 I welcome everyone to the third meeting of the Public Audit Committee in 2024. The first item for consideration by members of the committee is whether or not to take agenda items 3 and 4 in private this morning. Are we all agreed? We are agreed, thank you very much. The substantive item on our agenda this morning is consideration of a section 22 report into the 2022-23 audit of NHS 4th valley. Can I welcome the four witnesses that we've got with us this morning? Stephen Boyle, the Auditor General, very welcome. This morning the Auditor General is joined by Pat Kenney, who is an associate partner audit and assurance at Deloitte, and Rebecca McConaughey, who is a senior manager at Deloitte. We're also joined by Lee Johnson, who's a senior manager at Audit Scotland. We've got a number of questions to put to you based on the report that was produced into the performance of NHS 4th valley, but before we get to those, Auditor General, can I invite you to give us a short opening statement? Thank you, convener. Good morning, committee. I'm bringing this report to highlight matters of public interest in NHS 4th valley that I prepared under section 22 of the Public Finance and Accountability Scotland Act 2000. The external auditor issued an unmodified opinion on NHS 4th valley's 2022-23 financial statements. They also highlight that the board met its financial targets in 2022-23, achieving a small surplus of £229,000. They go on to report that the board needs to make £40.6 million of savings in the 2023-24 financial year. Financial challenges, however, are not unique to NHS 4th valley and to varying degrees are being felt by NHS boards across Scotland. We'll be reporting to the committee in a few weeks on our NHS overview report, which we'll go into in more detail. My report today highlights concerns raised by a range of review bodies during 2022-23 in relation to the governance, leadership and culture of NHS 4th valley and the subsequent progress that the board is making to address those issues. On 23 November 2022, NHS 4th valley was escalated to stage 4 of the NHS Scotland performance escalation framework due to those concerns about governance, leadership and culture. Concerns have been raised firstly by healthcare improvement Scotland in relation to patient safety at 4th valley royal hospital. Then, the national planning and performance oversight group on a range of performance-related issues in respect of GP and primary care out of our services, unscheduled care, mental health services and progress on integration. In January 2023, NHS education for Scotland further reported concerns about clinical supervision arrangements. Stage 4 escalation brings direct formal oversight and co-ordinated engagement from the Scottish Government in the form of an assurance board. An escalation improvement plan was developed by NHS 4th valley and agreed by its board in December 2022 with the aim of strengthening its leadership, supported by effective governance and improving its culture. Its action plan is also in place to address the requirements arising from its unannounced safe delivery of care inspections. Regular monitoring and updates have been provided on the actions in both plans. The mid-year review by the Scottish Government reported to the board in May of last year that it confirmed that it had received assurance that the board's leadership remained committed to delivering the required change. It also highlighted the importance of achieving changes within the timeframe set out in the escalation improvement plan and keeping staff, local people and their elected representatives informed of progress. The chief executive announced her intention to retire from the board in September of last year and an interim chief executive is in place. The board will soon be recruiting for a permanent replacement. NHS 4th valley is responding positively to the escalation framework. It has put appropriate governance arrangements in place and has made progress in the months since agreeing the escalation improvement plan. It is critical that sustained progress is made, especially under the new leadership, with sufficient resources put in place to drive forward the changes that are required. As you mentioned, I am joined by colleagues from Deloitte and from Ordet, Scotland. I look forward to answering the committee's questions. Ordered General, thank you very much indeed. We are going to go straight away to those questions. For the first series of questions, I am going to invite the Deputy convener, Sharon Dowie, to put them. Page 4, paragraph 4 in the summary, this report highlights concerns raised by a range of review bodies in 2022-23 in relation to the governance, leadership and culture of NHS 4th valley and the progress that the board is making in addressing those issues. Can you give us more detail in the nature of the concerns? Good morning, Deputy convener. We can, and perhaps just highlight to the committee's attention Exhibit 1 from the section 22 report, which sets out a timeline of events tracking from April 2022 through to January 2023, arising from a range of independent external bodies that apply regulation and inspection processes on NHS. I will bring Lee in a minute just to say a bit more detail in some of the nature of the work of the inspection bodies, but perhaps just to kick off right at the start of that timeline, we draw attention to the work of Healthcare Improvement Scotland, who inspected quality of care in an unannounced visit as part of their arrangements. They will arrive at a health facility to form an assessment of how well patient care has been delivered, how safely it has been done, and engage with staff on their views and so forth. That inspection report raised concerns about the quality of care on a couple of examples, so they found that in respect of a patient's ability to consent to care, a lack of documentation and risk assessments in respect of an adult with incapacity. They then also highlighted concerns about the capacity and use of an extra bed within a ward facility within Fort Valley Royal Hospital. They went on to say, Deputy convener, about the frustrations that staff who are engaged with the inspectors conveyed about the extent to which they were being listened to and supported by management. As his regularly do, where they have found concerns, they will then follow that quickly, and they carried out a further inspection later that month in April 2022 and found that the concerns that they had raised a couple of weeks previously hadn't been addressed. That brought about a report and escalation arrangements. I can go on, Deputy convener, but I can convey my introductory remarks. Those were followed up by further matters identified by the Scottish Government's national planning performance oversight group about arrangements for unscheduled care, progress in meeting out-of-hours services before our wait time within A&E, mental health services, progress on integration and aspects of governance, leadership and culture. There are a range of issues that have been highlighted by inspection bodies, accepted by the board, associated action plans and the need for progress that drew my judgment for today's report that it was worthy of public comment and scrutiny through a section 22 report. I will pause for a moment and again happy to broaden out the discussion to colleagues who wish to support further. I guess that I do not have much to add to what the Auditor General has already said. I think that in terms of some of the service performance, obviously accident and emergency within NHS 4th valley and the meeting, the four-hour waiting time target performance has been poor for an extended period of time now alongside access to children and adolescent mental health services. Again, NHS 4th valley was one of the poorest performing NHS boards in Scotland. The only other thing that I would raise was some of the concerns raised by NHS Education Scotland around clinical supervision and a lack of consultant oversight of doctors in training. Doctors in training are expected to work beyond their competence, and NHS Education for Scotland will be monitoring that and looking for some improvement there. I know some of my colleagues will come back in with further questions in governance later on. Again, section 5, 2022-23, NHS 4th valley delivered a break-even position, achieving an underspend of £229,000 against its revenue resource limit. However, the board experienced significant financial challenges during the course of the year due to on-going capacity and staffing pressures, increases in medicine costs, on-going Covid-19 legacy expenditure and delays in delivering recurring savings plans. Can you tell us why there have been delays in delivering the recurring savings plans? I invite colleagues from Deloitte to update the committee on the extent of financial progress that was made to deliver a break-even position. I appreciate that the committee well-sighted on that, but perhaps worth stating for the record that NHS boards are required to break-even every single year in terms of their revenue and capital position. They have to deliver a programme of activity within the financial limits that are set by the Scottish Government. Paragoras 17, which you referred to, notes that there are a wide range of financial challenges facing NHS boards. I think that it is reasonably mentioned in opening remarks that these are not unique to NHS 4th valley. Every year, NHS boards start with a requirement to deliver savings programmes to support the efficient and effective use of public money while delivering their services and meeting their financial targets. It has been a common feature in packing, and Rebecca can say more about this, that in order to move to a more sustainable position, there is an expectation that boards will deliver recurring savings, so an element of transformation, so rather than either opportunistic or one-off style of savings, non-recurring, actually move to a way that the service is delivered in a way that is financially sustainable whilst achieving operational ambitions. What we have seen in 4th valley and elsewhere is that there is an on-going reliance on non-recurring savings, so you might get the target in that year in question, but you will be back to square one effectively for the following year. I will pause for a moment or two and invite Pat to set out for the committee some of the nature of the non-recurring savings and what steps the board is taking to look at some of that more transformational activity that will be recurring in nature, Pat. Thanks, Auditor General. Rebecca has actually got that detail, so I will pass that work on. The non-recurring savings in 2022-23 were approximately 60 per cent of the total savings programme. 4th valley did achieve the full savings programme that they required in 2022-23, but there is still an issue with the majority of savings coming from a non-recurring basis. They expect in 2023-24 to again have 60 per cent of savings on a non-recurring basis, while they are working towards more recurring savings on a transformational change basis in line with other boards in the sector. They are still reliant on a heavy amount of non-recurring savings at the moment. Is there a lack of pace? Every business needs transformation to basically keep it viable. You mentioned earlier on about lack of communication with staff as well, so is there a lack of pace with the board and with NHS to actually transform to make sure that they are going to have these recurring savings? We will certainly be able to speak further with the committee when we publish the NHS over your report to give you a rounded picture of the financial position of NHS Scotland and how savings are progressing in terms of recurring and non-recurring in the next few weeks. In respect of NHS 4th valley, where financial position is not the root cause of concern as it relates to the operation of the board, they were not escalated by the Scottish Government in respect of the financial position in a way that some health boards have previously been so, but nothing is in isolation. As Leigh's mentioned, NHS 4th valley's performance in respect of A&E, CAMHS and also on aspects of its psychological therapy arrangements are in the lower quartile of performance. Although its financial position is more healthy than other boards, its service performance is not. What needs to be looked at in the round to how it delivers improvements in its performance whilst managing its financial position? The examples in terms of non-recurring savings, you could say, are slippage on developments, slippage on recruitment. That is one of the factors that we have seen through our audit and through Pat and Rebecca's work, is that there has been slippage in the recruitment to key posts. Leigh mentioned a lack of clinical oversight. Those factors are all connected. As the board moves to progressing all the actions in its actions plan and addressing the findings of inspectors and regulators, it is reasonable to assume that that will have a bearing on its financial position. It will have to manage all those factors in the round as it transform its services and still meets the requirements of the Scottish Government to deliver its financial balance over the years to come. There is work to be done here, but it is fair to say that the nature of the escalation was not on its financial position for the time being. You have mentioned that NHS Fourth Valley will be facing the same challenges that all other NHS boards will be facing across the country. Are there any challenges that are unique to NHS Fourth Valley? If you could tell us a bit more about them, if there is any. There are certainly very clear challenges for NHS Fourth Valley. I will bring in colleagues from Deloitte and say a bit more about the financial position. I know that other members will want to come in about the nature of the challenges that brought the concerns of regulators were in respect of leadership, governance and culture. Those were the key factors that led to the Scottish Government through its escalation framework to bring in enhanced monitoring and supervision of NHS Fourth Valley. Those are the factors that they need to address satisfactorily. Together with the evidence base to show progress—perhaps I speak further to the committee on that—in addressing those factors, we will allow it to give assurance to the Scottish Government patience within NHS Fourth Valley and wider public that the board is making the necessary progress. Pat might want to say a bit more, but we set out paragraph 20. Those were some of the range of challenges that are facing NHS Fourth Valley in setting a balanced budget. It has still got progress to make in 23-24. We are coming towards the end of January now, with the end of the financial year, just over a couple of months away. There is a gap to fill in terms of delivering financial balance. We know that the Scottish Government is working with Fourth Valley to identify solutions to fill that gap, but I will pause when Pat might want to say a bit more about that. I think that the key challenge for this specific board—and going back to your point about what are the specific challenges that NHS Fourth Valley faces—was summarised in the recent governance report by the chair of NHS Greater Glasgow. In terms of performance, the two main challenges were that the integration model hadn't been clearly defined, the business model in terms of role responsibilities, and that the second major challenge was a lack of a high-performing executive management team. Those two core root causes that that review concluded were the main root causes of the governance, leadership and cultural issues that the board had. Obviously, as the Auditor General mentioned, there is a clear linkage between governance, leadership and the financial performance of the board. They go hand in hand, but I think that those were the two root causes—the integration model not being fully defined and issues with the executive management team. My last question is about sharing best practice. Have there been any good practice models that NHS Fourth Valley can learn from other boards that are facing similar challenges? I think that I will pass right to draw attention to the work of John Brown, who undertook a governance review in NHS Fourth Valley, referencing the blueprint for effective governance within the NHS. There are benchmarks, deputy convener, that NHS Fourth Valley is being tracked against. Again, there is much more to say about this, but it gives NHS Fourth Valley the opportunity to say, well, here is the expected standard and here are the steps that you will want to take to get to that. Somewhat helpfully, Mr Brown's report contains over 50 recommendations to NHS Fourth Valley on its governance arrangements. Progress undoubtedly needs to be made against those, but, as a framework, it provides NHS Fourth Valley with the steps that it needs to take so that it is able to assure itself, demonstrate clear effective scrutiny of the progress that the executive leadership team is making and, as Pat rightly says, the necessary progress with their partners to deliver a sustainable health and social care integration model. I appreciate that the committee will be cited on that, but those are very similar to the findings that Audit Scotland made back in 2018, when we produced a report on health and social care integration that again drew attention to the need for clarity, consistency and effective application of health and social care integration. NHS Fourth Valley has got the steps to go against those benchmarks. I think that Graham Simpson wants to come in with a question in this area. I'll leave it all at it, but I think that the question that occurred to me may be covered by others. Okay, that's fine. Can I take us back to current financial year performance? Colin Beattie, for example, is going to talk about the deficit issue, which is a major feature of the report. If we can just look at the current year, you mentioned in the report that there's been an overspend of £3.2 million in acute services, but an underspend of £1.3 million in corporate functions and an underspend of £2.245 million in ring-fenced and contingent budgets. Can you explain a little bit more the detail that lies behind those figures, please? I'll quickly pass to colleagues in Deloitte, convener, who will have the detail that underpins what looks like to be a range of over and underspends that lead to a small surplus. That is always a feature of the NHS board financial management at the end of the year, just to deliver what are ultimately multi-million-pound organisations. As a feature of public sector accounting, we have to deliver that financial balance. It's not uncommon to see that kind of level of in-year management, but what's this behind it? I'll pass to Rebecca, just to share that detail with the committee. The key things, particularly within acute services, relate to contingency bed and temporary staff and arrangements that the board has had to put in place. This has been recovered via underspend on corporate functions, which is generally due to delays in certain projects that they've undertaken on an organisation-wide basis. Ring fence and contingent's budget was underspend, but that's offset by the delegative functions and operational services. The main concern there is in relation to increased cost and volume of prescribing medicines under that budget, so those are the key things that drove under and overspends in those different categories. Can I ask about one of those in particular, which is the spend on agency and bank staff? I think that the Auditor General in his opening statement mentioned about elected representatives being briefed by the health board. I speak as one of the elected representatives who's had these briefings. One of the features of those which I've been trying to interrogate is the extent to which there has been a ballooning in spend by NHS 4th valley on bank and agency staff. I think we had a report back in May of 2023 where it said year on year there was an increase in spend in the region of 71%. I think by December of 2023, which was the last briefing I attended, the figure that was being cited was a 46% annual increase in spend on agency and bank. Can you give us your understanding of the reasons for such a big escalation in costs in that area just on a year on year basis? What lies behind that? Do you have any sense of how that compares with the reliance on agency and bank of other health boards of a similar size? It's such an important factor, convener, on one that I've guessed both through our overview reporting and engagement with the committee and previous committees, we have discussed about the need for sustainability of services. Ultimately, if there are vacancies, and vacancies arise, primarily in nursing that will be in respect of bank and agency services, and the health board has an obligation to respond to that, it usually covers its need for resource where it's not available on its roster through the use of bank and agency. Bank being preferable because it's much more commonly at early rates that are aligned to those of permanent staff. The use of agency, however, always comes at a premium. In terms of the specifics, so I perhaps need to turn to Colleys and Deloitte whether we have any detail that sits behind the movement from one year to the next. If we don't have that, convener, I think that it's something that we may need to come back and check our records and come back to the committee on writing whether we have that detail. On a Scotland-wide basis, it's something that we are considering carefully for our reporting of the overall financial position that will be set out in the NHS overview report in the next few weeks. I'll pause again just to send that Colleys can add. I think that something that we may need to come back to in writing, convener. Okay, that's fine. I mean, I don't know whether I'm asking you to break an embargo, but could you give us an early insight into how 70 per cent and 46 per cent compare to the kind of figures that you've been unearthing in your preparation of the overall NHS report? It's very similar across Scotland, and I think that you'll see that in our NHS in Scotland report when we bring it to the committee. I don't think that that's specific to NHS Fourth Valley. I think that's a similar picture across NHS in Scotland. Right, so it's not a function then, for example, of the level of vacancies, or it's not a function of a particular sickness absence rate in NHS Fourth Valley, for example? It's level of vacancies in sickness absence rates across NHS Scotland is reflected in the high costs of agency and bank staff across NHS in Scotland. Right. One of the inferences, I think, is that the poor leadership and some of the things that came out of the Healthcare Improvement Scotland report suggest that there might be higher than average levels of absenteeism and that this figure of banking and agency expenditure might be a function of that, but we've been told this morning that's not the case. I just want to try and clarify that. I'm not sure we'll be able to be a definitive conclusion that these aren't related, convener, that the report from the inspectors clearly draws attention to the fact that there were staff concerns about not being listened to, about the engagement with senior leadership in the organisation, and the implications of that for the wider culture of the organisation. There will be many factors, quite sure, of why a person is unable to go to their work. What's undeniable though, there were very specific concerns over and above the wider factors that affect NHS Scotland and that would lead to somebody not being at their work, but NHS Fourth Valley has to address in terms of its leadership and culture. The action plan that accompanies that will have to be delivered so that NHS Fourth Valley, the Scottish Government Insurance Board, can be satisfied that the cultural leadership issues are not exacerbating wider national challenges that cause people to be off their work. Healthcare Improvement Scotland's initial report identified an excessive reliance on banking agency staff as one of the concerns. The description that they used in that report was that they had serious concerns, and that was one of the serious concerns that they had. I'm going to turn now to Colin Beattie, who's got some more questions to put and maybe an initial observation to make to start us off with. Colin Beattie. Thank you, convener. Or at a general, before I come to questions, the one thing about this report from my perspective is that it has a different feel to it than some of the reports that you've produced, and some of the detail that's normally in reports isn't there. We talk about issues around governance, leadership and culture, and there are some explanation of that, but it doesn't seem to go into the depth that you normally do. I'm still sitting here thinking, okay, well, leadership, what's happened with leadership? Where is that demonstrably failing? You can imply a little bit from some of the things you see, but there's nothing specific. I want to be grateful for your observations and your feedback. I think what I would note is that this report is slightly different from other section 22 reports that we produce. I recognise that, whereby many of our section 22 reports, as you know, draw on the work of the external auditor through the annual audit process. Where the most significant departure from this report is drawing not just on the work of the external auditor, but also from a wider range of reporting from other external organisations, his, Nez and others, who have produced their own reports. We're set out more detail on the accompaniment of the findings that have led them to arrive at those judgments. We can think about that for similar style reporting, about the extent of detail that we go into in our own section 22 report that perhaps needs to be accompanied with the detail of others. It's something that we can reflect on, Mr Beattie, about how accessible all of the associated judgments are alongside, in many respects, a summation through the section 22 report. Thank you for that. Obviously, from our point of view, from the point of the committee, I'm sure that every member simply wants to get a full understanding of what's behind the comments that are being made, in detail, so that we can make our own judgments. Turning to financial sustainability. Paragraph 19 of the report says that, despite the savings of £25 million in 2324, there's a £15.6 million residual deficit. Can you tell us more about that deficit and what the short and long-term impacts will be if it's not addressed properly? Certainly. I'll pass to Pat, first of all, who may share with the committee what we understand to be the most up-to-date position, recognising that we are now closer to the end of the financial year than we were when we finalised the drafting of this report. I think that it's significant, Mr Beattie. The board started the year with the need to make nearly £41 million of savings to ensure financial balance. Through the work that Forfally and other boards do each year, they identified £25 million of savings, with only 10 of those expected to be recurring, and therefore further work to find £15.6 million of savings. We understand that progress has been made, but there's still a way to go within the region of £10 million to be found within the final two and a half months of the financial year. That's significant. You would have to rightly have questions about whether that can effectively be bridged by NHS Forfally on its own, without a significant impact on its ability to deliver services as planned. We know that NHS Forfally is engaging with the Scottish Government, and Pat can say a bit more about what steps are being taken to fill that gap, and then more widely what happens if they don't. The committee will be familiar with some of the support mechanisms that the Scottish Government is able to offer. How has it been escalated? They're in that process. I'll hand to Pat to update you, Mr Beattie, on where they are, and then potentially what comes next. Yes. The latest position with about two and a half months to go, Mr Beattie, as the auditor general says, is that they're looking at around a £10 million deficit. I spoke to the finance director recently, and he's hoping that that might come down a bit. There are in discussions with the Scottish Government on how that deficit is financed. If you like, there could be implications on the revenue programme or on the capital programme, possibly on timing of capital receipts. There are various options at play at the moment, but I think that the big issue here is that there is obviously an underlying deficit in the board's finances, which, if not addressed, will carry on into later years. I think that the big challenge for the board, and again, they're not unique in this sense, is that they need the transformational resource and capacity to, if you like, address that structural deficit through innovation, through change, through new technology, new ways of working, et cetera. I think that there are challenges at 4 Fally in that respect. I understand that the internal audit that I reviewed recently on the transformation resources available to the board and raised some serious challenges in that respect. I think that the key consideration was that the internal auditors asked the board at NHS 4 Fally to satisfy themselves if they had sufficient resources to adequately address the transformational change required. So, I think there are definitely question marks for me in that respect. That, I think, is the key challenge going forward, is the transformational capacity and resource there in place which will address that underlying structural deficit? In the report, you quite clearly talk about the leading times needed to bring in these savings, and also about the lack of staffing capacity, which is what you touched on just now. How did we get to two and a half months before the end of the financial year, and we're still £10 million out? I'll maybe start with a couple of points to raise. Whilst I mentioned earlier, Mr Butie, that NHS 4 Fally hasn't been escalated for its financial position in the way that some boards have, the scale of financial challenge facing the NHS across the piece in Scotland is significant. As we look to set out in paragraph 20 to the report, there are multiple challenges facing NHS 4 Fally, and for many of those, you could read across to the NHS in Scotland across the piece that they need to address. Whether it's recruitment challenges, banking agency factors that the conveners mentioned, the need for recurring savings, health and social care integration model to be sorted, inflationary pressures that are affecting all individuals and businesses, and then some local factors. NHS 4 Fally accommodates through health services a significantly higher percentage of Scotland's prison population, for example. 23 per cent of Scotland's prison population resides in the NHS 4 Fally service area. Those are all factors that most years NHS 4 Fally has been able to keep a lid on. It's not an escalation category for finance, but it's becoming more challenging to deliver financial balance. Therefore, the second point to make about it is that, as part rightly leads us into transformation, it has to be at the heart of service delivery to secure effective services and financial balance. Colleagues might want to elaborate on that, but it rung a bell for me when reading that the committee will recall some of the evidence that was taken on NHS Highland a couple of years ago. The central function of a programme management office is that it is brought around as part of its attempts to transform its services and deliver financial balance. We are seeing similar patterns in NHS 4 Fally, so learning from other places about work to do, Mr Beattie, and, as paragraph 20 sets out, there are many challenges to overcome. I think that there is some doubt, as Pat's mentioned, as to whether it will be able to turn all this round within the short space of the remaining months of this financial year. The issues that 4 Fally faces are not dissimilar to other NHS boards in terms of the difficulty in identifying recurring cost savings, but they are very high at 69 per cent in terms of the 29.3 million in 2022-23. A huge chunk of it is 69 per cent, and that means that they have got to identify that again the following year. So what steps are they taking to address that problem, because they are only rolling up the problem into the future? They are not resolving it. That is the classic conundrum that health boards need to tackle, so that you get to the finish line of financial balance one year with non-recurring savings, but the clock resets for the start of the following year if you do not transform and deliver recurring savings. That becomes harder and harder, especially when setting out, again in paragraph 20, if I may, the scale of the range of issues that health boards are facing. If you cannot do that on a sustained basis, even for health boards such as NHS 4 Fally, but have not been experiencing financial pressures as significantly as some others, you are now in the frame of having a significant risk that cannot be definitive on it yet, because there are a number of months to go, but a significant risk of not being able to deliver financial balance in the year in question. Transformation, effective partnership, working, deploying technologies, looking at the base funding arrangements all have to be part of the decision making for NHS 4 Fally in conjunction with its assurance board and wider discussions with the Scottish Government. There is a 3% recurring savings target required by all NHS boards. Are they addressing this as a separate specific item, or is it just part of the whole in terms of meeting that deficit? I think that it is going to cover this one, Mr Beattie, but in terms of NHS 4 Fally's wider approach to savings and how it is integrated, that is, Rebecca. Thank you. I look at the 3% Scottish Government target, but essentially the savings requirement that it has will be over and above that amount. It is forecast in approximately in 24, 25 that they will need to reach an 8% savings threshold in terms of the target they will need to achieve financial balance in that year. I suppose I have to ask the question, is that achievable? I guess for us to say, we cannot say at the moment the board is going through a budgeting process and that is not finalised, so at the moment we don't know, but I would suspect that, as we have reported in session 22, there is a significant risk to financial balance in the short term and onwards in terms of sustainability. Sounds about gloomy. I think that, I mean, Rebecca is right that it is probably not going to be possible for us as the auditors to say whether they will be able to get there or not. I think that what we can say is that there are significant risks around their ability to do this, and at the risk of repeating myself that you can get over the line in one year with non-recurring, but it is becoming harder and harder to sustain that position if you are relying upon non-recurring. I would not underestimate that, because I think that to recognise that there is not a lot of flexibility in overall NHS spending, so much of it is demand-led, so whether it is the cost of prescribing, some of which will be within the control of the board, other elements not, staffing cost, pressures, demand requirements overall, the board has to take a longer term view about how it can move over time to a sustainable model. Health and social care integration plays such a fundamental part in that, Mr Beattie, the committee has heard for many years about shifting the balance of care, a preventative approach to the delivery of health and social care services. NHS Port Valley is not as far forward as Pat has mentioned, but John Brown's report refers to that as well. This is at the heart of moving to healthy populations, sustainable health and social care models, and we will assist over time in the delivery of savings to support financial balance too. Just something that comes up fairly regular, is Fourth Valley using vacancies to help address the deficit in managing its vacancies? I think that all health boards do that, so that all will be attributing slippage in recruitment or vacancy management arrangements to support the delivery of financial balance. Deloitte may want to say a bit more, Rebecca, if you have any further detail on the quantification of that. Although you might win on one hand of vacancies, you will lose on the other, especially if you have to backfill with higher-cost bank and agency services, or even worse, perhaps, if you can't backfill the vacancy, you might have a financial saving, but to the serious detriment of your service performance and impact of one patient care on the other. Do you have a percentage just to those vacancies? I don't have that to hand. If it's something that we can check our records, it may be... Just be interested to see if it's in the same ballpark as other organisations. I think that it's something that we need to check, Mr Beattie, or indeed that the board themselves would have more detail on if they have a planning assumption, what you're suggesting around vacancy management and how that informs their budget setting. Just one last thing. The report refers to the recurring funding gap associated with the implementation of the primary care improvement plan, if that's not addressed by the Scottish Government. What's the funding gap in monetary terms, and what does the Government need to do to address this gap? In terms of... This is a factor for the health board and the board to discuss. I'm not sure we have, unfortunately, the detail of the scale of that gap in our records, and I apologize if we can come back to... Will you be able to provide that? Of course, we can come back to the committee as part of our... as we follow through on it. As you'll see, it's one of a number of aspects of the financial challenges that they need to address, both to secure financial balance in the current year and potentially for next year too. Thank you very much. Perhaps if I could go back to Rebecca McConnack, just check with you. Did you say that the NHS 4th Valley would be required to make savings of the order of 28 per cent threshold? Just to clarify, 8 per cent. 8 per cent? Right, okay, thank you. Right, that's a bit of a relief for my constituents in the 4th Valley health board area. I mean, but nonetheless, what you are describing is a situation where we're talking about recovery from Covid and the backlog that there is in treatments there. We're talking about an already existing ageing population. We're talking about a climate of probably then rising demand in... and yet the health boards, like 4th Valley, are expected to make produce savings of 3 per cent across the board. In the case of 4th Valley, as you've described, it's going to be at least twice that amount that they've got to come up with. I mean, could you maybe explain how that works? I mean, it strikes me that that may be unsustainable financially and in terms of outcomes. That was exactly the comment I was going to make. And reiterates judgments that I've made on the NHS in Scotland in the round in previous years about real doubts about its sustainability in terms of the current way of delivering services. So NHS 4th Valley, as you've heard, has to make recurring savings in the current year more next year, whilst it needs to improve aspects of its performance. So any wait times out of our services, mental health services too. I mean, at risk of being really glib, you know, these are incredibly difficult challenges to pull off, you know, and squaring off financial balance on one hand and service improvement in the other. And you can see, therefore, it does require transformation within NHS 4th Valley and the wider model itself so that we can get to a place where there's a healthy or sustainable population and with the finances to support it. Okay, thank you. I'm now going to invite Willie Coffey to put some questions to you, Willie. Thanks very much, convener. I just wanted to ask before I get to more on questions. Stephen, there was mentioned in your report about the high prison population in 4th Valley having an impact on health portability to deliver financial savings. Why would that be such a significant impact on the prison population? Interestingly, by coincidence, Mr Coffey, we will be briefing the committee next week on a further section 22 report on the Scottish Prison Service 2022-23 audit, which will go into some of us in a bit more detail. At a higher level, the demands of the prison population and the ageing prison population will bring a call on health service within the NHS. As I mentioned, the scale is a bit significant. So, 23 per cent of Scotland's prison population is within the NHS 4th Valley area, with glinocl, sterling and polement always hiding within 4th Valley's boundaries. That will vary, but, as we've seen, and again, I'm very keen to talk to the committee in more detail with the report, as the nature of the prison population in Scotland is changing, it is ageing, and that is also bringing fuller demands upon not just the prison service itself, but NHS providers too. The irresponsibility to deliver healthcare services for the prison population falls within that health port, rather than being flattened out across Scotland, does it? Yes, that's correct. That's one of the factors that NHS 4th Valley is identifying as exacerbating the scale of the financial and service challenges that it has. On my questions about performance escalation measures and so on, you've mentioned several reports and a variety of recommendations from different people. Initially, HIS produced a set of nine requirements in Able 22 for the 4th Valley Royal Hospital. It then said that, in that same year, it was followed up again by a further 11 requirements. First, it gives a little flavour of what are the requirements around and why are they not being actioned now? I'm going to pass to Lee. It's been quite helpful for the committee. The various reports, the associated action plans, how they've been tracked and monitored, and the progress that's being made. I think that what we've seen in exhibit 1, hopefully, helps out some of the timeline of the reporting. Again, even since that cut-off date, there have been more reports. We mentioned a couple of John Brown's report on governance arrangements and the number of recommendations that that's produced. Maybe Lee can set out what's been reported and then the progress that the board itself, together with the Scottish Government, are tracking progress and how they are being assured. Following his inspections, an action plan, which was different to the escalation improvement plan, was a healthcare improvement Scotland action plan, which addressed the different recommendations that healthcare improvement Scotland had made. As the Auditor General has already outlined, there was a range of different areas that he was concerned about in terms of contingency beds, particularly in non-standard areas, about the dignity for patients, about emergency evacuation procedures in very crowded areas within the hospital, but also a range of different cultural issues in terms of staff not feeling like there was an appropriate level of staffing, that there was the right mix of skills, or that their concerns were being listened to. Obviously, healthcare improvement Scotland will have been monitoring progress with those different actions, but we know, for example, that there have been new procedures that have been put in place to monitor staffing levels within the wards at the hospital. More support staff and leadership have been put in place on a 24-7 basis to support staff as well. There are new mechanisms in place to encourage staff and patients to raise concerns to speak up, if they have concerns about their experience or the safety of care. In terms of the 11 requirements and the nine requirements, there are 20 requirements that have been placed on a unit position to say if they are making good progress with these now, have they completed any? Are they still in the middle of this? Where are we in terms of those specific 20 requirements that has given them? I need to come back with the specific detail. We know that they have made progress in some of those areas, and obviously healthcare improvement Scotland will be monitoring the progress with that, but I would need to come back to you with the specifics of that. Just when I was listening to the conversation convener and auditor general, we have got his reports, we have got the oversight group, we have got Professor Ritchie's review in October 2022, we have 12 recommendations there, John Brown's report, 50 recommendations, the escalation improvement plan, the measurement framework. Are we a wash? Is the health board a wash? On top of the report here, do you feel—is that a factor here? There's a lot to get through, Mr Coffey. I think it's probably fair to say that these are not competing findings, so they are—some of them are quite specific about arrangements within Four Valley Royal Hospital from his, others from the oversight group about, again, specific service delivery arrangements, whether it's out of ours or unscheduled care, and then the wider Brown report about governance arrangements. There are a lot of recommendations. What Four Valley has sought to do and, again, still making progress of work to do on is having the right measurement framework in place that sets out very clearly what the recommendation is, what steps have been taken and that there's governance and scrutiny of that through the Scottish Government assurance board that says, have they done what they needed to do? I think that that bit is still work in progress, that they have—can satisfy the assurance board of the Scottish Government and their own committees on the health board that they are taking all the necessary steps. I accept the principle of the point that you're making, though. Actually, there's a risk that you can't see the wood for the trees because there are so many recommendations and reports. But it's maybe just an illustration here that because there is so much interest in getting this health board to a place that is sustainable and delivering safe and effective patient care, that there is going to be interest and work to get through. The board and the Government through this escalation process have just got to be satisfied that the steps have been taken and they can effectively score those recommendations off and move on to a sustainable platform. For many years, General Yu and your predecessors have talked about service redesign and transformation and here we are talking about it again. Do you get the sense that the recommendations that are made in that word are about service redesign and transformation? Is it understood by the health boards that they are able to deliver that service redesign and transformation that we are talking about here in a position where they are even confident that they are making progress on that journey? There's a range of recommendations, as we've talked about. Some of them will be very detailed and specific to a particular aspect of healthcare within a hospital setting and others are much more wide-ranging, whether it's governance or culture. Culture, for example, takes a lot of effort to sustain and even more effort to transform, to spend a moment on that, for example. Referencing NHS Highland, the committee will be familiar in recent years of some of the cultural challenges that that health board faced went on for a number of years and has taken time to move on to an even keel with a reconciliation process. There are references in the report that NHS Forth Valley is thinking along those terms. That's an aspect of resetting rather than redesign. The redesign element of it, Mr Brown's report, has rightly picked up on in terms of health and social care integration. This is designed to be the redesign transformation component of how healthcare will be delivered in Scotland. That NHS Forth Valley is further behind its peers. There's a clear signal that there's work to do to transform that aspect of service. I think that you've got a spectrum of issues here, Mr Coffey, that some will be about just getting back to where they needed to be. Others, in terms of out-of-hours, is perhaps in the middle. Up until the report, out-of-hours service was run by the acute service provision within NHS Forth Valley. Again, quite at odds with what you see elsewhere, that typically an out-of-hours service would be run by GP's primary care practitioners, NHS Forth Valley has now moved to that model. Some might say that's just a step, others say that's transformative. Then you've got the wider pieces at the end of the scale of transforming culture and health and social care integration. It's a pretty wide range, but most importantly is that the board and the assurance through the Scottish Government have to have that clear oversight that progress has been made on all these fronts. I presume that it's still at stage 4 that hasn't changed, has it? No, you're right. The board is still escalated to stage 4 of the escalation framework. I think that there's a big matter really for Government to be satisfied of when that will move to be de-escalated. You also said that to an independent review of the board and the Assurance Committee arrangements, that the report was due to be considered by the health board in last November. Do you read any review site of that report? What are its recommendations and conclusions? That's the report by the chair of the NHS Greater Glasgow and Clyde on the Governance Review and EMAID 51 recommendations, which we referred to earlier, 46 of which are still outstanding. They have been incorporated into the escalation improvement plan. There's a clear measurement framework in place in terms of KPIs, outcomes to deliver, evidence, et cetera. We will look at that as part of this year's audit in terms of how they're delivering against that in terms of progress made. Was it a bit late in the day coming to arrive at the governance issues? It's usually the first quarter call for the committee and the members over the years. That seems to be the starting point for a lot of these issues. How come we got so late to the deal? The NHS4Falley board commissioned the report once they were put in the escalation framework. They wanted an external view, so they have to be commended for that in terms of they reached out and commissioned a review, agreed the terms of reference. It was a wee bit late in terms of delivering the final report. We were expecting it a bit earlier than that, but they have taken it on and, as I say, their recommendations have been captured in the improvement plan overall. I think that Pat is right that we might have reasonably expected this to have been commissioned at an earlier stage, given how central governance, together with leadership and culture, were to the basis of the original findings. That's perhaps supported by the volume of recommendations that Mr Brown has made. Over 50 recommendations on the need to improve governance within NHS4Falley. There are undoubtedly some mitigations to this. As we reported in previous NHS overview reports, NHS Scotland deployed during the pandemic a governance-like model to focus on patient care, safe protection of population and staff during the pandemic. However, it is probably also true to say that whether that model was switched back to the more traditional governance settings early enough as we came out of the pandemic is a question for NHS4Falley. The timing of the review suggests that the pace and centrality of effective governance was not quite what it needed to be, given the recommendations that we have made. We need to see progress against those now. I will ask the convener about that. I think that he said that 4-7 out of 51 have the action yet. Is it reasonable to ask when we could expect to get through that? That's a huge number of recommendations on governance issues. What could we look at six months a year or whatever we are talking about? Certainly when we conduct this year's audit as part of our wider scope work, we will be looking at the progress. I will be asking myself the question, are they making reasonable progress as the pace is good enough, sufficient enough? It will take them a bit of time to get through the scale of the recommendations. Some of the recommendations are very wide-ranging. Cultural recommendations, leadership recommendations, one of the major recommendations is a complete review of the integration schemes, which will take a bit of time. However, as I said, we will assess progress during this year's audit and report back. There has also been some change on the board of NHS Forth Valley that has looked at Mr Brown's recommendations and given more confidence and assurance to him that the effect of governance is in place to address the recommendations and support the wider stabilisation and change that is required in the health board. Picking up on some of those themes that we are developing there, Graham Simpson has got some questions around the Assurance Board leadership and culture. I am just looking at the timeline that you produced in Exhibit 1. That starts in April 2022 with this visit by Healthcare Improvement Scotland. Do you think that that was the first that anyone knew that there were problems in this health board? Or would there have been issues raised before that that might have spurred HIS to pay their visit? In terms of the motivations for HIS to carry out their unannounced visit to Forth Valley Royal Hospital, I do not have a clear view on that, Mr Simpson. It is fair to recognise that healthcare regulators and inspectors exist for a reason. To provide assurance to population elected representatives, to the boards of health boards of effective patient care, as to whether they had a model that was rag-rated, risk-rated to lead them to Forth Valley Royal Hospital, I am not cited on the individual motivations. I think that we can probably take some assurance, but these organisations, together with the oversight of the Scottish Government, employ the engagement that regulators and inspectors routinely have with one another, that the model is working, and if they need to escalate, they did. Healthcare Improvement Scotland carried out their work and were not satisfied and they escalated. That feels like a process that was working as intended. Obviously, they have gone in and found quite serious problems there. It struck me that, if there were these serious problems, why did it take a spot check to discover them? It is a really interesting question, because there are meant to be a range of avenues for members of staff and patients to raise concerns. As we summarise in our own report some of his findings, particularly focusing on staff concerns about not being listened to, as to whether or not some of the well-established arrangements were working as intended. I would not want to infer aspects that do not exist. Perhaps separate from this example, but we know that there are well-established whistleblowing arrangements within the NHS, whistleblowing champions and so on, to give members of staff the opportunity to highlight concerns if they need to. As Heser clearly set out, something was not quite right that staff felt that they were not being listened to by the leadership. That is also, to some extent, reassuring, though. Rather than focusing solely on individual arrangements to get right within the hospital itself, Heser has drawn a much wider conclusion that says that there are aspects to be addressed in terms of governance, leadership and culture within the board that do not just focus on those arrangements around the number of patients within a ward and so on. Again, there are various strands to this. After that April visit, there is a period of months until we get to November of that year when it is escalated to stage 4. Obviously, it has gone to that stage because there has been a lack of progress. Do we know why there was a lack of progress? You are right. To what the Scottish Government effectively has said, and indeed the letter from the director general to the convener and myself setting out that the Scottish Government were not satisfied that the leadership within the board was taking sufficient steps to address the concerns raised by Heser, the oversight group, and subsequently, very short time later, by NHS education for Scotland. As we set out in the report and discussed to some extent this morning, leadership, governance and cultural issues were of such significance. The Scottish Government was not satisfied that the board was making progress against the findings and recommendations of these regulatory bodies. Ultimately, are we to pin the blame for these issues on that leadership problem? The chief exec who is now gone and the board, were they not doing their jobs properly? It is difficult to reach a very specific source, Mr Simpson, on responsibility. Health boards structurally do not have an executive leadership team, they avoid the boards of governance. They have very close relationships with the Scottish Government and their regulatory bodies. However, we have an accountable officer system within the Scottish public sector, and that involves personal responsibility. Clearly, as we have set out in the report, there has been a change of executive leadership within the board, but it is due to recruit permanently for a new post holder within the next month or so, we understand. However, it is not just about effective executive leadership deficiencies that there were in John Brown's report, but also deficiencies or governance not operating as effectively as it needed to. The governance light model that we talked about through Covid is not moving back to the pace that it needed to, especially with the concerns that are evident in the report. I pace an elements of timing, culture and pace to have the necessary arrangements in place. That whole leadership comes from the chief exec and it comes from the board. To have got itself into the position where we have to escalate it to stage 4 because there have been a whole series of problems, which I will come on to, that surely will have to say that the chief exec was not doing their job and the board was not doing their job properly. Surely, it is fair to say that. The facts are laid out in the various inspector's reports that there is a consistency of finding around governance and leadership suggests that there are issues to be addressed. I think that it is pretty plain to see, Mr Simpson, that there were concerns around the factors that you are referring to. Yes, it is plain to see. I want to just ask you about something which is very concerning. It is on page 10 of the report. It is actually contained in that timeline. HIS inspectors identified instances of unsafe practice around medicine's governance that could result in serious harm to patients. Do you have any more details of what that means? What lies behind that? The leaders are set out in aspects in our report and in more detail in his report. Lee might want to say a bit more about the circumstances. I think that we would just support your judgment on it, Mr Simpson. However, if we are in the realms of potential patient harm through unsafe use of medicines and the factors around staff levels, skill mix, experience of NHS workers applying medicines and concerns not being listened to, it is also set out in the report, and not being supported or listened to effectively by senior management paint a picture of one of real risk to patient safety. That has identified that as evidence that the different part of the system is working as intended. We have inspectors and regulators for a reason. They did their job, raised concerns and escalated it when they were not satisfied that appropriate steps were being taken. I do not have any more detail to give about the governance of the medicines that would be in the head's report, but I think that what follows that would give you an indication is just about the more senior oversight of staff. I am sure that it is feeding into that, but for the very specific detail, you would need to look at the Health Care Improvement Scotland full report. Presum that the unsafe practices have now ended, whatever they were? I hope that you will appreciate, Mr Simpson, that I am not able to give you that assurance. It is something that the NHS, which is validated by its inspectors, would be able to give assurance to the committee on. You say that the board has responded positively to the escalation framework, so what do you mean by positively? I think that that is fair. What we have seen is that there has been an acceptance by the board of the various factors that caused them to be escalated and the resultant steps that they have taken. We are now on the third version of the escalation improvement plan, and underpinned by themes that we have set out in paragraph 26 of the report of the NHS for Fally's ambitions to put patients first, support their staff and work in partnership, and then referencing back to the discussion with Mr Coffey, that the assurance arrangements, the governance around that is in the right place in overall terms. What the Scottish Government, through the assurance board and the health board themselves, will want to see very clearly, though, is that for the wide range of recommendations, it is that they have the evidence to support that they have met the recommendation that could progress, which ultimately, for this health board, will lead them to be de-escalated by the Scottish Government. I think that our judgment is one of acceptance, progress and overall arrangements, but the next step really matters, Mr Simpson, that they have the evidence across the piece to show that they are making progress, so a way to go yet. How do we measure whether they actually have made progress? We are not just going to take their word for it, are we? Some of it is going to be harder than other bits as well. The example that you have asked about is safe prescribing. His will be able to satisfy themselves through their procedures that they have addressed in that style of recommendation. Other bits are going to be harder, although culture, for example, is not going to be resolved overnight, and that will take a programme of activity, reconciliation perhaps, between members of staff and leaders within NHS 4th Valley. Governance is also going to take investment too, effective working across the executive leadership team. As Pat has mentioned, he and his colleagues will track progress through the annual audit. As I conclude in my own report today, I will take a view during the course of 2024, the extent to which further public reporting will take place on NHS 4th Valley. However, there are a range of aspects to this evidence matters. This is the principle of the measurement framework that the board, the assurance board of the Scottish Government, are clear when effectively saying that that one is done and we have got more to work to do on this one. You mentioned in your report that NHS 4th Valley is about to embark on what is called a culture change and compassionate leadership programme, which is apparently used elsewhere, so I have no idea what that means. Can you explain what that is? Probably not to any great degree, Mr Simpson, but if we draw on NHS Highland, for example, it is not a perfect analogy, but you can see that there are models that exist and have been used elsewhere in NHS, not just in Scotland, but across the UK to reset relationships, fundamentally, between staff, leaders and governance within an organisation. We should not be underestimating the scale of challenge that is going to be required here. Culture, as there are many management clichés that can be set out, can dominate an organisation. Once a change of culture has been put in place, again, it is going to require considerable investment to reset. That supports NHS 4th Valley's missions, so as I mentioned in a moment or two, again, it is important to put out that the priorities of this health board through the escalation improvement plan are about putting patients first, supporting their staff and working in partnership. Culture will be at the heart of that programme. The detail of how the intent to address that will be multi-fasted, but NHS 4th Valley, I am sure, would be able to provide the committee with the range of steps that it is taking. I guess we will have to ask them, because I do not know what is wrong with the culture and what needs to change. In a couple of places from various inspector's report, staff felt that they were not being listened to. That is a huge significant aspect of culture. Staff need to be able, in any organisation, that they are respected, that their voices are heard and that management is listened to them. It is clear that some members of NHS 4th Valley felt that the culture was not effective for that to happen. I have just got one final question that has been covered before. We talk about the financial sustainability. You say in your report that there is a risk that the board is not financially sustainable in the short term. Rebecca, you have talked about that as well. I just want to understand what happens if that continues. If the board remains financially unsustainable, what actually happens? Do we escalate it even further? I am going to ask Lee just to set out for the committee what happens. Arrangements have changed a couple of times over a number of years. The committee recalls that, previously, you had brokerage arrangements. If you did not meet your financial target, in fact, you got a loan from the Scottish Government that was called brokerage. Those arrangements changed. Covid or just before those amounts were of previous debt was written off and there was a reset. Then we moved into a slightly longer-term planning horizon, medium-term financial plans. Where we are now, again, I think, I am going to bring Lee in just to set out. Bear in mind, this is a real-life example here. As Pat set out, there is about a £10 million gap or so. That may or may not be bridged, but if it does not, the Scottish Government offers support and Lee can take us through that. I guess that during the pandemic, boards were fully funded. Now that we have moved out of the pandemic, arrangements have gone back to what was brought in 2018. Boards have a 1 per cent flexibility, so they can be in deficit 1 per cent, but they have to break even within three years. Other than that, they will seek additional financial support from the Scottish Government, essentially brokerage, a return to receiving brokerage. What would happen if the Government turned round and said, no, you are not getting it? In a hypothetical situation like that, the NHS boards would report an in-year deficit from an audit perspective. That would be, well, I will not speak for Pat, but he would have to give consideration to the regularity of that spending, because there is not budget cover or approval for the board to produce an unbalanced budget. Therefore, that would again bring my attention and potentially a statutory report. I think that services would continue and it would be a call for the Scottish Government what it wanted to do next and how it would look to support the board. Escalation frameworks exist, a review of its service provision arrangements and how it would then help the board to return to financial balance. A range of tools available for the Scottish Government primarily, Mr Simpson, and undoubtedly decisions for the board itself. It is really interesting. It reminds me, my convener, of the work that we have been doing on colleges. We have heard that a number of them in a similar position may have to be bailed out, which sounds like that could be the case here. Again, we are closely tracking, as Pat and his colleagues are, through the audit of the NHS Forfally across the piece. However, as we have said a number of times today, the financial challenges are clear for NHS boards in Scotland to deliver financial balance in year and in years into the future, for all the reasons that we try to cover in the report of the extent of demand, cost pressures, inflationary pressures and enacting the routes through to transformative change that will deliver sustainable health services in Scotland. Thank you. We are drawing towards a close. I have just got a couple of quick questions for you. So Auditor General, you mentioned the importance of staff being listened to, and you referred, for example, to whistleblowing. However, it is not the case that staff being listened to is not just about individual whistleblowers using public interest disclosure. It is also about routine collective listening to trade unions, for example, in the forums of health and safety, as well as partnership working. The committee may be aware that there is a unique aspect of NHS governance with the presence of an employee director on the board of health boards that underpins the importance of the relationship and listening to staff. Okay, thank you. My second quick question is one that we have addressed in a number of other reports. That is the question of induction training for members of the health board. Do they get that in 4th Valley? I am not sure that we have covered that in our audit work, convener, and I would be very surprised if that was not the case. I think that it is almost certain that there is a programme of support and induction for all public appointees in Scotland. In fact, to correct myself, I know that there is and, indeed, Audit Scotland itself has played a role in providing induction materials. We have given presentations to public appointments, including health board directors, as part of a wider programme of activity. Yes, there is a programme of induction, convener. That is not an issue that you have always identified by the John Brown inquiry. The specifics of John Brown's report have found that, regardless of the quality of induction, it is not an entirely sufficient safeguard to make sure that there is effective governance in place. As can happen on any board, whether it is a public sector or a private sector, you can have all the effective governance induction arrangements that you like. That does not guarantee that there will be effective decision making throughout the lifetime of somebody's presence on the board. In fact, I want to say a bit more about the specifics of 4th Valley. I know that John Brown raised his report on issues regarding board challenge and board scrutiny, which is obviously a key element of governance, convener. That is another one of the recommendations, and I think that that will be reflected in the induction training going forward for board members. That level of challenge scrutiny is absolutely essential, because I think that there were some deficiencies there in the past. That is fine, convener, but it is not in itself going to guarantee effective governance, cultural effective leadership. That has to be constantly worked at. Examples that his and other regulators have found would have all been within the confines of effective governance, but yet they still happened. The board has to constantly assure and check itself. As all health boards do, governance is robust enough to deal with challenging scenarios. One of the lessons that we have learned is that culture change is one thing. It is keeping the culture change going. That is probably the harder task. My final question to you is, and you alluded to this in answering some of Graham Simpson's questions about how far it is to go through the assurance board process and so on. Again, when I had a briefing from the assurance board, which I think was as far back as May of last year, the expression that they used was that they thought that there was a long way to go at that stage now, with several months down the line, so that position might have been revised. However, at that time, they were saying—I took a note of it—that there was no clear path to de-escalation. What is your assessment today of that? I am somewhat reluctant to speak for the assurance board, convener. I think that they will be better placed to assess their intentions than I am. I am sure that the assurance board will want to be satisfied that there is clear evidence of progress in meeting the significant range of recommendations, as we have heard a number of times, another 50 on governance from John Brown culture, which will take a period of time to evidence progress on two. At the moment, for us, it is a way to see and close engagement through our audit activity on progress, but the timeline is probably one for the assurance board themselves to speak to. I was quite taken aback when they said to me and other elected representatives who were taking part in that discussion that it could be years before de-escalation takes place. Is that a sense that you get? Is that the experience that we have had in the case of other health laws that have been escalated to level 4? We have not seen that length of timeline in terms of years. That being the case, I think that it probably illustrates to committee and those who have engaged in today's session that the scale of issues here are significant. They require very careful attention, focus, all the actions and evidence of progress. We know that to be the case that the assurance board is focused on those to be satisfied that the evidence framework is robust and that it can see progress being made. Again, I am not in a position to say whether it is going to be months or years. On that note, can I draw this morning's evidence session to a close? Can I thank Auditor General Yu for the evidence that he has given us and from Pat Kenny from Deloitte, Rebecca McConaughey from Deloitte and Lee Johnson from Audit Scotland. Thank you all for the evidence that you have shared with us this morning. I am now going to draw this morning's session to a closing public and move the committee into private session. Thank you.