 Gael defnyddio diwrnod mewn gweithloi o'r 11 oed am gyfnod y Ylif yn Cymru. Gweithio'r gweithloi o'r 11 oed ar gyfer, ac ond teimlo'n bwysig o'r ddechrau ar gyfer. Felly, mae hynny'n cael ei cyffrous a'r unrhyw hynne gyda'r ddatblygu, ac eto i'r holl ym Bandwg Fffolwyr yn teimlo unrhyw unrhyw unrhyw hwn. Rwyf ni'n ceisio i gyfnod y seiswyddiadau yn gyfoeth, ond those children and adolescent mental health services. I would like to welcome to the committee Lorna Wigan, chief operating officer NHS Tayside, Tracy Gillis, medical director NHS Fourth Valley, Jackie Irvine, Children and Families Committee, Social Work Scotland and Barry Seym, chair of the Association of Scottish Principal Educational Ffamilies Cymru, Social Work Scotland, Barry Seym, chair of the Association of Scottish Principal Educational Psychologist and Principal Educational Psychologist Glasgow Service. We are going to move straight to questions. We have under an hour for this session. Alex, would you like to start? Thank you for coming to see us today. Everyone in this room is aware that the last mental health strategy expired at the end of last year and we are still awaiting a new one. Given that over the summer we learned the news that some children are waiting as much as two years in some parts of the country for treatment at CAMHS and that some of the CAMHS inpatient beds are sometimes rendered unavailable because staff are not there to service them, can the panel give us reflections on what they hope will be in the next mental health strategy and particularly with a focus on CAMHS and whether CAMHS itself should have its own strategy underpinning that? That is one of the points that we make in our submission from Social Work Scotland. In looking at CAMHS in isolation, it is not going to solve the problem. It is that continuum from lower level tier 1 to tier 2 services through to CAMHS tier 3 and tier 4 because we know often and has happened in the past and possibly still is happening. Children are referred to CAMHS when there could be other services that they could get earlier on in their journey of mental wellbeing and that creates the bottleneck into CAMHS. The mental health strategy needs to look across that variation of provision and make those connections helpful. I wonder if it would be helpful for me to say something about 4th valley's waiting times because they have been particularly low in the recent ISD reported figures and I would like to give the committee some reassurance that we have taken this extremely seriously and put a lot of time and effort into working with the service. I am very pleased now that our waiting times in terms of 18 week referral to treatment were 74 per cent for children in September and 87 per cent in October. That has been a very significant turnaround in those waiting times and you might have been referring to our very low waiting times in June. Those low waiting times are partly influenced by making sure that children who have been waiting a very long time are seen. Obviously, as those children come through the service, they have a negative impact on the overall RTT time that is reported but it is still important that children are seen and prioritised appropriately. I have a perspective of looking at the whole life continuum. I would like to see much more emphasis on birthright through to adulthood in terms of how the pathways of care are provided. I would like to see much more emphasis on building up at tier 1 in terms of family resilience but also individual young people, children's resilience as well. I continue development in terms of tier 3 and 4 to ensure that we can provide as comprehensive a service as possible for those young people and children who need that level of service. It is imperative that we work across agencies but also with voluntary sector, third sector and families and young people themselves to get that right. I would like to think that there will be an emphasis on that in the next strategy that we see. Just to pick up on my question about the lack of availability of tier 4 beds, we put in an FOI over the course of the summer and the numbers coming back as to those kids who were referred to tier 4 beds but turned away because they were not available only not because they were full but because they were not in staff to man them was quite astonishing. Would you like to see further investment, particularly given the fact that we have no tier 4 beds north of Dundee? Is that an actual gap in our provision within Scotland? I think that we currently have all 12 beds open in our facility that serves in North. It is not always just to do with staff. It can be in terms of the young people who are actually in the unit at that point in time and a risk assessment from our clinical and multidisciplinary team about what is safe to look after in that one facility. I would like to see more emphasis in terms of keeping children and young people out of in-patient facilities. We can do that and we have seen some good models emerging in terms of intensive support at home. We have a programme called MacX, which puts in very intensive multi-agency, multidisciplinary support to keep the children and their family home in education. It is a combination of both. I do not think that it is just beds, I think that it is all the infrastructure that we can put into the community services as well. Is there a gap? I accept that. That certainly times a lot of what we hear about giving people care in the community and that is absolutely laudable. Are all the needs being met? If we are getting people who are referred to tier 4 beds and turned away, are they then getting that support at home that you describe? Some of them will. Some of them who need admission obviously would need to seek a bed for them elsewhere that is suitable to their needs. We have seen through work that we have done through our eating disorder pathway that our admissions have gone down through more intensive family behaviour and cognitive support that we are putting in. I do not think that it is simply just a matter of keeping putting more beds into the system. I think that it is looking to see what that individual child or young person requires in terms of support, intervention at an early stage if possible, obviously, because it stops the deterioration, but if they do require that, we have to be sure that the inpatient option is the right option. I honestly have not seen any data in terms of a whole system risk assessment that would tell us how many beds would be the right number of beds. I suppose to add to that in relation to the point about trying to keep children supported young people in the community. There is probably an issue also, certainly from my experience in Greater Glasgow and Clyde, of needing to manage that transition from inpatient out to the community. My team has done a piece of work on that. I am responsible for both children's social work services and health services to have responsibility for community calms. We have made sure that we have a transition guidance there. Sometimes young people get stuck in the inpatient position and there is a level of anxiety, certainly from family and professionals around them, about them coming back into the community. There are advantages and disadvantages, and short stay is preferable. We have some very complex cases that will stay in longer, but I am not in a position to say that what we have probably all experienced across the country is variation in terms of availability. At one point, our 12-bed unit was full at the moment. I understand the vacancies and I think that it is just very difficult to anticipate that, but I would agree that I am not aware of any whole system look at what the indicative needs would be for inpatient beds. On the issue of rejected referrals, many submissions highlighted the increasing number of referrals to cams. Some felt that that reflected the growing need, but they were concerned at the number of rejected referrals. Last week, we heard from Sam H and they were calling for a wider review of how we refer, and they also wanted to understand better what is happening at tier 1. Jack Irvine said that some young people are being referred to cams when they could be referred to other services. Finally, latest ISD figures show that 18.7 per cent of the referrals were rejected in 2015-16, and West Lothian Council, for example, has called for an urgent review. It is very concerned that some children and young people are missing out on help that they may urgently need. I cannot comment specifically on West Lothian. What I would say is that what we have recognised is that if children are referred to tier 3 cams and they could actually be fitted into or been dealt with appropriately at tier 1 or 2, for example, school counselling, then that creates a demand that is maybe not being addressed as early as it could be. We have worked across the country in partnership ways to try to build that tier 2 service, but they are funded in variable ways. Some of the funding will come from councils, some will come from health boards, some will come from education services within councils, some will be third sector. The variation in terms of what we are experiencing across Scotland is probably reflective of that variation about what is sitting around cams. I know what is in my area—I have heard from other colleagues what is in the area—but I know that in some areas they will be really short of those supports. Even at tier 1, there is a real need to support the development and confidence of staff who are working with children in the communities, whether that is nurseries, primary schools or secondary schools, so that they are able to deal with and not become overly anxious. One of the things that we manage at times is the professional anxiety around children, which does not help children and does not help to provide things when they need it for as long as they need it. Some children might be escalated into calms when they could have been managed and helped to recover within tier 1. I suppose that one of the other aspects is that quite often children are experiencing adverse childhood experiences, so they are coming to family relationships. From the point of view of the calms service at tier 1 and 2, we are seeing a slight increase in growth of functional family therapy in the country, but that is very, very variable and quite costly. We have invested in West and Bartonshire and, certainly Glasgow in functional family therapy, but it is from 11 upwards. The feeling is that children's behaviour and signs of difficulty start much earlier than that, necessary into primary 1 transition, even earlier, but certainly into the early primary years. It is that package of options. We sometimes try to fit the child into the services that we have, as opposed to saying what service we need for that child if it is not available. I think that last week's evidence session there was a view that better training for teachers and so on would enable them to help young people instead of feeling that they had to refer on, because they did not have the capacity themselves. How is rejected referral experienced by the young person themselves? Are they going along to tier 3 or tier 4? How does that work? I will tell you how it happens in NHS Tayside. The referral will come in and it comes in via various routes, so it could be from a teacher, a GP or a school nurse. That referral is then looked at by a multidisciplinary team in terms of the information that they have available. If they require more, they will seek that. Once they have looked at the referral, they will then see whether it fits into tier 3 and whether they are required to be seen by the specialist or whether there is an alternative that that child or young person should access. The referral will always be contacted to say why they are not suitable and what other options are available and signposted to other services that may be more appropriate and some information advice tools that may be beneficial as well. It is not a matter of the young person having to come up and then be told that there is no need for them to be there. I do not know if that is a similar practice. That matches our experience as well. We have done a lot of work at looking at our referral criteria with GPs and other primary healthcare services to make sure that those are well understood and agreed by all. Then we provide information to go back if a referral does not progress forward following a multidisciplinary discussion, the same as Lorna has discussed. We also have an advice-only email referral service, and we have a professional advice-to-advice line as well. There are ways for people to discuss referrals or to receive further information about services. Is that your experience as a practitioner? It depends on how they get to CAMHS. In Glasgow and other authorities, we try to follow the GERFEC multi-agency meeting. We are trying to push referrals. I hate that word, because it implies that we are putting it someplace else, but we would say that ownership remains within the establishment of the school, so a referral to CAMHS should go through that multi-agency group, where we call it a joint support team or a joint assessment team. The advantage of that is having people around the table from social work, health and education where they can give some advice about the appropriation of that referral. The majority of referrals that we know come through GPs, but there is a piece of work to be done with GPs to say how to link in GERFEC with your practice, so that the most appropriate referrals go to CAMHS, but if it is not deemed appropriate, then what other supports are there? There are lots of supports around, but quite often it is pretty much a postcode, so you find that even within a large city like Glasgow, certain parts of the city will have certain resources and others will not. It is having that local knowledge. In Glasgow, we have 28 joint support teams, and we are working towards using that GERFEC model. Referals would go through the joint support team, so that is on what captures the most appropriate ones going, but also saying that if it is not going to CAMHS or if it is coming back from CAMHS, it should also go back to the joint support team, because what other supports are available? One of the issues is the quality of the referral in terms of when it gets to CAMHS. If it has the most pertinent information in there, it gives them a much clearer, quicker idea about whether that is an appropriate referral and providing assistance. From my point of view, from Western Bartonshire, we had a pilot with GPs and education colleagues in relation to sharing information around GERFEC. It has been widely reported to Government ministers, and one of the outcomes of that very early doors was that quite often schools knew the child, the family, much better than the GP. They would have parents, they would know the siblings, they would have that background knowledge, so what we moved to doing with allowing, rather than the GEP, not that educational services are not allowed to, but just encouraging education to convey to the GP that we can do this referral if that is what your mum is saying and you are supporting it. We do not know whether you have done the referral or not, but we also think that that is required. We can complete that, and, as everyone has said, if referrals do not seem to be appropriate, there is a response back to the referer as to why that was. However, we encourage people to use the telephone conversation around the referral in the first instance, if not at the point that they are not accepted. Leading on from what we are talking about in referrals here, and really if we could just expand on that a little bit, we had some of the panel last week and some of the written evidence that we have talked about differing referral criteria for different services, and perhaps the need for some national guidance on referrals. I would be interested to hear the panel's view on that. There will be variation across health boards in terms of referral criteria and even in terms of the tiers of patients that they will see. I think that it would be advantageous to have some national work, where, at least if you are a young person or a child or even a family member, you understand what type of service you are going to get and how it is going to be provided for you, but there is no doubt that there is variation at the moment. I agree with my colleague that there is variation. It is not even across Scotland. It is within neighbouring authorities and neighbouring health boards. In Glasgow, we find that because my particular area of the south city border is three other areas. It causes problems for parents. A couple of weeks ago, when a parent had been told that the child required an educational assessment by an educational psychologist, there was an expectation set there. When we were contacted because of the geographical area, our threshold within Glasgow was different. I think that there is a piece of work to be done there from our perspective. If there are differences in referral criteria, would that account perhaps for why there is such a variation in the accepted rate of referrals sent to your services? Are you getting lots of inappropriate referrals sent to you because they do not meet that criteria? That would seem to me to be quite a waste of healthcare professionals' times of your time. It is also setting up expectations from families and from young people that they are going to receive a service that really is not appropriate to them. The variation occurs more in terms of the availability of what other support is there, particularly within—I suppose that I would look at it more from a health perspective, although my colleagues have said that it is very appropriate. However, what we are also seeing is quite a lot of pressure in primary care resources with a lot of GPs who might be doing locums or not working in the area and moving from some of that fragmentation of primary care services that we are all experiencing with difficulties in GP recruitment means that sometimes people are less aware of what is available locally, where that does differ, particularly with third sector or local authority provision, just where things might be called different things. I think that there is some need for a little bit, I guess, just better signposting to make people aware of what there is. We have not really touched on some of the admin processes that sit behind all these services, but where referrals are not necessarily received electronically, then sometimes they just do not contain enough demographic information or all the pieces of information that would be useful. That can lead to somebody asking for more information and the referral to be sent again, so it is not that the referral is necessarily inappropriate, it just did not have all the right information to start with. Those are counted in the ISD numbers, so it is just important to separate out those that are administratively incomplete from those that do not meet the referral criteria. If those are issues that you are picking up, what are you doing as health boards to address those? We have put in place a way to make sure that we can receive as much information electronically as possible and to then be able to work with all our colleagues in local authority and third sector to be able to provide electronically available information for people about what support services there are, so that can be passed on to the young person, so that can be kept up to date. There is also a push system of the advice sheet back out to refer us, so that can be handed over at the point of the referral being made to let them know what other support is available. The other thing is that we use our information and our data that we get, so we have a dashboard for the service and for the clinicians to use. That lets them look at themes. If they see that there is a particular issue in terms of a school or a cluster of GP practices, then it means that they can go back in and do some further education and try to understand why the issues are arising. It is a mixture of trying to make sure that the information is easily accessible and trying to ensure that people are up to date with what is available because things change and ensuring that, if you have an issue, you can identify it quickly and try to do something about that. Can I ask what happens after a referral is rejected? You might have addressed this and I have no picked up on this, but what happens after a referral is rejected? In Tayside, what happens is that the referer is contacted in order to tell them why the child or the young person has not met the criteria, what other services would be more appropriate, and signposting to any other support, information advice, any tools that may be helpful in that individual situation. However, there is always a contact back to the referer. Whoever that is, and it is not always a GP, it could be a school nurse or a teacher or whatever. Is that the end track? No, once they are referred back, they are obviously discharged from the service at that point. They are referred back and there is no follow-up to see whether that action that was referred back was successful, so we do not know whether the rejections result in the people coming back through the system. We would monitor that just in terms of... How do you monitor that? For readmissions, obviously, everybody has got a CHI number, so we would be able to... I am not necessarily saying readmission, but how do you monitor... If they are re-refered to outpatients. No, how do you monitor what happens after they have been rejected? I think that, obviously, if the referral has been from a named person, so education or health history, etc., or from a lead professional predominantly social work services, then that case, and I think that's why the use of the word that you mentioned earlier, referral, feels like something being moved from one place to the other. In terms of gerffec terminology, we've moved to talking about requests for assistance, so the originating referer, if you want to put it that way, or lead professional named person, still maintains responsibility for that child on that case. Obviously, there are a variety of things that a lead professional named person might do, so they might go back to CAMHS and have a further dialogue about why that hasn't been accepted, but they would certainly come back to the team around the child to look at what other service can be put in place for that child. That's obviously more difficult if there are fewer alternatives, but certainly from my knowledge and from our growing implementation of gerffec, that's certainly helping keeping an eye on that child and making sure that they don't just drop off the plate. Do you collect data on that? Is there a standard reporting system for that? No, I would have to say probably nationally. No, we're not in a position of doing that because we have different information systems across social work services, across education authorities and health authorities. So do you then know how many have been rejected and then come back? No, I would be honest and tell you that I wouldn't have that information, but from my point of view of being head of children's health and care, I would know in my area if we had an issue a bit like yours. Does anyone in the panel be able to know that? The transition from child and adolescent services up to adult services, we heard last week that there are different cut-offs in different parts of the country, some relating to full-time education, some 16, some 18. And we also heard from the representative of the Scottish Youth Parliament, and also from the lady from SamH, that they would really prefer there to be a bespoke service for children between 16 and 24, seeing them through these really vital periods of transition in their life so that any damaging consequences from having been severely ill at that period of time are limited so that, for example, if somebody has had to come out of education because of their illness, they are still in a team that can support them to get back into education even though they might be 17 and a half. I just wondered if that is something that you would support or if you have any thoughts about that particular variation in the service? Our services currently go to 18. I think that it is very difficult to make one size that fits all in this area. I would agree with you that there are some individuals who would very much benefit from a very clearly staged gradual transition and maintaining that holistic team approach to a longer period of time. Equally, there are some people at the age of 16, 17 and 18 who very clearly wish to mark that they do feel that they are ready to move to adult services and would prefer to be managed in adult services. I think that it is difficult to make one size that fits all. Maybe what we should be doing is making those opportunities more available where they are appropriate. If young people are telling us that that would be the best pathway of care from them, we should be listening to that. It is about looking at what we have currently and what are the steps that we then need to take for those who would benefit from that type of approach. However, there are some young people who will definitively opt to move to adult services. Sometimes that can be because of their experience in a young person's unit where the age group may be quite young. Therefore, they feel that that is not the right place for them. You are right. There is a kind of age where they fit neither, probably in one nor in the other. It is probably just finding for them what that would look like in terms of their individual pathway. In fact, Clare mentioned that last week that we were talking about. It refers to the other end of the age scale where there used to be a 65 cut-off where you went to older adults and perhaps naming a number is not useful. It is more about based on the individual's needs would be a more useful way of looking at it. That is what you guys are saying as well. The other thing that I wanted to ask about might just be me who does not understand how this works. Please excuse me. I just wondered how educational psychology fits in with CAMHS and how the services work together. I imagine that somebody with autism spectrum disorder or ADHD is more likely to be—the lead professional is more likely to be an educational psychologist rather than a psychiatrist. Some people, the lead professional, will be a psychiatrist. I just wonder how the two systems work together in terms of providing care. I think that over the past probably 20 years the role of education psychologist and working mental health has certainly increased. Last year, as Pep Hunter took an audit of all services in Scotland, 32 services, and we did an event sampling for a week to look at how much time we spent on mental health. It came out that 29 per cent of our time was on mental health work. That ranged from direct work with working with young people and children to advice, etc. Across Scotland you will find that services will vary depending on their size because it is about capacity. You have places with two psychologists and places with 40 psychologists, so it is an economy of scale. I think that in the last count there are about 20 different interventions within mental health that education psychology will probably offer, ranging from cognitive behaviour therapy, high movement desensitisation, reprocessing, and video interactive guidance. We have developed a skillset. We would say how we fit in with the tier. It has taken a long time for educational psychology to get its head round the tier model that works. We are now trying to target our interventions at a different tiered level, but we are trying to focus on tier 1 and tier 2 because that is where we know what the gap is. In fact, we are going broader than that and saying that it is at tier 0, the universal protein resilience. That is what we are pretty good at as education psychologists. We are trying to target our interventions and focus on those evidence-based interventions. At tier 1 and tier 2, the primary example would be safe talk. My authority pushes safe talk, which is suicide awareness training. Every establishment has a safe talk member of staff trained. We are now rolling out safe talk to S5S6 pupils. That has been done by education psychology alongside health and social work services, so we are working with them. In response to your comment about autism spectrum disorder, how would we work with CAMHS? Diagnosis would either come from Scottish Center for Autism or from the local CAMHS team, depending on the set-up. However, all that is getting there is a diagnosis, which is absolutely fine. It has to do with a medical diagnosis, but it then comes back to what you are going to do with that diagnosis. What are the implications? That is one of what we are doing with CAMHS at the moment, and education psychology is the same, right? The implications of that diagnosis are that you need to help us with that, because that child has to go to school, has to be educated. What are the implications of his sensory issues? He cannot cope with loud noises, he cannot cope with the dinner hall. How do we then make environmental changes to that child's curriculum so that they can be within their local school? That is where the partnership work comes in. It is certainly improving. There is further work to be done. There is on-going discussion with greater Glasgow and Clyde CAMHS, particularly clinical psychology, on how we can formalise that in a better way. We know exactly what we are doing. Much of our focus has been on CAMHS. When we are looking at CAMHS, are we capturing that activity? I do not think that we are. I think that it is an untapped resource. We would say that all education psychology colleges are health, HCPC trained or registered, so we have to conform to those guidelines. We have the skills because part of the training is very—there are similarities with the training with clinical psychology. We also have to make the difference between clinical psychology and CAMHS because the two are separate things, but I do not think that it necessarily has been captured. I think that it is a resource that could be used more widely. I wanted to explore briefly the issue of how you measure the performance of the system as a whole. There is a target in place for waiting time at tier 3, which seems to be the main indicator that you are using. Is that the right thing to measure? Should you be measuring other things as well, and other unintended consequences of measuring that particular indicator? I think that there is a view that I would concur with, that measuring just the waiting times is a hard outcome is fairly limited. Obviously, it is a real indication that people are not getting a service. A lot of health boards that I am aware of have moved, and certainly Great Glasgow and Clyde have, to the CAPA model, which is the choices and partnership approach that allows you to look more at general outcomes for the family and the child. Collating that can be difficult on a local area basis, or certainly on a health board basis, but certainly that is. We are looking more at outcomes around reintegration back into education, reintegration back into communities. Having a CAMHS service in itself would be a bit limited in assessing whether that was working or whether that was right. The other bit, again, I suppose, is that it comes back to that transition back into education and communities, even if you have not been in an inpatient bed. It is about helping those professionals around that child to continue on that support and understand what has made a difference. There is a real issue, I think, for communication, and that is why the partnership approach is providing, I think, more of a holistic, because it is not a start calms, end calms, back to life, it is a start calms, and then educating other people about what needs to happen for that young person. In some areas, again, it is not consistent, it is variable. There are teams within CAMHS in Western Bancers and young people in mind. We have other areas that have it where they will work with carers, and that can be foster carers, residential carers or families, about helping them to understand the behaviour that might be exhibited by their young person, so that they can understand what the premise of that is and, therefore, how to respond better. That also provides good outcomes. We would measure that on an individual child basis, and I think that this is the difficulty that we have with any outcome approach across Scotland. We have certainly been discussing that with colleagues in the care inspectorate. Is it your ability to measure that? Aggregate that up from a one child to the population is very difficult. Why is it difficult? You measure the outcome, if you want to call it that, for that child successful, and then you aggregate up all of those individuals? I suppose that it is a subjective question about whether the outcome is right, and I suppose that the best person to give that view would be the child and parent. A professional can say, yes, we think that we have achieved an outcome. We measure population information in relation to numbers of referrals, the number of children who are looked after, and the number of children who are referred to the report. It is a very different thing when you are looking to measure for children who are presenting with very different circumstances, whether their outcomes are improving. We are measuring them, but aggregating that up is more challenging, particularly nationally. I think that we do not have good systems, as you have heard earlier. Health has a separate system from social work, as does from education. To try and do that work takes a lot of man effort and hours. That takes away from the time that you have to provide service, so there is a balance. Access to service is important, but it is only one indicator. We would all agree that you would want to have some more qualitative outcomes that you are measuring, both for children and families, but also in terms of how we are using the resource and to be able to understand that variation better. Is it the right variation? Sometimes variation is right, but sometimes it is not. I suppose that the question is about the performance measurement of the system. You are telling me that it is difficult to measure the performance of the system, so we will not. No, we do measure it obviously. We have a whole dashboard of different measures, which we agreed with our clinicians and our multidisciplinary teams. The question was about the weight and time target at tier 3. What other measures should we perhaps use that are measurable, and are there unintended consequences of having the primary measure as the weight and time target at tier 3? Can I make a comment from an education perspective about how we monitor the performance of the system? We do not look at waiting times. What we would look at is outcomes and how we track those outcomes over time. The number of services that we are doing is looking at if we are doing a direct piece of work. We could either use standardised assessments, core or whatever measures that we measure before and after. To some extent, that is a pretty dumb way of doing it. The better way is to specify the outset. What are you looking from this? That is a fundamental thing about referral to CAMHS. What are you wanting out of that referral, or for that piece of work? If a piece of work was coming into an education psychology college, the first thing that we would ask is what do you want from us to do, and then we will agree whether we will do it or not. We will measure the outcome at the end of it to say that you are in agreement with the original, you know, what the intended goal was, but you then also have to measure that over time. A piece of work could be, you could do a piece of video interactive guidance for parenting with a family, and the parents say that they are a lot happier, and the cases are effectively discharged and inactivated, but down the line is that child still a mainstream education. I think that is what we need to be better at, but I think that that is what in education we are starting to do. Yes, we are. We are starting to measure it. That is part that has been driven by Education Scotland. It is part of the inspection process, but again, we are just like the smaller. That is how you do that nationally across CAMHS. Is that a better measure than the waiting time target at two or three as a headline measure? I think that it is, because ultimately if you are just going to keep on forcing that waiting time, that is when you are going to put your money. Yes, that is what I am trying to get to. The problem that you have is that people are saying that target is not a good target. Okay, what can you put in its place and I am not hearing anything that is made? Well, I am hearing something from yourself Barry, and you are right what you measure gets done. If you are not measuring the right thing, then it is not getting done, but I am kind of a bit disappointed. There is not a here is what we want to measure. It all sounds a bit vague to be fair. I think that is a statement rather than a question, Tom. It is a very hard question for Jack Evans. I was just to pick up on something that the convener raised, the issue of what happens to those who are rejected from CAMHS. You mentioned in your answer that the data required to answer that was not available nationally. Do you believe that there is a greater need for data sharing between services? What I meant was that how a rejection is dealt with will probably vary somewhat across the country. I can only speak about my health board area although I am here to speak on behalf of Social Work Scotland. It might be one of the things that you want to reinforce in the mental health strategy in relation to the management of that process and the information going back. I think that it is standard that information will always go back to the referer as to what is otherwise, what was the reason for the rejection, or what other services might be more preferable or more appropriate for the child. That is not quite sure exactly what you are wanting me to answer. You were just giving us a range of services. Do you think that the data sharing between services at the moment is seamless enough? No, I think that there is work still to be done on that. I think that the GPs that we involved in our pilot went very well locally. We are still looking to roll that out from one area of our patch to the next, when West of Arch is very small. Clearly, data sharing is with consent at the moment. If families are presenting to their GP and presenting to the school with difficulty, that is much easier for us to then say, well, it might be helpful to find your pastoral care teacher to speak to GPs and do the referral on their behalf or with them. GPs always get a notification of whether a child has been accepted into CAMHS even if they are not the referer, so that is helpful so that they have that up-to-date information. I suppose that there is the issue about communication generally around what you are experiencing in a local area with the demand at the time and making sure that that comes to all services to address it in terms of a solution-focused way. We do that through our community planning partnership children's services strategy work. We make sure that we have a particular focus on children's mental health and wellbeing within that, and that reports up to community planning partnership. Clearly, if we were having significant difficulties in managing services or accessing services, that would be one of the things that we would report up. That might be to do with resources and a spike in demand. It could be to do with a lack of appropriate services at lower levels. I wonder if any of the other members of the panel would like to comment on the issue of the data sharing. It seems that it seems to be in some ways insufficient, and whether the lack of data sharing is potentially a barrier to better outcomes for users of the service. I suppose that my comment would be that, in general, we will all have data sharing agreements and protocols that specify what we can share and the levels of consent and the information that goes back. I think that those principles and protocols that are set out are probably different from having systems that speak to each other easily on a day-to-day basis. That is probably where there is greater need. On that systems issue, it is not just that all of education services have a different system from all of social work. Within social work across the 32 local authorities, there are different information systems in terms of their client-held record. They do not speak to each other, and within health there are different levels of recording for client-held information, so their own record. It is not just three systems that are not suitable to make a connectivity. There are variations in that. That is where the complexity comes in, and I am trying to address that. I think that the teams around the children share information and work well together. Obviously, I think that what we have is IT systems that do not enable that to work seamlessly and in real time and smoothly. We are embarking on a product that will enable our social work and our health and other colleagues to have a single system that they will be able to see all the information that is appropriate for them to see and respect to that child and young person. That has been rolled out at the moment. The information sharing is there, and when you have a child in front of you, you have a single plan. That plan is developed by the multidisciplinary multi-agency voluntary sector to support that child. Obviously, if you are an individual and you are going into that family and it is a paper-based system, you do not always have all the access to all the information at that time. That is the solution that we are working on at the moment in terms of enabling that to happen so that it is there when you need it. If we had more time, I would get you to explain functional family therapy, but I could have a guess. In the Social Work Scotland submission, they talk about a much more holistic approach to early intervention and a better way to deal with mental health is through a social model. I cannot say that I would disagree with that and I totally endorse that, because I think that much of that is about poverty, inequality, poor housing, poor environment and the rest of it. In a previous inquiry that I was involved in to look after children, a number of people spoke about the need for social workers or social work. Previously, they would be social work assistants, even some people referred to them as homemakers from years ago, and they went in and done fairly basic work with families, getting people into their routine systems of behaviour and boundaries and all that kind of stuff. I personally think that that is desperately needed, but how can that be done in the current climate when local government budgets are under such pressure? Fallen on from that, do you have the human resources, the people on the ground who are able to deliver that but also the other-range services that involve the camps? You are asking a very sensitive question. I would say to you that we still have a model of what we would call home helpers or family support assistants, but that is a very precarious service to keep afloat in terms of the current financial climate. If I am responsible for social work services in my area, we have some very difficult decisions to make west of Bartonshire, but I will not be any different from anywhere else in the country. How many people are delivering that service on the ground in west of Bartonshire? Well, we have in the region of about 48 to 50 social workers qualified in field work that would be out in communities. Given the pressures that they are under, can I stop you there? In that inquiry that we did, we spoke to social workers who were saying that, given the pressures that they are under, that element of their work has largely gone and they do not do that very much at all these days. I think that in the 21st century review of social work, there was a recognition that you should be having professional, but the same in any profession that professions should be doing what they are trying to do. Therefore, there was a real need for social work assistants or family support workers to do more of that hands-on work that you are talking about, setting boundaries, helping people to get into a routine understanding what children need in terms of keeping them healthy, well behaved and managing families' stress and chaos at times. I am sure that, if we did a study, there has been staff lost in those areas. That means that you have social workers doing a wider range of tasks possibly because they have not got that earlier support. For families as well, they find those type of workers—what we would call paraprofessionals—much less stigmatised. People that can come out in the community do things with them and get them used to shopping than a social worker coming to your door. We are a very small area and people in the community will know who the social workers are. There is a huge stigmatism around that. We have some staff in our health visiting service who are funded by education, which is really helpful. They are young family support workers. Equally, we have outreach workers from nurseries who are funded from education. They work really well with those lower-level families where the concern is not about immediate risk, it is about helping families to struggle with poverty and some other difficulties that they are experiencing. I suppose that there is a varied level. I think that what we are experiencing and, again, it is anecdotal that it is not on behalf of Social Work Scotland. It is about what I see and why, so we are not in many more complex cases. Can I ask the others about the resourcing issue? How many are we short, or have you got an oversupply in your particular area? I am talking about across the field. In terms of the staff that are working within child and adolescent mental health, what are the particular types of workers? Child and adolescent mental health, but that is associated also. We have seen a significant increase in the number of staff related to the investment and redesign that we have put into the service, which has been in part to address the waiting times issue that has been previously referred to, but has also been to make sure that we have good provision at tiers 1 and 2. In particular, as Barry said, at that tier 0 level, it is about your comment about the community support that is available. We have just gone on to finalise some recruitment of some extra nursing staff, and that will be as an at-establishment, we think. On the other hand, we had an investment at the start of the last year of 2015 in terms of nursing psychology, professional leadership from both medicine and nursing, and further work in terms of looking at how to further enhance the support that we had available at tier 1 to go out and do the education and training and also support for families. At the moment, our biggest issue is recruiting to consultant psychiatrist posts. Currently, we have 2.7 whole-time equivalent vacancies in outpatients and 0.5 vacancy in patients, and that has been quite a long-standing issue in terms of there being a shortage of individuals available to take up those posts. That obviously brings some challenges in terms of the resources that are available in Tayside as well. We have one university outtake that we recruit from. We do recruit very small numbers from elsewhere, but we really rely on Dundee University and Aberty and the students that they train. That, therefore, can sometimes restrict the amount of registered mental nurses that we have available as well. At the moment, we have managed to recruit some additional staff, so I do not know if that helps or not. We have a panel before us who are saying that they do not need additional resources. In terms of additional investment, there is a recognition that referral rates are increasing. We are just embarking on another. Last year, we did a very big look at our demand in terms of making sure that we had the right resources, so hence the investment. We are just embarked on another round again to re-look at that, knowing that our referral rates have gone up, trying to understand why that is and what it is and where we need to think for the future. I am not saying that we are in a position where we do not need any further investment in CAME services. We also know that we are hard to reach populations and probably do not seek services. I am sure that children and young people are no different from the rest of society, so I am not complacent and I am not thinking that we are in a position where we will not need further investment. I am going to bring in Miles. Both are the submissions that I have been reading. I have referred to the issue about looked after children, particularly those in residential care. I will not comment on that, but I think that we have to put that on the record that there are real concerns about that group of young people. Miles, and then we will have to finish up. My question was about disparities within the referral system. To what extent does your experience show that potential referrals are more successful if they have come from a GP rather than an in person or from the school? As we have got you held captive this morning for a wee bit longer, are there any priorities that you want to identify from your experience for the next mental health strategy and what you think is important to be included in that? I suppose that the disparities in referral data, I could not with confidence say that there is one group that refer better or more appropriately than others, but I certainly know that we have locally, and I think that colleagues have already mentioned, that education work with GPs and referers to make them clear about what we can achieve with incomes or what we are looking, if I am a social worker, what I am looking for. I think that that does help as well as being clear about what other services are available prior to that tier 3, so that people are getting those referrals in early. I think that that is the main gist of it. Other than, obviously, we have mentioned already that there may be a variation in criteria specifically for getting into incomes, and I think that that would be something that you would want to eradicate. You would want that to be standard across Scotland, so that the families and professionals are understanding and speaking about the same thing. On the mental health strategy, I think that I would go back to what I said earlier, I really would like to see, and certainly social work Scotland would like to see, that emphasis on the tier 1 and 2, because if those services are not there, then children will be exacerbated or escalated into incomes services inappropriately in some occasions, or they wait so long, they are not getting that service when they need it, what they need for how long they need. That is very variable, and that variability does come down to funding. Obviously, we have talked about those services being funded by the voluntary sector, and some community planning partners have put money in in varying ways, but I am sure that what we are picking up is that there is a significant gap in that area. To just ask for extra money into incomes, notwithstanding that the demand has gone up for incomes, particularly in relation to autistic spectrum disorder and ADHD, and those assessments and diagnosis take some time, so they take up a lot of work. I think that I would be wanting to see a sort of emphasis on every community planning partnership having a view of what they have on that pathway, which is from, I think that my colleague said, almost tier 0, which I think is quite a helpful terminology all the way up, so that people can understand how they route children into the appropriate service at the appropriate point. Obviously, we identified children quite early in the main, but it is not unknown for us to suddenly a child reaches secondary school, mid-secondary school, who is struggling with a lot of that transition, and that is when their mental health deteriorates rapidly, so it is that kind of balance across. If we just focus on one area and I suppose that comes back to the, if we only look at waiting times for CAMHS, we are missing out a lot of preventative work that we could be doing that will keep children and young people from needing CAMHS in the future and from needing adult mental health services in the future as well. That is another issue, so there is a sort of almost spend to save approach that needs to be taken. There is much more that we could look at and say on this issue, and I am sure that we will in the future give a thank panel very much, and we will suspend briefly to change the panel. Okay, the second item on our agenda is an evidence session on targets, specifically looking at the Scottish Government's review into targets. Can I first of all, before I forget, we have received an apology from Colin Smith this morning. Can I welcome to the committee Harry Burns, chair of the Targets and Indicators Review, Jeff Huggins, director of health and social care integration in the Scottish Government and Paul McClay, chief policy officer of health and social care at COSLA. Welcome. Can I invite you to make an opening statement? When I was asked to lead this review, my discussions with ministers were very much along the lines of let's have a fresh look, let's decide what we want out of the complex system that is health and social care, and let's have indicators of progress that would be based on the principle of information for improvement, not for judgment, because my experience over the years in which we carried out the Scottish patient safety programme in the earliest collaborative and so on was very much along the lines of if you give front-line staff freedom to solve the problems that they encounter and the opportunity to test solutions, they will learn and the system will improve. As a result, we have had huge reductions in mortality in Scottish hospitals, huge reductions in infection rates, reductions in infant mortality and stillbirth rate and so on, of a level that no other system has achieved. It seemed to me that we needed to approach this review with in mind targets and indicators should lead us in the direction of a change that we wanted to see. The change that we want to see is improved health and wellbeing across the Scottish population, which is based on people being in control of their own health and wellbeing and control of their own lives, ways in which we support people who are in difficulty to find ways out of that difficulty and become more engaged in the pursuit of wellbeing themselves. I am standing back looking at the whole system. Having said that, I think that the public will expect some reassurance around waiting times and that kind of thing. We have made huge progress on waiting times in Scotland over the past few years, certainly since I was a surgeon at Royal Infirmary, when people would routinely wait two or three years for elective surgery. We want to keep some of the things that are working, but we want to find new ways of moving the system towards a much more holistic approach to wellbeing. That is how we are setting out what we are setting out to do. I have not got a background in health, but I do have a background in performance measurement over 30 years in business. When I started looking at it from a health point of view, I was very confused about the terminology that was used, because on planet NHS, they seem to use words that have a different meaning to what they have in the rest of the world. I talk about outcomes, targets and so on, because there is a very well-established process for doing that, but the health service seems to have gone off on a tangent in looking at it from a completely upside down back-to-front direction. At the end of the day, you figure out what your strategy is, and that seems to be called outcomes in the health world. You then figure out what it is that you want to measure. An indicator has an outcome or result, and it has a target. Those are all part of a coherent measurement system, but in the health world that seems to be an outcome is a completely different thing from a target. They are all part of the same, in my mind, coherent structure. You need to have that in place to understand where you are going and how you are getting there. The first step to that is to drive the performance improvement, because you need to then break that down to various different levels to understand what it is all about. It was really just to get your reflection on that, and what you thought about that process and what I am saying, if I get a correct understanding of the kind of mix-up that we have managed to get into. I think that you are absolutely right. We have inherited a set of processes. The target culture came from some of the horror stories that we found predominantly in hospitals in, well, from memory it was London, where people were lying on trolleys for 40 hours before being seen in A&E departments and so on. Absolutely unacceptable situations. Targets were imposed on the system without any real sense of understanding as to how that would influence the broader suite of activities. Things like waiting-time targets. When I was a lead clinician for cancer in the 90s, I remember the discussion around treatment time guarantees for people suspected of having cancer and 62 days seemed a reasonable time for people to be seen and get that reassurance. A lot of those things were imposed without due consideration for the broader system. I think that we need to step back and see what that broader system is telling us. One of the interesting comments that we had at the first meeting from the emergency medicine community was that the four-hour waiting-time strategy—well, what they said was that the accident emergency department is a barometer for what is happening outside. It is a barometer for what is happening out in the community. If there are stresses and strains in a community, you see eight different patterns of problems being presented in one place, in another, and so on. I think that that is a very insightful comment. However, we cannot judge performance in those accident emergency departments without consideration of the broader context in which they are working. For example, there is a lot of stuff about breaching for our waiting times. When I worked in any departments, which was some years ago, you did not have CT scanners, then you did not have MRI scanners in any departments. Any departments were triage places where, if you came in and you had a broken bone, you went to the plaster room, if you had a cut, you went off and got it stitched, if you had a sore tummy, you went to a surgical ward, if you had chest pain, you went to a medical ward, and so on. Now, all of that investigation in most A&E departments takes place in the A&E department. Treatment starts in the A&E department. If you are having a heart attack treatment, very often, it will start in the ambulance. Yet, we are still acting as if people are hanging around on trolleys. They are on trolleys being investigated and treated. We need to rethink that for our targets. It is important that people do not lie about trolleys not being treated, but as soon as they start treatment, that is them not lying around in a trolley. So, we are not thinking about the broad system. There is no appreciation of this complexity of modern healthcare. I think what I would want to do would be to come up over the next few months with some suggested things, get them out in the system for testing, get the opinion of front-line staff as to how it helps them to achieve better outcomes for patients, and then move on from there. We want to start with an industrial process control that is probably not the right way of describing it, but it is a different way of thinking about performance within health and social care. I am delighted to hear that. The target is essential. The trick is to figure out and measure the right thing. That is the hard bit. So, there are just a couple of other quick comments. One was the envisage that this would be aligned to the national performance framework at a national level. Secondly, I had a wee look at the list of people that you have in your expert group, and there was about 25 or something on it. They all seemed to be health professionals. If you were building a hospital, you would call on an architect and a civil engineer, so if you had not just have clinicians on it and were building a performance measurement system, it would not be a good idea to bring in people who have done this in other walks of life. We have patient reps and health and social care reps. We have a backup of people who are very much involved in the redesign of services. Another piece of work that I have been doing recently has brought together all the modern theorists, and I am writing some stuff up about that just now, so we are feeding a lot of that thinking in. I must have to pick you up on one thing. You said that we did this on the back of things that happened in London. I think that many of those things also happened in Scotland. Now, when the lake has to rewrite history at the very start of this, we all have constituents who have experienced similar things up to the present day. The four-hour target was initiated in England by NHS England on the back of a number of scandals. I am not saying that we were perfect, although, interestingly, we have looked at performance in other countries—very few other countries outside the UK—impose targets in any departments, and, in comparison to those other countries, we actually do pretty well. One specific and one general. The specific one is about the sense of enshrining targets in law. The treatment time guarantee is enshrined in—I think that the patient writes Scotland Act 2011. I looked at the legislation this morning. If there is a breach of the guarantee—I think that the health board must do three things—it must make arrangements to ensure that someone is treated early or the next available opportunity. It must give an explanation to the patient and it must give support and feedback. My own view, provisionally, is that that does not provide any kind of pressure, really, substantial pressure to the health board. One thing that I would like you to consider in your review is the logic or the sense of enshrining targets in statutes. It does not seem to have much point to it. As I come back to the—I would like information to be used for improvement. If you set a target, that is as good as you are ever going to get. It might be that we are actually looking at excelling, exceeding those targets, doing better than those targets. It might be that we would find ways of improving way beyond the existing guarantees. However, while we have a target, particularly when enshrined by law, that is as good as you are going to get. Folk aren't going to have any reason to go any further. I have an open mind just now. I think that by the time we sit down, engage with front-line staff, engage with patients and so on, we may well come up with a set of ideas that lead to better performance than company enshrined. I think that enshrining things in law is for you guys to decide to be honest, but it does ossify the process once you do that. Maybe just to offer something a bit more, because some of the early feedback that we've had, and I guess one of the reasons why we're having the review, is because of the perspective that those targets that were enshrined in law have so much more force within the system than other issues in respect of provision of services in the community or broader population health care. The challenge that you're presenting is that it's not got enough force, but quite a lot of the feedback that we get is that it has too much force and it distorts. I guess that that's one of the issues that we need to tease out through the review as well. My second was a general question that picks up on what Ivan McKee was asking, which is that it seems that the fundamental question is what should we be measuring. We need some kind of benchmark for performance, and I think that patient outcome is talked a lot about. It would be sensible to measure efficiency of some sort. The four hour A&E target is a good example, because in the public's mind, how long it takes them to get to your A&E matters to them, and they will walk out of a hospital, either having been seen quite quickly or having taken forage, and they will make a judgment in their mind about whether they think that was a good experience. Yeah, I think that you're right, and I absolutely accept that, but what we are seeing and what is being presented to me in part is the idea that actually people who may be in the A&E department for four and a half hours, two hours of that time might be them actually being treated and being investigated and things, and that is something that, in days gone by, would have required an admission to the ward and an overnight stay and so on. So, we need to collect data to see what is actually happening within that four hour target and have some kind of rational way of meeting patient expectations for a timely encounter with the health service, but at the same time allow the patient to get rational investigation and treatment, and if that should happen in the A&E department, then so be it. I think that you realise that it's a much more nuanced picture than simply measuring a time frame. We've all heard from hospitals who say that actually the A&E target is useful because it shows how quickly people are moving through the hospital and how the hospital itself is working. On the other hand, I spoke to a doctor who said that actually if your primary care system is working well, then a lot of people might be being seen in primary care by their GP, not getting to A&E, and then only the hardest cases are getting to A&E, and they're breaching the target because they take longer. Yes, there's an interesting Australian study we've encountered where they've reviewed the four hour waiting time target in 59 hospitals, and what they've found is that mortality of patients increases the closer they are to the four hour target. Now, they haven't, in the paper, come up with a rational explanation for this, but it seems to me that those are the sicker patients. Those are the patients who come in and are being worked on and having things done and being resuscitated and so on. Therefore, mortality will be higher. We've got to understand the processes that are at work in A&E departments and come up with a rational way of supporting them to support patients. I'd like to welcome the panel this morning. Thank you for coming to see us. Thank you in particular to Sir Harry for that very elucidating opening remarks and subsequent answers in terms of the multi-dimensionality of the targets that we measure at the moment. The nuances are points well made, particularly around A&E waiting times. Targets are fresh in the mind of this committee, not least because last week we had a cross-examination of the Cabinet Secretary about the Audit Scotland report, which was very uncomfortable reading for the Government, in terms of the eight targets that had been laid out. Only one was met, and a couple were very nearly met, but the rest were pretty poor. It was suggested to this committee in that session that the targets at which Audit Scotland were assessing are some of the hardest in the world and some of the most challenging in the world. I'd like to ask the panel if that's accurate, if that's a good thing, if it doesn't capture that kind of multi-dimensionality that you're describing. Sir Harry might have offered some kind of mitigation in terms of that slightly binary black-and-white pass-fail report that was given to us and how that might be improved. As I say, the four UK healthcare systems all have broadly similar targets. Republic of Ireland, Australia and New Zealand are the other three areas that we've looked at that have attempted this kind of target approach. We think that some European countries have targets for some bits of their system, but we can't find consistent publication of data or whatever. When you look at some of the other, the Republic of Ireland, Australia and New Zealand, they are far laxer than the ones that we've got. For example, off the top of my head, Republic of Ireland is waiting times for admission. From memory, it's something like 25 per cent of patients will be admitted within two months and 100 per cent within a year, whereas ours is much shorter than that. We have set ourselves pretty challenging targets. Where we fail, my bet is that a number of those failures will have robust and sensible explanations underpinning them. The problem with the data up until now is that those explanations haven't been sought. It's a target and all the management evidence that I read is where you have targets. Management effort is put into ticking the box. Whereas what I would like to do is I want to understand what's going on out there, because if 90 per cent of people meet the target and 10 per cent don't, you need to learn from those 90 per cent in order to help that 10 per cent. If all you're concerned about is just ticking the box, you don't learn. I think we can improve way beyond what we're currently doing, but we've got to make that effort and we've got to de-stigmatise the process in the interim. The other thing is that, looking at data from one of Scotland's largest health boards, which says that the number of patients attending any departments has declined significantly over the past few years, which suggests that primary care may well be doing the right thing. Again, that didn't come out in the Audit Scotland report, so there's stuff happening out there that we need to understand a bit more of. I think that the next three or four months is our effort to understand it and to reshape it. To come back, I think that the primary target should be for improving the health of the public in Scotland. What do we need to do in order to achieve that through the health care system, the social care system, the criminal justice system, the education system? I'm not sure if the Scottish Government knew what it was getting when they asked me to do this, but I'm looking at the whole system. I agree with everything that you say. I think that it's probably the knee-jerk visceral reaction of any Opposition member, and possibly it's incumbent on us to react like that with some scepticism when a Government fails a set of targets then to commission a review as to whether they should be setting those targets in the first place. I want to go where you're taking us. I just want to have the confidence that we're not just giving the Government a pass on this. I don't hope the knee-jerk reaction against you. I was heartened to hear Sir Harry speak about the need to have a much more holistic approach to Scotland's health and wellbeing. It's obvious that targets affect how budgets are. We spend the money to meet some of those targets, but do you think that that is having an impact on perhaps what some of us might perceive as a lack of intervention and a more preventative approach because we're obsessed with the target at the end of the day? I'm sure that Paula will have some comment to make on that, but you're absolutely right at the moment that budgets are siloed for all the efforts to get integration and so on. If you save money in acute care, investing it in primary care, investing it in social care and so on, it's different because people are accountable for different bits of that budget. I think that there has to be an effort made to bring that money together in order to make sure that it flows to the correct place. There are tools for doing that, but accountability at the moment makes it difficult. Different accountability streams make it difficult for that money to come together. I can say that some of the stuff that I've been looking at around the way in which frontline staff engage with people. There are some studies from England that show substantial reductions in costs in criminal justice, substantial reductions in costs in healthcare when you get things like housing right. We need to be thinking very broadly—Polly, you. Maybe you could just address this point too. GPs at the deep end have produced research arguing that the way that we allocate NHS resources, particularly the Scottish resource allocation formula, doesn't do enough to tackle health inequalities, so could you perhaps pick up on that too? I've got some sympathy with that. I come back to the point that health inequalities will not be fixed simply by healthcare. I make the point that we're just reading about one major set of interventions occurring in the north of England. What he found was that the single most important public sector worker in fixing a lot of these things was the housing officer. Helping people get out of difficulties in their housing seemed to have a big impact on their health, wellbeing and the way in which reducing domestic violence and all this kind of thing—reducing stresses and strains. That's very difficult to quantify that. Could you have some NHS targets around reducing poverty? NHS targets around reducing poverty? We know of income maximisation schemes like Healthcare, Welfare, Children and Glasgow, where health visitors and midwives helped families on low incomes access benefits. Ready happening in Lanarkshire, a earlier collaborative, found that health visitors doing 30-month assessments are referring people to money matters centres and all this kind of thing. That's what happens when you empower the front line. When you say to the front line, solve the problem here, they come up with innovative solutions and they just get on and do it. This is part of the culture that we want in gender. I suppose that the value of bringing in the review of NHS targets and the review of health and wellbeing indicators together is that we are asking whether the whole system is pulling in the same direction. That question is a really important one. When you look at individual targets, we know that targets fundamentally drive behaviours. Whether the answer to an A&E target is to invest in A&E or to invest in the preventative services that would keep people out of A&E is where we need to be focusing our attention. How do we ensure that we have the right targets and indicators to shift the behaviours to deliver the outcomes that collectively we are all in agreement need to be achieved for people? Fundamentally, that's the task that's been set here. Just two things on that. What we are beginning to see with integration authorities who have the resource for A&E and the resource for unscheduled care bed days is them increasingly looking at what they can do upstream. Sometimes people say that targets drive money too much, but sometimes you might also say that maybe they don't drive it enough in that the better solution to what's going on within the hospital sector is better preventative and anticipatory. The challenge is that we now have, in some places we've only had them for seven or eight months, the organisations in place that have the pooled budget, which is able to look across that component of the system and develop and approach offer different solutions to the ones that we've had historically. We're beginning to see that. In terms of the health and wellbeing outcomes that support integration, the fifth of those is a requirement and partnerships that they address health and equalities. What we're seeing within that is exactly the sort of project and work that you've identified there. They'll be required on an annual basis to report on what they've done to address health and equalities within the areas that they're responsible for, which is going beyond simply healthcare systems. One of the processes that we introduced in the patient safety programme in the earliest collaborative and so on is encouraging people to collect data on a daily basis. How many people did you see today? How many people did you give debt advice to? How many people took up the debt advice? How many people have come back and said, yes, I'm better off as a result? Having annual reports is one thing, but what keeps the front line staff trying new things is seeing the run charts up on the wall that says, yes, actually, I mean, the classic example I used in my lectures is bedtime stories for children in the earliest collaborative. We know that enhances cognitive ability and so on. The nursery used to ask the kids did they get a bedtime story and they did things and gradually it went from 60% of children to 90% of children because they were following it on a daily basis. When we implemented infection control, specific interventions and control programmes in the patient safety programme, the more there was compliance with the programme, the lower the infection rate went and that's tremendously motivating to front line staff. They see change happening and they want to make it happen. We want to discuss a key bit of this, the methods that we use to implement these high level objectives. I would suggest that annual reports aren't sensitive enough. We need that day-to-day flow of information. Can I ask at the beginning of the list of successes on infection control and mortality rates? How many of those successes have been driven by the targets? If we were meeting the targets, would we be reviewing them? The patient safety programme and the earliest collaborative set their own objectives. They said that when you try to do this, you get the system together and you say, what do you want to achieve? The earliest collaborative is to make Scotland the best place in the world for children to grow up. How do we know we will get there? If we reduce infant mortality by 15 per cent by the end of 2015, if we reduce stillbirth rate by 15 per cent by 2015, if we improve developmental progress to 85 per cent by age three, and so on. Front line staff set those aims and then they set about trying things that would achieve it. So we made the 15 per cent reduction in infant mortality. We overperformed on stillbirth rate. It's 18 per cent reduction. We will know at the end of this year about the other ones and so on, but the point is that if someone from outside comes and imposes something on the front line and they've had no say in whether or not it's a credible objective, then they maybe aren't as engaged, but you get them to set it. They will set a more challenging. For not for a second did I think we would reduce infant mortality by 15 per cent. I can't find any other country in the one that's done that over the last three years, but they did it. So it's a different approach to externally set targets. This is set by the system and the system tests ways of achieving that target, so you know right from the start that they're engaged with it, and it might be that that's something we come up with in the course of this review. It might not. It might be that we have a mix of externally imposed targets. If we were meeting the targets, we'd be reviewing them. There's a wider context to the work that's going on in Scotland at the moment. The OECD at their ministerial meeting early next year is looking at how advanced healthcare systems across the world look at issues to do with quality and performance, and the expectation there is increasingly that they'll be moving towards patient reported outcomes. So not how did the system as a machine operate, but what was your experience of health and care? Did you feel safe? Did you feel listened to? Did you feel that you would control over what happened? So we have a wider context of what's happening in terms of how we understand what healthcare systems are for. Michael Porter, in his work on value-based healthcare, again looks at the moving beyond simply the how fast did it happen or how much did it cost to the degree to which it produces either greater health or greater satisfaction, so thinking again about how people actually understand their relationship to the healthcare system. The challenge with those things are because increasingly they become relate to people's expectations and people's experience in a very complex distributed system is that they're probably more difficult to achieve than mechanical targets, and it's probably more difficult to offer satisfaction to a population of five million people in terms of their experience each time they go across the door of the GP surgery than simply saying how quickly were they seen. So the challenge within this is actually opening up a space where different forms of data collection are likely to be required, but also different ways of understanding the benefit that people receive are likely to be required and they're not necessarily easier things to do. So I think you have to understand that while there will still be and we expect that there still will be things in respect of efficiency and sustainability and that people expect a predictable healthcare system, they expect one to be well managed, but the ask that's been put in here which relates to people's experience of their own health and wellbeing and the degree to which you produce health gain is quite a big ask. So I think please don't underestimate the ambition of this work. A few years ago, since the push came for the 12 week target, did, I don't know how long you've been in post, Mr Huggins, or your predecessor, or people within that directorate, but did they encourage or discourage Government from going down that route of targets, and are the same people who were sitting advising on that, are they in post now saying, well, actually we need to move away from something that we were actually involved in implementing? Try to get to the bottom of how the decision was made in the first place and how some of the people who pushed for that decision might be in the same place and saying actually we were wrong in that. Now, there's nothing wrong with people saying they were wrong, it was a wrong approach, and indeed some of the stakeholders who have been involved, I went to an RCN seminar recently where the RCN said, you know, at the time we were kind of all involved in it, there's a bit of an atmosphere around and everybody just went along with it and maybe we shouldn't have. Now, plain devil's advocate here is part of our role in this committee, is it the case that maybe some people are sitting saying, this is the kind of mood and atmosphere now and maybe we should just go along with it, where actually they might in the same number of years regret that? I suppose I can't entirely understand the different motivations that a range of people would have had for saying different things or saying what they said at the time when they said it. Our challenge around this is that often what people say to us is that they would wish that we review targets because they think that we have the wrong targets or we have the targets which are too specific, but then quite often what they ask for is a target that relates to their particular specialism or professional interest as being the one that we actually do need. People will say different things for different reasons. I think that, as I've indicated, the broader context within which we understand targets and performance and outcomes and indicators continues to move on. If we think that we go back even three or four years and maybe the work on the indicators is a good illustration of this, the first nine of the indicators that support the outcomes, the nine health and care outcomes, largely would be derived from information that comes from the Scottish health survey. We ask qualitative questions of the population. At that time, that seems to be the best methodology for understanding people's experience of health care, their sense of safety, their sense of control, things like that. For exactly the reason that Harry's outlined in terms of the need to have real-time day-to-day information that gives feedback groups and engages people in the service that they deliver, our view is now, and this is one of the reasons why we are reviewing the indicators, is that we need faster access to knowledge about people's experience of health care. The idea within that is that we still need access to people's experience of health care, but the methodology that we used to get that information has moved on. Our understanding of the change process has moved on, so now we are looking to develop systems that enable partnerships to know this week what the experience was, not what it was 18 months ago when the survey was done after it has been collated and published, because that does not give them any ability. The broad themes continue to be there, but the methodology by which we get to them continues to be the same. Again, the example was given earlier and was discussed at the first meeting of the expert group in respect of the 4R target. Different people have different views and have had different views of that over time. At the same time, it is a good indicator of overall sustainability and overall the ability of the system to run effectively. How we understand that as part of a broader objective of producing health gain and the wider benefits of the health and care system will probably change over time, but we will still need something to do that function in the system. Partly my question has been answered, but I have great respect for Sir Harry Burns, I am sure that he will do a good job. Mr Huggins, boards are diverting resources to meet targets. Disproportionate amounts of money are being spent in order to manipulate targets, bring in people to surgeons or whatever to work overtime. That is the charges that are going to be made against you and the Scottish Government. The charges are that you have not met these targets, so you are changing the system. I know that you have partly answered my question, but in all honesty do you agree with me that over the years we have built up so many targets, so many ways of doing things, so many political parties attacking the health service, attacking people like yourself, so you brought in the targets, you are responsible, so what are we going to do about it, how are we going to solve it, how are we going to make sure that people like me and others do not turn around to you and say, oh you are going to manipulate it again, so that we can have clear and concise targets that are meaningful to people, are meaningful to the public and everyone can respect those targets. At the end of the day, I would like you to answer that number, Harry Burns, because Sir Harry Burns has spoke for most of the meeting and I have listened to him intently. I want to ask you how we are going to get the right targets in place that can be respected by all political parties and the general public? As Sir Harry Burns has outlined, we have a process in place to seek a wide range of views. We have the ability to draw on expert advice, we have the ability to test the ideas that come out of the review process and that is what we will do. I think that the challenge that we have is that we are looking to do something that is complex and will need to operate on a number of levels, so it will need to take us to the situation where we are able to produce better health, which is the intention of the health and care system, that we are able to demonstrate that the system is running effectively and that we are able to give confidence to those who hold us accountable that the stewardship of the system is being discharged in an effective way. Those are a range of slightly different ideas and I guess the challenge that we have around the review is that we tend to load all of our expectations on to this review of targets as that this will be the mechanism why we fix a range of ills and this will be part of a solution, but it is only one part of the solution that we need to bring forward. That is the Harry Burns one question and I know that you will comment back on that. Are you under any pressure at all to deliver a certain target or what your group is going to come up with will be fully accepted by the Government? I think that you know me well enough to know that I can pretty good at withstanding pressure and I would never put my name to something that I did not fundamentally believe in. In discussions with ministers I have said, look I want to stand back and take an overall view of this but however I do recognise the fact that there will be public expectation around some guarantees of the way that they are treated and it will do my best to make sure that we bring all those competing priorities together and come up with something that is credible and insightful and does something for the wellbeing of the people of Scotland. That is the fundamental thing in my head overall. It is not about how fast you go through a bit of the system and it is about how well people are and can we move them to a better place. Commenting on Jeff's answer, we are where we are because at the time these things were brought in that is what people did. That was the notion in people's head as to how you moved a system and we have learned from that. We will come up with an insightful way forward but five years from now there may well be some other insights that emerge that will lead us to tweak the system even further. We can never say that there is a gold standard set of targets. Now that I am a free agent in terms of an academic, I am going all around the world just now telling people about the changes Scotland has made. People are asking me to go and help them set up an early years collaborative in the same way that we have done it. They want to know what our thinking is around health inequalities and all this kind of stuff. Scotland is getting a lot of attention because of what we have already achieved. What I see is a next phase of this coming along but I am not fooling myself that in the process we will not learn even more about it and then find an even better way of doing it. That is the way systems change. Can I just say on the point of if we had met all of these targets would we still be doing this review? My answer would be I certainly hope so because how well we are doing or not right now in terms of those targets is no indication of whether the system we have got is fit for purpose for the future that we want to achieve, whether it will drive the changes that are about changed models of care shifting, the bands of care, more care in the community's investment in social care and supporting people's outcomes. What we have at the moment is siloed and operational and it is not that those things do not have a place but they are unlikely to get us where we want to be for the future. Regardless of what the performance indicators are right now telling us about the system, I certainly hope that we would be having this review to ask whether the whole system can drive the change that we want to see and support the change that we want to see. The Audit Scotland report maybe does not point towards this but to what extent do you think there is manipulation and massaging of these figures taking place around the targets? I have met professionals and I do not say this to criticise them but they are not putting people on the system because they know that they are not going to meet their target, so that is both in CAMHS and also in alcohol and drug partnerships. I have seen that happening and know of that happening. To what extent do you, from your work that you have done, know that that is taking place and my concern would be whatever we put in place that will happen all over again. Secondly, where do you think the realistic medicine agenda fits into this? Well, certainly from the first meeting of the expert group, this issue was something that I raised with the emergency medicine people and they said that if that was happening, it was happening at a very, very small number of cases but the ones that I was speaking to said that they are just working hard to achieve the four-hour target. As far as the CAMHS lot are concerned, I do not specifically ask them and it is not something that I have any direct experience of. I do not know, Jeff, if you have any comment on that. We did a review about three years ago following the challenges that we had in Lothian to assure ourselves that what we had seen in Lothian was not happening elsewhere and at that time we were satisfied with the outcome of the review. If you have information that suggests or things that you think that we should look at, we would be very happy to look at them. Our experience, though, is that in terms of the value that clinicians take from targets is that they see it as being something that gives them influence also in terms of securing resource and so artificially presenting a better position than they are in is not always seen as being necessarily the best way forward. The other element of that is that part of the improvement process is allowing front-line staff to try things out, to do something different and see if that produces a better result. What I say to them is that if it works, tell everyone about it and if it does not work, tell everyone about it. The only shame and failure is not telling people about it because they do not learn that that particular intervention does not work. If there is a punitive sense out there, that is not a good thing. Information should be used for improvement. If there is a failure, why did it happen and what can we do the next time to make sure that it does not happen? If we create that kind of climate, the whole system will gradually improve. Odeon was that the manipulation of the system was happening and no-one was being told about it. That is the issue. Realistic medicine is entirely compatible with the chief medical officer's approach to realistic medicine. The medical system is part of the broader health system, which is part of the broader social system, and the broader social system needs to change in order to achieve that wellbeing agenda for Scotland. It fits in very nicely. It offers a way of conceptualising the healthcare contribution to this, so I will be having conversations with her to make sure that we are all on the same page. Can I ask the timescale and what happens next? What is going to happen with the system that you have undertaken? We are developing some work streams around understanding the data and gathering evidence from what has happened elsewhere as to what might make these improvements and understanding how they might be applied in Scotland and the method that might be used to drive the changes. I would hope by the end of March, around about April, to have an initial report ready for ministers, and I would hope that that would include some proposals for testing, trying things out and seeing that they do not create perverse incentives within the system or that they do not create unanticipated effects. If that is the case, then to adopt a continual improvement process approach to delivery of services. In the course of that process, we would want to engage with the public in a number of ways. Obviously, the committee, the members of this committee, are a key link to constituents and so on, so we would want to hear your views. When is that likely to be in the public domain? End of March. Thank you very much for the attendance this morning and can I suspend briefly to change the panel?