to listen. I think other colleagues have spoken about in their submissions the need for training and of that group of staff and I think that that's a very good thing to identify and focus on because I think that that is a key issue. I would say there's been a more recent summary or analysis undertaken by Penn State University which I think is in the system somewhere and that also speaks very highly of partnership and in particular the staff governance model. It is unique to Scotland and Scotland's NHS and the interaction and interface as we work in the integrated joint boards is absolutely challenging that agenda because we have another big complex beast involved in joint boards who don't necessarily have at its heart that staff governance commitment. I think that's something that needs to be worked through a bit more but generally speaking I think the report card would say ticking along nicely but needs a bit of focus. I would agree. I would say that nationally the staff governance standard in Scotland is strong and the tripartite agreement with the Scottish Government, the employers and the trade union works really well at a national level. However I think we would question how aware staff on the ground floor are of the staff governance standard. I think they become aware when something happens if there's going to be an organisational change in their area and they suddenly have to become aware but I think we all and I mean the tripartite agreement the three lots of us all struggle to ensure that we get the positive messages out there because sometimes there's some really good work done within staff governance with the engagements with the trade unions however that message doesn't always get out there to staff. It's extremely difficult for nursing staff to actively engage often because they're under immense pressure. We all know how busy the clinical areas are both in the hospitals and in the community. We've got huge vacancies at the moment both within the community and within the hospitals so that puts incredible pressure on. The complexity of patients is so huge that it's actually very difficult to get staff to be actively involved. I would question whether it's working as well on the ground floor. I would echo some of those last points. I think we're very pleased that the partnership arrangement in Scotland is a good positive model which has worked and obviously will feel greater strains in a period in which budgets are tight. I would add from the allied health professions perspective they feel a little more disadvantaged in that traditionally for example at a local level there isn't backfill for allied health professions to take on roles that aren't directly dealing with patients so in order to engage they have to often cancel appointments that's the reality of it which is not the case in other areas where cover is arranged for that. I think also just in terms of things like continuing with professional development where courses will have to be funded by allied health professions themselves there isn't funding very often made available for that and getting release for that can be sometimes restricted so I think in many ways the allied health professions do feel somewhat disadvantaged in the overall picture. I have to agree with my colleagues I think that the tripartate agreement is a very good and strong agreement however I don't always feel that that is delivered to all the employers and I don't think that that cascades down through the employers so the work that's done at the tripartate level doesn't always reach the people who are working in the NHS. I do agree that it's time consuming if there's something so not just a reorganisational change but if you're looking at something where you're raising grievance or there's something going on along the lines where there's actually complaints and dispute between colleagues that can take years to sort out and one of my worries is that sometimes when we're going through governance what we should be saying is what do we want to achieve by starting to use this particular framework so if you're using something for example for reorganisational change we know why we're using that we know that there's going to be a change we know that there's a business model to consult on we know that we need to take on staff views and stakeholder views to make sure that the right end point is reached but in staff governance when I'm representing a senior manager very often I'll say to somebody who has raised a complaint has anybody asked you what you want to get out of this and more often than not the answer is no and I'll say well what do you want to get out of this and they'll say I'd like an apology I'd like it not to happen again but I don't want the senior manager to be suspended for 18 months while somebody else does an investigation and I have to bring in all my colleagues through as witnesses so I think it might be useful because we do have very good staff governance and we do work very well together but I think it would be useful to actually sometimes stop and take stock and then review what we're doing and then say is it time to evolve what we're doing are there other things that we can put to one side and how do we reintroduce certain skills that are lost such as talking to one another rather than putting in a grievance for example when we feel a bit ticked off with one of our managers. I know certainly and I'm sure other colleagues will have this where we have constituents who come to us who work in the health service and they have a particular issue. They often come to us because they can't work through the system that's there and my perception is that there is an arrangement or a deal struck or whatever at the level of the tripartite arrangement that they are completely unaware of the person on the ground floor is completely unaware of and they'll come back and say well who agreed this who told us about this so they then come to their MSP for representation because they maybe go through their stuff you know there could be their union it could be whoever to try and get a solution to that and they are unaware that somebody up there has agreed a course of action that's where we find that in our constituency case what I certainly do and I'm sure others have as well. Matt sorry yes. Convener just to pick up that point I think you've had on a fairly significant challenge in the partnership arrangements and I just smiled when you mentioned it because I think I do remember a long discussion with a colleague on your right when she was a unison shop steward about getting sucked into, remembering the mind these are volunteers part time doing a professional job as well, but getting sucked into the machinery of meetings and I think all of the members here I'm sure I'll appreciate that meetings can become their own industry and it can be very difficult in those circumstances when you've got you know political direction when you've got chief official direction when you've got chief officers locally when you've got local managers locally saying to you we need to make that change we need to make that change we need to make that change to then make the space in place for the shop steward to go and have what we might have called a shop meeting in the old days to go out into a workplace and just have a chat with colleagues and so there's a lot more done now I think electronically and in bulletins and flyers and again in your own professions you'll know that you can write to people to your hands for laugh if they don't read it or don't comprehend what you're writing to them because they're maybe busy with real lives then that can be a major a major challenge. The other thing I would say though that I think we need to recognise that there is a need for a space to be made for that and commitment to be made for that when we do localised change agendas. I think there's a couple of things that just challenge that a wee bit and we're seeing a bit more of it. Staff governance doesn't mean we can't disagree and again I look to the colleague and you're right because I can recall the conversations we had when Claire was a shop steward you can go into that arrangement and say I'm sorry we don't agree with that and then work through a mechanism to try to get to agreement if that's the case but people still have natural traditional industrial methodologies available to them if we can't get that that consensus but look at the number of employees if we strip out equal pay look at the number of employment tribunals that are lodged against the NHS employers in Scotland they will compare very very favourably with every other industry including local government and the voluntary sector, private sector in the country there's a reason for that it's because there is at least a point in time where we albeit that the machinery moves at a pace that you wouldn't recognise is progress sometimes but there is always that opportunity to get through that staff governance route through that partnership route to solutions and problems and we I think collectively use that with the employers and we call these in government to our to our maximum benefit so that's a key measure I think of of where we are in the staff governance route yeah Marie I wonder if I could ask specifically about the how easy it is to raise concerns or to whistle blow if you've got concerns about a colleague's practice so I guess I need to remind everyone that I worked for 20 years as a clinical pharmacist in a psychiatric hospital so in the 20 years that I worked from the mid 90s till recently there was a transformational change was my perception and how easy it was to raise concerns about other people's practice or about practices that you witnessed in the hospital would the panel say that that reflects a national trend or is that simply my own experience because I actually went back we have link members we don't have reps we have link members so I have people I can just directly contact and say could you answer this question for me so I have some evidence here from senior managers who say they have never seen somebody raise concerns through whistle blowing and not had a particularly devastating impact on them personally whether it's them on their career whether it's them and their relationships with their colleagues but we whistle blowing is a is a very vital part of you know the staff governance and how we how we safeguard you know our interactions but I think that from what our members say the senior managers they think it's still a very blame orientated attachment to you that you have had the temerity how dare you raise concerns through whistle blowing there are other routes to use you know it's an undignified way of doing it but we need whistle blowing and we need people to feel safe in whistle blowing and I don't think that they do in the medical fields raising concerns about our colleague is both a very professional and a very personal issue for a doctor your personal your professional reputation is all and a slight to that is a real wound and felt and people tend to react against that and I think what is often seen is a very toxic reaction when when people's practice is held up to question and of course in the in the medical field it's not so much raised necessarily raising concerns as you would understand it in terms of whistle blowing it might be more a case of referring that person to the GMC for the GMC to take appropriate action and then you get into a kind of tip for tat thing as well how can they accuse me they're not exactly blameworthy themselves and all the rest of it you know so so so there is that but I don't know whether this is the time to mention either you said convener that you were going to look at raising concerns in more depth no not carry on generally but I think medical professionals and all the clinical professionals in their day-to-day practice in the health service see things which they're not comfortable with and they want to raise concerns it's always a a tricky issue if it's about your employer you have it you have protections at law but even then we've seen and you'll have you'll have read in the testimony of various individuals that sometimes those protections don't really amount to much and relationships are destroyed careers are destroyed and and and all the rest of it and that's with those protections in place as I was starting to say earlier junior doctors in the unique position that in that they have a power relationship with an HS education for scotland's who control access to and retention on their training programme and if the relationship with nes goes wrong and they fall out of their training programme de facto they've lost their their job and their career as well and they have no protection against the against the actions of nes that's not to say nes are a bad organisation clearly they're not they're very good and important organization but these things do happen from time to time and place to place and recently in in in england arrangements being put in place with health education england to provide the same protections within the training relationship for trainee doctors there but so far nes have been not been willing to pursue similar arrangements here so junior doctors are still even more probably reticent to raise concerns if it's going to put their training relationship in jeopardy rose i think there's a big difference between raising concerns and whistle blowing and we we have our members come to us on a daily basis raising concerns normally about staffing levels um but whistle blowing i think it's very early days with the legislation to see how it's going to work i was a lothian area partnership forum yesterday and they actually gave a report back to us on the whistle blowing and there was they've had nine cases of that have gone through the whistle blowing policy since september last year which they've investigated a number of those are anonymous so it's very difficult to be able to feed back and to get some further information but i would say that people are now very much aware of the whistle blowing legislation and they know about the policies there's been a lot of work done certainly in the health boards that i cover with regard to that however i think it's always difficult to raise a concern it's very hard to put your head above the parapet but like the bma you know a lot of our members are a regulated profession as as well as the our ahp colleagues so they are bound by their own code of conduct so that if they do see it anything that is putting patient care at risk then they absolutely have an obligation to do that and we always support and encourage our members to do that because you know we're about patient safety and quality yeah just to add yes of course that regulations will ensure i mean clinicians have a duty of care and they will have to look to their um uh code of conduct and to their duty of care if they have serious concerns the difficulty is as we've said whistle blowing is about revealing something that has perhaps been hidden whereas sometimes um the concerns are whether or not the quality of service is suffering but at what point does that become whistle blowing at what point does that become unsafe isn't always clear we will clearly um uh uh uh be with our professional the various professional bodies of the allied health professions will be there to support and advise members in those circumstances but of course these pertain to particular circumstances and i'm not always sure that the the notional whistle blowing is is often seen as uh for the the headline scandal aspect of things rather than a a run of the mill way in which you can raise concerns where the quality of services is being diminished. Matt? Yeah i think just briefly convener i appreciate you by busy i think whistle blowing is an emails an issue i mean at our positions quite clear we think the nhs has the machinery to deal with whistle blowing the dictate system that exists across the nhs in scotland i think is a very good principled system what people don't get is they don't get feedback from that when they make a a referral or a report at a local level if there's something there are no quite happy about. Colleagues have spoke about the need for professionals to reflect, and that's absolutely key as well. I do think that at a senior level the NHS can be quite defensive and risk averse. I think that there's a hierarchical, macho culture exist in some places. I think that that causes any ability for the service itself to properly reflect and deal with genuine concerns in a sensitive and sensible way and so therefore we get into conflict, we get into positions and that doesn't help so but I do think we have to say that the machinery is there, it's about how it's about people investing in that. I think some of us who were here when they loaded in waiting time scandal emers the, see exactly that culture or saw exactly that culture. Clare, very briefly now because we need to move on. Could I just say we haven't got a lot of time this morning so could people keep their answers pretty snappy? I just would like to draw the committee's attention to the fact that employees in the NHS are aware of the fact that since the Francis report they do have a duty of candor to raise concerns which don't always lead to whistleblowing as we've pointed out, there's a two different and it's how to balance that in a very risk averse often system. I wanted to ask about one specific situation which is raised with me frequently when I'm out meeting folk who work in the health service and that's the issues around the quality provided by locum and temporary staff. So there is probably a much better system in place for managing people who are employed within the NHS service. Do you think that the system is robust enough for people who are not permanently employed but working in the NHS? In the interest of keeping it snappy, any organisation or system that relies on bank or temporary workers is going to have difficulty driving staff governance and quality and we have a lot of areas where we're reliant wholly on bank workers or temporary workers. I'm absolutely delighted to work with you to resolve that. Okay, Alex. Mina, good morning to the panel. I'm very glad Marie raised the issue of raising concerns and I'm quite sure that the environment for raising concerns, as she described her experience as a clinical pharmacist, has transformed because there are far more concerns to raise, not least in terms of workforce planning, in terms of delays, blockage in the particularly social care end of the spectrum which leads to an interruption in flow across the NHS. I think that those are two very different things and we brought this up so whilst it's okay for staff to raise concerns at the macro level and we see that and I get doctors in my surgery all the time raising concerns about the macro level. Whistleblowing is an intensely personal thing and we've seen from staff surveys across the workforce that they have no faith in current whistleblowing structures so that they're not first of all convinced that they'll be believed, that action will follow as a result of it and that there will be no recrimination as a result of that. I know that we don't have a lot of time, convener, but how do we stop that? How do we change that? Clearly, if there's bad practice in the NHS, we need to root it out. If there are individuals responsible at any tier for bad practice, then we need to address it but if there is no belief in the system, we can never do that. What we need to do is wider than staff governance. We need to make sure that the culture set by those up top is supportive and enabling and unless we've got that throughout the health service, then staff are not going to feel confident that they're going to be supported if they do raise a legitimate concern. I think that we have to be able to enable people to understand that there will be no blame. I think that we have to really bring forward the fact that you do have a duty of candor but also you have to be mindful of emotional intelligence and say, well how do I bring this forward? Many of the senior managers have a clinical or former clinical background or a professional background and they are aware of having that particular part of their identity that would have been seen as a slight as you have mentioned before. We have to reset how we talk to one another in the NHS. We don't accuse one another of doing things. We don't blame one another and we certainly don't blame people for bringing concerns or for raising whistleblowing because things usually only get to a whistleblowing level when people who have tried to raise concerns haven't been listened to. It is about resetting from the top down and that's from the political impact all the way through to everybody who has any interaction with the NHS. How do we work together and take national pride in working together and how do we put blame to one side and seek understanding and that's the way forward in our eyes. We put great store within the governance arrangements on a constructive approach to resolving concerns raised and working within teams and boards. As has been expressed over very many years and it is also seen in the last staff survey that there is a significant degree of lack of trust that concerns will be acted upon, you can't just wave a wand and make people trust in arrangements when they perceive that there is a vested interest in bad news stories being exposed or getting out and reflecting badly on the organisation. While I think that it is a responsibility on all of us to do all we can to support the existing constructive internal arrangements, ultimately there needs to be some sort of impartial appeal arrangements that can oversee that. I think that people would see the floor in the helpline, there are first people always back to the internal arrangements and there's no escape from the inward looking way of addressing things and there has to be a degree of proportionality about that so that people aren't always escalating and escalating and escalating. Is it right and proper that there should be an appeal? There needs to be a mechanism to judge that as to when it's safe to leave it where it is and when it's appropriate to have somebody impartial cast a second eye on this and say that that's not really best practice. Okay, Alex. Following on from that, you spoke about perhaps the need to have an impartial appeal arrangement and you're probably aware that there's a current petition in Parliament for the establishment of a new national whistleblower hotline. Do you think that an independent organisation would be beneficial if Matt was shaking his head? I think that our evidence in that matter is fairly well established and we don't support the view that you should give money to the private sector to develop a hotline, a call centre on these issues. There are problems, the governance exists, I think that the notion that we might have some kind of whistleblowing ombudsman is much more sensible and constructive, because that would then deal with the appeals issues. We've seen the ombudsman approach work in other sectors and I think that that would work better here than just handing money to a call centre somewhere. Was that abused by the panel? I'm not sure what evidence there is that the availability of a hotline would mean that people would have a motive to call it necessarily, I'm not sure. I wonder what circumstances that would happen. Can I ask another question, convener? I'm probably directed to Roshaw and Matt McLaughlin again. The Royal College of Nursing highlighted in your submission that integration authorities don't operate at the same partnership model as between the NHS, the Government and the unions and unison, you noted to that integration means, and I'm quoting now, that health services and workers find themselves managed on a daily and strategic basis by non-health professionals. As a result, there's a need to ensure that there is no dilution of the standards for affected NHS workers. I just wonder if you could expand on how staff governance has been affected by integration. I think that it's early days yet in that the structures are just beginning to get set up now and being developed. In the integration authorities, our members from the NHS are still employed by the NHS, so they will always have, whilst they will have a manager potentially that's from the council, where they have a very different culture of working with the trade unions. I think it would be fair to say that our members would always be able to go back through their professional structures, because they have professional accountability to the NHS. However, it's something that we are keeping a very close eye on, because we have concerns that the same partnership arrangements are not going to be in place there for our members. I think that there is just the significant potential for confusion when one person understands and knows and is steeped in one culture and one set of rules of engagement. They are managing a group of people who have a different culture, rules of engagement and stuff. Let me give you two very, very quick examples. In recent months, the IGIB leads in the NHS Greater Glasgow and Clyde area have decided that it would be a good idea to slash the school nursing budget by over 50 per cent, with no reference to the staff side, even at a high level, let alone at a local level. That runs contrary to the work that we're doing with the Scottish Government and a whole host of areas in terms of getting it right for every child. There's a major issue there in terms of the big-staff governance picture, and that's a rear-guard action that we're having our way through at the minute. However, even in a very local level, last week I met a group of workers who had been transferred from Parkhead hospital to Stoghill hospital, with a very clear set of shift patterns, very clear contractual entitlements, and a colleague from another organisation who sits above them in the hierarchy structure decided that they would just be issued a 90-day notice of change for their hours of work and their place of work and their working arrangements. That's just how we do things in the NHS. What that does is it generates hours of work for poor old me over a long weekend, when people are quite rightly upset. We're not getting it right at that level, and I think that because of their nature and their constructs, we have the potential for those cultures to clash a wee bit. We could do a bit of guidance for the Government and the Department on how that works. I agree with what Matt Ross is saying. What we find with managers in partnership is that some of our members are line-managed. They are experts managers in health. They have MSCs, they have PhDs, and they've worked into this particular role and into this particular profession because they have knowledge and credibility and the ability to do very, very difficult jobs. Then they're line-managed by somebody from local authority who doesn't understand that particular part of what they do. How can I save that money? Can I maybe do some reorganisational change? Can I look at spending your money in a different way? Or actually, if one of our managers, our members, goes to talk to their non-NHS manager and explains what the risk is, then it's not seen as being credible, it's not understood, and the correct steps that we've all spent a lot of time establishing the framework of governance to help us all have a core point of understanding that we all go to and say, that's our starting point, this is what we follow. Then we find that that's put to one side and we end up with a bit of a mess that a lot of people have to then spend a lot of time sorting out. That would, and presumably that's a two-way arrangement. I should imagine that if you were to have somebody from local authority, they would say the same thing. Yeah, absolutely. Donald, did you want to come in? Yeah, just very briefly. While we support the idea again behind integration, we do have a number of concerns about how it's applied, but in terms of employee involvement and engagement for medical staff, it's just not happening, barely happening at all for primary care staff for GPs and not happening at all for secondary care doctors. Now, it will be said that we speak to medical directors and people at that level, but they're not talking to operational doctors who deliver the services. In terms of planning services and doing what integration is meant to do, which is to link things up and join things up and have smooth systems across health and social care. They're not involving the doctors who are doing the delivery and so potentially they're setting themselves up to fail at an early stage. Ross. Just to come back on that, we lobbied in 2014 to ensure that there was a nurse board member on every integration authority. Recently, we've done a bit of work looking at some of the decisions that are being made with regard to community nursing. Unfortunately, some of those decisions are actually being made without the involvement of the nurse member on the board, which is extremely concerning for us. The Government vision, the 2020 vision, is all about transferring care into the community and ensuring that we've got the right numbers of nurses and other healthcare professionals out there. We've got massive vacancies in the community at the moment, particularly within district nursing, and as Matt said, in school nursing. That example that he used was one that we're aware of as well. There's also another example where senior managers have been stripped out, who are the clinical decision making. Again, I believe that that's in the Glasgow area as well, where the band ATA senior managers have just been stripped out. That is where the nurses on the front line, their healthcare support workers, their community staff nurses, their district nurses and health nurses would go for some professional support and look for advice, and that's been stripped out in Glasgow without a great deal of consultation. I would add that we did not get a legislative specification for an allied health profession on the IJBs. An allied health profession representative is representing 12 professions, and those professions have the kind of expertise and knowledge in specific things that are not going to be well understood, and even that has to be co-ordinated by the AHP, representing all of them. To cut that out from IJB decision making can lead to significant gaps in going forward, or just less good decision making, sometimes bad decision making, simply from that lack of understanding about the contribution of the service being provided. Thanks, convener. I just want to pick up on a point that you made yourself, Donald Harley, about the fact that doctors' voices are not being heard at the IJB board level. Does the BMA feed into the staff side representation that sits on the IJBs? Are you talking specifically from a trade union point of view, or are you talking about a professional point of view? Well, both, essentially. I'm just going to repeat to myself. What we would hope to see from it is that people who are involved in clinical decision making at a local level would be engaged by the IJBs. What I'm saying is that our members say that that isn't happening. Why is that not happening? If it's professionally, should it not be fed through the medical director? If it's from a trade union point of view, should that be not fed through to the staff side representatives sitting on the IJB? Well, we don't... Well, I think it's more complicated than that, to be honest. I don't understand the point that you're making then. I'm not sure that we have time today to go through the detail of our... Maybe you could follow up with detail and write to the committee and follow that up. Is that okay with you? Yes, thank you. We've had sessions with front-line staff, we've had sessions with middle managers in the NHS, and the themes that came across there was a system that was under massive pressure, where people are feeling the heat from their managers, and the managers above them and ultimately from, presumably, the Government in this place where targets are demanded and budgets are... We've already had a debate about budgets this morning about budgets that are under huge pressure, and that seems to be creating a culture within the system where people are afraid, intimidated, fail, unable to raise concerns, and frustrated at where they go when there are concerns. Is that a reflection on the system that you're working in at the moment, or is that an exaggeration? I think that NHS workers are no different from any other. I suppose what I'm asking is, are the pressures now more than they've ever been? I think that the pressures are being more keenly felt than they've ever been, and I think that some of the issues that you've heard about staff and levels, and some of the issues that we've heard about culture, and some of the issues that we've heard about people just having to do more for less feed into that, particularly in an agent workforce, particularly in an agent community where the demands on people become more. However, I also think that that can sometimes be a bit overstated as well. I do think that people globally need to take some responsibility for their own lives. Everybody should be a political activist in my view or a trade union activist in my view, and I think that people can certainly work with their trade union colleagues more positively and rather be passive trade union members. I'd encourage them if they're unhappy to be active trade union members, because that's how we get the message to their good selves and others. However, it's tough, it's hard, and people are feeling it. I would agree that it is tougher than it's ever been. The pressures with the budgets are immense. I think that it would be remiss not to mention the fact that healthcare professionals and nursing staff have had a loss of earnings, which has severely impacted on the numbers within the wards. We've got members coming to us who are saying that they're demoralised, they're lacking in motivation because they've had this 9 to 14 per cent pay cut in real terms. That is significant, and it's the same across the whole public sector. That is coupled with absolutely massive workloads, which leads to stress and fatigue. People are taking on extra hours, bank work and agency work in order to make ends meet. I think that all that means that you've got your head down that you're working, and it's hard to engage. I agree with Matt. It would be great if all our members were active members, but when you're exhausted and you're doing extra hours and you're having to rely on your unsocial hour payments to make ends meet, it's really tough out there. It's a really difficult situation at the moment. I think that the reality is for many front-line staff members that they just don't feel empowered to be able to change the fact that services are being, you know, that they're just told that this is the situation and we're going to have to suck it up, clear? I've got a couple of points. I would like to make a few points. I do agree with my colleagues, and I especially agree with what Matt has said about people needing to take more responsibility. Very often, if people raise concerns to me or if I go to represent one of our members, people will say, such and such a person made me try to feel like this. And we'll say, well, what makes you think that person wanted you to feel as bad as that? Can we actually have a sensible conversation about what happened? Do we have to go down a grievance or a complaint where, you know, you're bringing in witnesses and everybody are being upset? Because that adds to pressure, and there is a lot of pressure in the system at the moment. You, Ros, is referring to members who have to use unsocial hours payments to make up their pay. Our members don't have that, but they're absorbing more and more stress. When I engaged with our members, I had a conversation with them recently. I was saying, what do you want me to do for you? And they had said, just protect our own time, because we are exhausted. There's been so many stripping out of middle management roles that actually that brings the interface between more senior managers and more junior managers right as a rock in a hard place. And there's no give, there's no support. There's a lot of blame, though. And people don't feel they can say no. So we have members who are in their workplace of work, you know, before seven o'clock. They will leave after 10 o'clock. They will do three hours, four hours on a Saturday and on a Sunday to the detriment of their family lives, and that's to the detriment of their health and their mental health. And they are giving more and more, and yet they're getting more and more blame. We talk about front-line services, but a lot of our members, you can't actually see them, and they feel that they're not valued. So if you think about when you open a new hospital or a new clinic and you have a politician standing with people in uniform, and the person who manages the laundry is the person who manages the catering, the person who project managed a new build and kept it within budget, is nowhere to be seen because they're persona non grata, because they don't wear a uniform. So we do have a direct discrimination system as well, where people don't feel valued. And then if we can come back to rumours, there's loads of rumours, and they start from the top down, and I mean beyond the NHS, they start in various other think tanks or other places. So I got an email from one of our members on Friday, and I think that that will be relevant to one of the points that Alex was making when we came into the room at the very beginning. I got an email from one of our members saying, can you please tell me that the rumours are not true, that all the alcohol and drug partnerships are being binned? Because it's my job, it's my service that I deliver in integration with local authority, but that is an entire team at four o'clock on a Friday afternoon, thinking that they're not going to be having any, they won't have any job in about three or four months time, but also think about the member, sorry, the people who receive the support from that particular group and what their weekend is going to be like when they have no access to support of the rumours. So I think, yes, there's greater pressure, yes, there's less money, people are in a pressured system and they need to be able to think, why do I think, why do I think, somebody's trying to upset me or what are my perceptions, how can I reality check them? Who's part of the team because there's always people who are feeling left out of the team, such as a non-uniform wearing staff, and we need to cut down on gossip and rumours because they're profoundly unhealthy. Okay, Clare. Thank you, convener. Can I just briefly mention something that you put in your submission there, Clare Pullar, about, I'm looking at section 8 here on page 2, where you say, there's a widespread belief that NHS will crumble without the on-going contribution of its international staff. As one member told us, the anti-immigrant culture in the UK at the moment is hugely embarrassing and personally hurtful. I wonder if you could maybe, if the panel could comment on the pressures that perhaps the current situation in the UK and Brexit are causing to our NHS staff. Do you want me to say something? I should imagine that we all have something to say, but particularly, it is unpleasant, but there is a spike in people seeking support because they feel decisions are being made against them because they're not being seen as part of the team of the workforce that's going to be moving forward. It's naturally assumed that you're not going to be here. Actually, why are you still here? Because you should see the writing on the wall you're not wanted. Although we want you because we want you to work here, if you're British, that would be fine. That's some of the attitude that is permeating at the moment and some of the newer case work that's presenting for me. The other member wants to comment very briefly, but we've not got a lot of time left. Certainly in physiotherapy, we know that we have international students who have studied through the Scottish system and have qualified as physiotherapists and are working in the NHS, but they have two years following, I believe, a graduation that they can work in the NHS, and then they have to be earning over a certain threshold or they are told that they can no longer work, and that threshold at the moment, I think it's about 35,000, it means that a band six physiotherapist does not qualify and we've got a few situations at the moment where they've been looking at ways in which they can keep on to those staff members and they simply can't because the rules are saying that that's not possible, and this is at a time when we're having trouble filling vacancies in many areas, and it's often the rural areas and the small teams where this can have the biggest impact, so we have those concerns and we have voiced our concerns about the current arrangements for overseas, for non-EU, and in this case, I think that it was Canadian born, where that leaves us in the EU in future is a large question mark, but the impact if it were to be applied to the EU workers in the NHS would be significant. Donald? Yeah, just very briefly, and you may already know this. A not insignificant proportion of doctors are EU graduates. Scotland already struggles to recruit and retain enough doctors overall to meet the operational commitments that we set. In the worst case scenario, if we were to lose EU graduates, we'd see another significant hole in the medical cover we provide in Scotland. Now, obviously, we all hope that that isn't going to happen, but there's no certainty about that, and we already see and hear many anecdotes of people making arrangements to look for employment elsewhere in the EU rather than take a chance that something adverse may happen if there's an appropriate settlement. Rose? I would agree. We can't afford to lose EU nursing staff either. I think we've got a significant amount of vacancies at the moment at the end of December last year. We had 1,800 hospital vacancies and more than 600 community nursing vacancies, so that's just in the NHS. I appreciate that this is about the NHS, but the situation is even worse than the independent sector, who's got a heavy reliance on EU nationals. Matt? I think just briefly, chair. Constant constitutional confusion doesn't help anyone, and particularly people who need a bit of confidence that coming here to work means that they can come here and they can stay here and invest in their futures. I think it's beyond professional grades as well. There are many, many areas where the support staff are quite heavily made up of EU colleagues and colleagues from further afield. It would be really helpful if we could get beyond the constitutional spin and get into some delivery service or stuff like workforce planning will help. Thank you, convener. I just asked briefly about iMatters, which has replaced the staff survey, the annual staff survey, and just briefly to ask for the panel's comments on iMatters and how effective they think that is, what their experience has been of it. Very briefly. Dead briefly, if people act on what they're told, it'll be a raging success. If people do what they did with the existing staff survey, which was completely ignored, it'll just be the same again. I think it's got the potential to be really helpful because it drills down into team level, so provided, as Matt says, people get the opportunity in the space to work within their team to get an action plan in place, I think it could have a lot of potential influence. Darl? As Ross said, there's a real gain in terms of employee engagement at team departments and board level in terms of driving local solutions. I suppose the slight concern is it doesn't cover all the areas that the old staff survey did. As I understand it, the plan is that there will be flash surveys to cover those areas, and these are particularly things around the issues of how people see that grievances are dealt with or discrimination or raising concerns and things like that. I think it's important that we see that those flash surveys do take place. There is no gap in what we're asking the workforce, but overall a lot of work needs to be done to get more people to engage with this. I think my rough calculations show that only 25% of doctors, for example, completed the survey. That's relatively low, and that might reflect a degree of cynicism about how valuable the process is. If you see the same figures year after year and action is in generating significant improvements in areas of concern, that becomes a harder sell for people to take part in it, I guess. Our members think that iMatters is useful, but you must be allowed to ring fence time for it, otherwise it's just more paperwork for people and just actually you don't matter. It's the paperwork that matters, so why are we asking people to do this, why are we saying it matters, why is it important and yes, you must have time to be able to prioritise this. You are allowed to prioritise it. Okay, could I ask a very final point to Donald? It's a very specific point, engineer doctor. A few years ago, we saw the tragic death of Dr Lauren Connelly following an extended period of long shifts, consecutive long shifts, and there were supposed to be changes occurred after that in relation to rotas for junior doctors and the like. You've raised issues around the protection of junior doctors for whistleblowing, and it could be that people would want to raise issues such as those extended long periods that leave people extremely tired, some people who have to travel distances to their work, and we saw the tragic consequences in that case. Has that changed? Is the position better for junior doctors in terms of not just officially the rota that they work, but what they work? Not that they're rota hours, but the actual hours that they work, and if they don't have the same protection as they do in England, what type of negotiations are you in with the Scottish Government to advance that so that they have protection, particularly on issues where, in many ways, this is life and death issues? It's a complicated issue, and action has been taken by the Scottish Government to address the concerns raised by both us and Dr Connelly's father, for example. But I think because of the obviously tragic circumstances of that, there's been quite a degree of emotion around this and sensitivity, and the things that are done are not necessarily the things that will have the best impact on junior doctors' quality of life. So the number of days back-to-back is one area that's been tackled, but you have to look at the whole arrangement for how juniors are employed. So, for example, you could limit those number of days, but it might mean you only get one weekend away in a month because you end up covering alternate weekends in a complex shift pattern. So, actually, your quality of life and your family connections are deteriorated. So ultimately, when you're looking to improve the arrangements, there's got to be some flexing of all these things, and I think in the aftermath of the Connelly tragedy, there was a rush to do something rather than take a holistic approach to what is a very constrained solution. So we would encourage the Scottish Government to have more and further dialogue with the Scottish Junior Doctors' Committee. So I suppose what I'm asking is the system better, the same or worse? Better, but more to do. And in terms of the legal protection that's missing in your submission, are there negotiations going on in that, in terms of legal protection for whistleblower in Scotland? My understanding is that, as we're not receptive to that suggestion. Okay. I thank the panel very much for their evidence this morning and suspend briefly till we allow the panel to leave, thanks. Agenda item 3 is subordinate legislation with two negative instruments to consider. Both instruments were considered last week, and the committee agreed to defer consideration so that a letter could be issued to the Scottish Government seeking clarification on the reason and impact for the delay and upgrading for the assessment of resources and the summons for personal requirements. We have now received a response from the Scottish Government. The first instrument is the national assistance assessment of resources amendment Scotland regulations 2017. There has been no motion to annul, and the Delegated Powers and Law Reform Committee has not made any comment on the instrument. Can I invite any comments from members? I think that the one issue that I would say is that, in the letter, we're not clear as to what the impact of the delay in implementing the regulations will have on individuals and financial implications. It might be appropriate for us to ask that when the cabinet secretary comes before us to try to find that out. Any other comments that people have? I understand that the delay was because of on-going discussions with COSLA. I'd also be interested to know the date on which COSLA wrote to all the local authorities, but perhaps we can hear those issues with the cabinet secretary. I think that we most certainly should, yes. The second instrument is the national assistance summons 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. Do you have any comments from members? Nope. Okay, thank you. As agreed at a previous meeting, we'll now move into private session.