 If you are going to state to questions in the boards, or are there any that are going to say them. Good morning and welcome to the 16th meeting in 2014 of the Health and Sport Committee. As usual at this point I would ask everyone to switch off mobile phones and other wireless devices as you know can disturb the full of the meeting and sometimes interfere with the sound system. Felly mae'r cyffredinol yn oed yn gweithio'r cyffredinol oherwydd mae'r ffordd o'r cyffredinol yn ymddangos cyfwyr, ac yn ystod o'r cyffredinol, mae'n cyffredinol o'r cyffredinol. Mae gennym ni'n gweithio'r cyffredinol, Cullen Care, Rhoda Grant ac Nett Mellon, ac mae'n rhaid i'ch gael Denys Robertson ar gyfer SNP. ond wedi gynllunio am y cyfnodd yma, a'r wrthym ni'n gwybod y ddweud yma yn ddiweddol o'r ddweud a'r ddweud â'r ffordd, ymddangos a'r ddweud a'r ddweud yn ffraeg, ymddangos a'r ddweud, yn ffraeg, mae hi'n gwybod, ac mae'n ddweud o'r ddweud o'r ddweud a'r ddweud a'r ddweud? Mae'n gwelwch i'r ystafell yma o'r Merthymau Pwysigol, mae'r bobl bod nhw'n ei wneud, ac byddwn yn ymddangos eu cyfnod o'r Ffyrdd Pwysigol, ac yn ymddangos i'r cymdeithas, Caroline Gilly, ymddangos ymddangos i'r ffinansol, Alan Gray, director of finance NHS Grampian, Paul James, executive director and director of finance NHS Glasgow and Clyde. Last but not least, Jerry O'Brien, director of finance NHS Ortenay. Welcome to you all this morning. There's a number of questions that the committee are interested in. Can I kick off with the question in and around earmark funding? We think it may be useful to explore this area. We picked up on a couple of things in terms of Ortenay. We understand particular relevance, which has 35% of your total allocation as earmark funds, which we might have expected to be reflected by Shetland and Western Isles. A difference is there that we would appreciate some explanation about the high proportion of earmark funds in Ortenay as compared to Shetland's and Western Isles. It's just an area that you may wish to enlighten us about this morning. Thanks. Yes, thanks. Mr O'Brien. Thank you very much. I think the level of earmark funding, I'm not aware of the details between Shetland and Western Isles and myself, but certainly for NHS Ortenay, we do have a proportionally high level of earmark funding. There's probably a few issues in there. We receive our Highlands and Islands travel scheme funding just over £2 million, which is an earmark funding. This is all in the context against a core revenue allocation of just under £36 million, so the proportions are quite high. Obviously, there's our primary medical services allocation, which again is just over £4 million, which again makes a significant contribution to that. Then we have a few other smaller allocations total, about £1 million for our alcohol and drug partnership or e-health money, where we receive just between those two, about £1 million. All of that adds up to quite a significant proportion of our total funding. I suppose in understanding the question, I don't fully understand what we would receive differently from NHS Shetland and Western Isles. I can just assume it must be in relation to the proportionate share against their core RRL. The earmark funding in itself doesn't present any problems for NHS Ortenay because the funding comes down for very specific topics and that's where we put it into. Although it's proportionally high and it's proportionally high against the other territorial boards, it really doesn't present any issue at all and in many ways helps us with the planning because it's certainly in relation to e-health. We work very closely with e-health colleagues and Scottish Government colleagues in relation to Highlands and Islands travel scheme, so we're actually able to plan on the earmark funding coming through on a fairly consistent basis. I accept that proportionally we are probably the highest in NHS Scotland, but I think it's probably relative. It's that relative position to our RRL position of just under 36 millions, sorry. Yes. I can give you some background information from borders. Our earmark funding is about £24 million, which is 12%, so much lower percentage than Gerry. But within that £24 million, the biggest element is just over £15 million for GMS contract, which is the nationally geed contract we have with the GP's independent providers, and then the other largest element within that £24 million is £3 million for our salary dentist service, so we employ dentists to do general practitioner work. So if you take those two allocations together, £18 million out of that £24 million is really for a very specific purpose. In addition, the final £6 million is some of the issues that Gerry picked up around about drug and alcohol, and another big element is e-health and how we actually take information technology forward within borders. So you can see, once you take the larger elements out, the amount of funding round about earmarked is quite small and for specific projects. Can I just say? Well, I think that the purposes of the earmark funding have already been mentioned by colleagues, but I think that the point to make, although it's obviously much lower as a percentage in Glasgow, it's for the same sorts of purposes that have already been mentioned to the committee. But I think the benefit of having earmarked funding is that it helps to achieve specific objectives, and that's, I think, what the key of all of this is. So in other words, the funding is given for something and it's used for that purpose. So the same is true in Glasgow, although obviously the percentages are very different. Another matter, convener, so I don't know, unless I've got a supplement on this one specifically. Is that okay? Yeah. Thank you. Thank you, convener. Perhaps maybe start with Orkney, and one of the things you mentioned was the e-funding in terms. I wonder, are you looking at a reduction eventually then in your travel cost? Because if consultations are going to be done through, for instance, a Skype-type system from consultants, and you're going to be looking at that, surely then your travel cost will diminish quite considerably, because patients won't be, for instance, going to Aberdeen for specialists, and the consultants won't be travelling to Orkney either. So do you anticipate a reduction eventually in the costs of patients and of consultants having to travel to Orkney? Yeah, I mean, I think that's absolutely one of our planning assumptions, and it's one of the areas we've been working very closely with our Scottish Government colleagues in, is in terms of the Highlands and Islands travel. For the exact reason you do, we're doing a lot of work to repatriate services to Orkney, principally from Grampiad, and we're certainly planning on the basis of we will be able to reinvest that money locally in services rather than spending up on airfares. So we'd certainly be looking at a reduction in travel costs and reinvestment locally. I think the other aspect to that as well, although the principal changes, or maybe the changes of the biggest magnitude will be between ourselves and Grampiad eventually, what we're also spending a lot of time on, and this is where we're really doing a lot of our eHealth work, is we're looking at all of our islands as well, because what we're trying to do as well is not to have people travelling, say, from North, Ronald's, or Westry into mainland Kirkwall for an outpatient appointment there, so we're spending quite a lot of our eHealth money last year and this year and moving forward and actually making sure the facilities are available on Ireland. So I'm totally expecting a reduction in travel off from mainland Orkney, on to mainland Scotland, but I'm also looking on a reduction of travel time from patients coming in from the Isles as well. So I think all of the aspects that you've picked up are certainly true, yes. All of it. In fact, you've actually got the return of better healthcare and wellbeing in terms of the patients. Do you anticipate the cost that you'll eventually save? Surely you've got a projection there? What we are looking at, a return journey to, I mean, if you use a good example at the moment, we are in the process later this summer. Our on-island CT scanner will go live and we're probably looking at a gross revenue commitment on that after we bought the scanner and kitted out the building of about £400,000 a year. Now, we estimate from the scans which we'll be able to do on-island because we still won't be able to do everything on-island that we'll be able to save about £150,000 a year of that from reduced travelling time for patients who are currently going down to Aberdeen for scanning. So although there will still be a net investment, we're probably looking at a gross investment of about £400,000 coming down to a net investment of about £250,000 and what we're tending to do is look at it on a service-by-service basis in one of the areas as we've made or move into a consultant-led model for medicine, obstetrics and gynaecology on island as we're actually looking to use the skills that we now have on island from those medical colleagues and actually looking at specific services. So we don't have an overall projection, we really are looking at a service-by-service and almost a specialty-by-specialty, but it would certainly be a correct assumption that we're anticipating a shift from spending money on travel, accommodation and lots of downtime that way to actually providing services directly on island and taking the whole patient experience and improving the whole patient experience. There are clear advantages to us, Dennis, in terms of the release of consultant time, there's a capacity of consultant time required to go up, do the sessions and not going to come back down. So we see that as being advantageous to us and to us on releasing clinical capacity to do more work within the gynaecology and gynaecology in north area. There are advantages really from a clinical person-centred perspective is that we're able to hold these consultations hopefully over time with not only the patient himself, but also the patient and their GP. The GP is an important part of the continuous care of patients, particularly in remote locations or in remote locations in Grampian. The ability for a consultant to have that consultation with the patient and the GP really has some really long-term clinical advantages in terms of helping that person to stay closer to home and well for longer. So we see the cost advantages, but in the longer term there are real clinical and patient care advantages overtaking on that model. It prevents people from travelling, even within the mainland, many people make long journeys for very, very short appointments and very little clinical benefits. It's a difficult moment for patient wellbeing in terms of the long term. However, are you projecting in Grampian a cost saving as well? Not just in consultancy time, but in terms of the provision you make within Grampian to some of your remote and rural areas and using the same e-type health that you're projecting, say, for Orkney and using a consultant in that way. The biggest saving we see is actually is avoiding cost, rather than cost saving in itself. We've got a projection. Surely there must be a cost saving. I know you're going to avoid, but there must be an eventual cost saving. Well, hopefully we will have to identify a number of cost savings over as part of our annual budget, so we hope there will be an element of cost saving, but clearly part of that is also avoiding the future costs in terms of increased activity. We face a rising population in Grampian. That's our biggest single challenge in addition to having to make savings. We're having to manage a population growth that over the next 10 to 15 years will certainly see a rise in the population, both of working age and also those post-retirement. So I think we do have to be minded to both making sure we're able to provide a qualitative care within the resources we've got. People then agree with you, we do have to find ways of making cost savings, and there's been one avenue where we can make the system more efficient in blue's capacity. There's also a challenge of actually workforce will be as much a limiting factor as finance and be able to recruit and retain very specialist staff, so this will be a way of using that scarce resource in a much more efficient way to benefit a greater number of people. Thank you. Thank you. The question that popularly in my head when Dennis was pursuing that line is that there was a significant investment of £400,000 in the new scanner, which obviously will benefit the people of the Orkney and the patient experience, but it seems with the relationship with Grampian that it was going to free up resources and efficiency. Did you make a contribution to the is there any sharing of the budget or investment for change that benefits both Grampian and Orkney? Yeah, we work very closely with Orkney in terms of the way that close enough to share budgets are not that close. We don't share budgets, but in terms of actually the way we cost the services that we provide to Orkney, we do that on an open basis with them, and in fact we don't cover the fuel cost of the service that we provide to Orkney, so in many ways Grampian do carry part of the burden of providing the service to both Orkney and to Shetland health boards. That's part of our annual budget decision making process. We work very closely with Jerry and the executive team in Orkney in terms of helping the future redesign of the service, so we're very much part of that journey and we do make a contribution both in terms of our thinking and input into that, but I do think that budgetary sense we do work very closely with both the island boards to make sure that we provide our resources in the most efficient way, both on a basis that's affordable to both health boards. Gil. I don't think it relates to financial matters per se, but I just want to understand the corroboration that goes on when the scanner is up and running, what happens, where does the personnel come from, does it come from, the sources in Grampian or is it new resources? Actually a bit of both, we're at the moment undergoing a recruitment exercise for additional radiographers on island and we will recruit those who have already recruited one of the three that we need them, we've got another two adverts out at the moment, so they are new resources on island, but in terms of the actual reading of the results that will be undertaken by the consultant radiology staff in Grampian, exactly as it is at the moment, so in terms of the reading of the scan it's actually the location about happening that will change and it just goes, it uses the e-health technology and goes down the line to Grampian and is read exactly, and that's one of the good examples of where Grampian and Ortony do work together, so there has been recognition by the radiology staff within Grampian, some of the scans which will happen on Ortony are currently happening in Grampian, obviously as we open up our new scanner on island we are fully anticipating that the number of overall scans will increase, but there's a recognition from Grampian that there will be some freeing up of radiology times although we are having discussions about a full reporting service, it's not the full cost of a new reporting service, so although there's not actually been a physical transfer of cash, it's not a full reporting service, so I think totally support Alan's point that I think the development of services on Ortony and I think this is one of the key elements for us, we have to develop services on Ortony and we are very keen to repatriate services to Ortony, but it's services which are appropriate and safe to do so, but it's also very mindful of services and the impact that then that has is because there's always going to be a residual left in Grampian which we need to send to Grampian because there's always going to be a level that we can do, we cannot go above in Ortony because we have no ITU facilities or so forth on island, so patients who may well need ITU services are always going to have to go to Grampian, so there really is quite a dependency I would, I think is probably a good way of saying that there is a dependency from Ortony on Grampian, so it demands that very close working relationship with NHS Grampian. The relationship anyway, particularly when you come to Glasgow to provide services for you know about how health boards are working and providing services and what programs could be made there. Dennis, I was going to bring Bob in just to move along a wee bit. Okay, thanks convener. I want to ask a little bit about budgets in relation to prescribing with GPs and in hospitals, not just the price assumptions but the volume assumptions that's been provided by to the committee. Now do a little bit of context to it and I'm sure there's been good work going on across a number of health boards but I do recall when I sat in the public audit committee at a report particularly praising a lot of work done in Glasgow and Clyde in relation to dealing with polypharmacy and most appropriate medications and some real not just cost efficiencies but also care improvements for individual patients so therefore constituents of mine. I'm sure there's been good work elsewhere but when we see differences in figures we want to ask questions why they exist so for example I'm looking at the table in front of me that shows a cost assumption for 1450 of a 1% increase in Greater Glasgow and Clyde in relation to the prescribing budget but it's 2.1% in borders but the most dramatic figure that jumps out at me is a 16.8% predicted increase in the hospital prescribing budget in in Grampian which is a dramatic outlier that might just be the way it's accounted for and some more explanation on that would be good but the general theme I'm trying to get to behind these numbers is apart from that outlying figure which I think needs some closer attention is for example Greater Glasgow and Clyde having done some good work already convener their baselines therefore are new baselines from which you move on from so dramatic savings cease to flow from that they become modest savings for a far more efficient baseline I'm just wondering between the four health boards we have present which of you feel you have squeezed as much as possible in terms of polypharmacy and best pharmaceutical advice for patients where there's still savings to be made and how you arrive at these cost assumptions so not that focused convener but I think we have to get beneath some of these figures in terms of the 16% I can maybe address that first the majority of our spend predicted spend increases in largely acute sectors opposed to the primary care prescribing budget and that's where a number of factors that's large around the foreman services cancer sorry there's cancer so dematology I think ophthalmology and the sort of the generic sorry orthopedic no it wasn't orthopedic I'll come to you but the rate of increase is largely due to the population activity increase within within Grampian and also the fact that we expect these drugs to be applied to new indications so new clinical indications over the next year so part of the reason that we've increased our budgetary spend on acute is largely the fact that underlying activity growth that we're experiencing in Grampian is largely linked to the population growth it's largely linked to the fact that in terms of cancer services we're seeing a higher increase in the number of patients who can take fairly aggressive forms of cancer treatment in Grampian we've got the benefit of a relatively healthy population so in terms of cancer treatments quite a lot of our patients can go through second third and fourth line cancer care cost or cancer care a big part of the increase and maybe that explains part of the reason that we are different from say Glasgow or some other boards in terms of the GP prescribing budget I think we're probably more in line with other boards in terms of assumptions around volume and to ask you a question on polypharmacy we're probably just at the start of the journey there that's looking at largely patients who've got multiple medications we already work very closely through we've got within each of our community health partnerships we have an aligned pharmacist whose primary role is to work with its primary roles to work very closely with the GP practices identifying whether there's variations in practice whether there's variation in prescribing to try and work with them to try and eliminate that and to make sure that we're making best use of the prescribing budget I know Mr Jay's what's in but there's a very specific point on grampian if we could follow that through so the good bit first of all of course is that means there's additional efficiencies to be saved by grampian that you're planning ahead on which so that's good that you've put that on the record you're you're starting the journey perhaps greater Glasgow and Clyde started two or three years earlier and we'll hear more about that in a second but you did mention that threefold increase in the pricing budget in hospitals and you mentioned treatment of cancers I think ophthalmology and you mentioned a third one actually don't worry about that too much it's just I don't see why that would be specific to grampian as opposed to any other health board and in relation to new indications for treatment of cancers and other conditions that would be fall that's a good thing incidentally but that would be fall every health board not just grampian so I'm still struggling to understand where the threefold increase from grampian comes from and I'm not trying to be awkward but when we get an answer that doesn't seem to make sense to the committee it's reasonable to come back so could you maybe try again on that one is there something specific to grampian in relation to cancer and ophthalmology and new indications that's specific to grampian and not to other health boards have sight in terms of the assumptions that other boards have made the way it works and grampian as we take advice from our medicine's committee so it's not a financial decision this is based on advice given to us by our pharmacy specialists and our clinicians within the hospital and we have to say that on past record their predictions have been relatively close to predicting particularly around acute budget to actually what happens in terms of underlying you know change or in terms of the prescribing practice within the hospital and also the cost of the prescriptions that we issue I come back on that still none the wiser and why grampian would be different than any other health board perhaps that's something if not just now you could certainly come back to the committee and writing in relation to because they imagine that you would be you'd be very aware if there was a dramatically higher prevalence rates of cancer and grampian than other health boards or there was a much much more significant demand for the treatment of certain conditions of grampian and other health boards I don't quite get that but if you could contact maybe the committee and writing with more information that would be good can you be there I apologize I know Mr James wanted in yeah I think we are looking from a response and Bob I think you also asked the question about a Mr Gray responded to it about previous assumptions being very close to being correcting and satisfied that the process you're going through is as a robust one and maybe if others could comment on that anyway but Mr James if I could just I don't want to revisit the evidence I gave last year to the committee but for us in our in our forecasts the time of major off-patent savings is coming to an end and so in our 14-15 plan we have not taken account of the sort of credit that we were able to take account of last year and I think it's important to recognise that if if I could deal separately with GP prescribing and then acute in terms of GP prescribing I think your points your first point is correct in the sense that to some extent we're now reaching a point where we feel that in terms of our move towards generic prescribing rather than branded prescribing which has been one of the things that's underpinned some of the savings we've achieved in Glasgow that probably we're reaching saturation point on that and that it will be difficult for us to continue to see major savings in GP prescribing because that's already been done you know tick that's in the past however there are some new drugs that always come on and there will be branded drugs and there will always be the opportunity in the future to switch to to generics when those opportunities arise and and obviously that's a clinical decision that's not a financial decision I think it's important to make that point so I don't see the complete end of savings in GP prescribing land but I think the the end of the large savings that we had last year in 1314 that I don't see that recurring in the near future I think if we look at other boards and just to sort of comment on your point it's fair to say that there is still quite a wide variation in GP prescribing practice even within Glasgow we see that variation so I think that it's fair to say that through peer group reviews and and informing GPs about the way that their colleagues are prescribing there is always the potential to still further improve and and that's that's a very active piece of work in Glasgow and will continue and I think that is something that other boards can also take advantage of and therefore I would see that the the variation that will exist not just in Glasgow but also around Scotland does give some opportunities in some other boards and I think you're right to to highlight that as something that the committee might be interested in if we look at the the drugs in in in GP prescribing area there is a new drug called a pixaban which is an anticoagulant which is going to incur some significant cost for us and that's part of our financial plan moving forward that's to some extent a substitute for what we thought would be a big pressure a drug called the bigotran but that was the uptake of the bigotran was not as great as we had expected because I think there were some some sort of clinical issues with it I mean I'm not a clinician so it's not appropriate for me to comment really but but there were clinical issues so for that reason it was not as widely prescribed as we had once thought but I think a pixaban is thought to be free of those issues and therefore may well be prescribed more widely in the future so we've built that pressure into our plan if we look at acute prescribing I do think it's fair to say that that's where for me that the largest pressure is beginning to occur and the points that Alan made I think are right I don't obviously know his figures but but I think in principle we're seeing much larger percentage rises in the acute medicines bill than we are in the primary care medicines bill and and I don't know whether that that trend will continue but certainly we've put significant funds into acute prescribing in the last few years and that and that continues there is a particular drug which is my current hobby horse which is one called sephospavir which is a newly approved drug for hepatitis C and which which is immensely expensive and which is not just it is not just immensely expensive sort of per patient as it were it's simply that there are a large volume of patients as well who suffer from that potentially suffer from that condition and Glasgow has a disproportionate share of the patients who suffer from that condition I think it's something like 17 000 patients out of a Scottish population of 40 to 42 000 so we have roughly 40 percent of Scottish patients now as it happens sephospavir will not be a drug that will be used for all of those patients because I believe it relates to genotypes and I'm afraid my scientific knowledge begins to run out at this point but to do with your to do with your genetic makeup so it'll work for some patients and not for others um and and and but what that means is that as we go through treating that certain patients each year um we will incur potentially an additional cost of several million pounds I mean exact figures we can debate but I mean people have talked about 16 17 million pounds a year and it will take us a long time to work through the cohort of patients in Glasgow so so that is an acute pressure which I just bring to that to that picture to sort of highlight the fact that we're seeing those sorts of medicines coming through now that I can highlight one medicine and I can and I can highlight the difficulty that Glasgow will have because we have 40 percent of Scotland's patients and 25 percent of its funding um but equally there will be other medicines in due course and one of the things we were discussing before this meeting is the extent to which medicines will be around this table I think an increasing and the continued area of focus for you because I think for us in in health boards we will continue to see expensive branded medicines hitting our budgets and working out what do we do about that uh I don't have a general answer I'm afraid to give you a solution for for the future but I do think that's that that's going to be a financial pressure which we will face in Scotland for a long period of time um the only other comment I would make is that I think that in terms of drugs like sephosphobia where there is a disproportionate share of patients in one particular health board we will need to look at the way that we risk share because um it would be inappropriate I think for Glasgow to have to suffer all of that cost and not to be able to share that around the rest of Scotland and I have made that recommendation to to Christine who I think will be giving evidence to the committee later on this morning so I'm hoping that will be taken forward by chief execs in due course before I call call call the others and and people are going to follow up I'm going to get a response from all the panelists on this but could you you know address the issue if you have an issue with um work that committee was was ostensibly involved that which was the access to you uh an increased access to you and rare medicines that are coming on the market and uh are any of that's working through the system is that reflected is it reflected in the budgets that you you you have produced and presented yes obviously the the details of the new medicines fund have not really been made publicly available I think you've decided upon as yet so we've made some prudent assumptions within our financial plans about the extent to which drugs such as either CAFTA and some end of life medicines and similar drugs will be funded um so we've made some assumptions around that but but I think it's we can't give a definitive answer on the amount of that will fund that will be funded in 14 15 and 15 16 because the plans have not yet been finalised patients will benefit from this but more yes it's thousands more yes is in the system if you estimate the work that will cost Glasgow those thousands I'm sorry we're relating Glasgow's figures to the all I've done is I've looked at the expected spend within our within our our drugs budget and I've made what I hope are some prudent assumptions about the funding that we might receive in relation to some of those drugs 5.9 million 5.9 can I have the responses from the others on the Bob's general questions and maybe address the question of access to new medicines and then then we'll let the panel come back and then of course anyone who wants in we'll get it yes yes perhaps if I start off with with the octane position in I don't want to repeat loss of what Paul and Alan have said we've got a very similar process and I think I think for the important thing for me is we do need to be separating the GP prescribing out from the acute and is undoubtedly true and the figures I can can actually talk about for for octane I think we're probably in the same place in GP prescribing in terms of what Alan has described for a grand pain I think we've done the work on the the the genetics and I think we've got to go to a place where we're relatively comfortable there's always room for improvement but we've got a particular couple of practices now and I think we can do some more work in terms of outlying practices and we're now engaging with one of our better practice GP practices to actually actually take that that work forward because we're now going to get into the realms of actually clinical decision making it's not a volume issue it's not it's actually understanding why GPs are prescribing so we're addressing that I think the bigger issue for us is in terms of our acute sector and I split that in between perhaps what might come through the hospital and what I might regard as the most specialist drugs which which Paul has spoken about in just in terms of octane I know within the financial plan for octane I've said a site of 15% uplift in the specialist drugs which is probably many of the drugs that Alan has spoken about in terms of cancer drugs and particularly the the hep C drug and I won't try and say it because Paul can say it better than I do and we are definitely seeing that I mean looking through the the Scottish Medicines Consortium's forward look which came out at the at the beginning of the the calendar year if you'll get the the drugs which are mentioned in that and I only taken taken a few of them there's a potential cost pressure on octane there of just under £300,000 which actually equates to just under just under 1% of our RRL which is actually quite a massive a massive increase for us so similar to Paul we've taken a view I've taken a view of my director pharmacy in terms of what that what that might look like and we've got we we believe in our overall financial plan in terms of drug spend and probably looking at setting aside an additional over additional £400,000 in 1415 because that is the rate of increase we're seeing primarily on the the acute side of things and probably when we were into the the specialist we've got a particular high prevalence of MS on the island and we're definitely seeing the drug spend on that area picking up or actually steadily increasing I think in relation to the to the rare medicines we are probably fortunate that we've not been impacted on that yet directly I keep a very close eye on it with our director of pharmacy so so we've had no go back into the last 18 months we've had no individual patient treatment request above and nobody go through the rare medicines fund so it's an issue for us in terms of if it arises it could be it could be a big issue so I've got within my £400,000 I've got a notional sum set aside for that so I couldn't tell you exactly how much the rare medicines fund might impact on us we've got the other added complication at probably some of our stuff will go through the Grampian specialist treatments there so that's another example of where Otney and Grampian really need to keep very close to each other because undoubtedly some of the requests that go through Grampian will be for Otney patients and we just need to make sure we manage that so I think our position is very similar to what Alan and Paul have described but I would certainly support Alan in terms of the growth that I'm seeing in Otney in terms of those most specialist acute sector drugs. That's it, with the risk of repeating what my colleagues have said, first of all if I go to acute drugs a process is very similar to that described by others where we have a medicines resource group that does the horizon scanning work to try and identify what the likely new drugs will be and the uptake. One thing I would probably add is that I think what I've put in my return is an uplift to my budget and so therefore the point I'm trying to make is your baseline might be different insofar as that if you've under spent your budget in the past obviously you've got that benefit so potentially that can mean you're requiring a lesser uplift if your baseline is a bit higher. When it comes to the GP prescribing budgets certainly from the case of borders there is much more to be done and I'll just give the committee a flavour of what we're planning to do. We have done well on generic prescribing but there are areas particularly around about our weighted patient costs that we are focusing in on. We're looking at, we've introduced a system in December 2013 called script switch which I think the committee heard about last year to help GPs pick the most cost effective drug. We're working with GP colleagues to look at specific areas of drug spend where NHS borders benchmarks poorly. One year we're looking at this year's respiratory drugs. We've also done as other boards have a work on polypharmacy which is not just about obviously the cost but it's about it's good medicine it's about quality of care and it is about patient safety but today we've looked at patients who are taking more than 10 drugs and are at a high risk of admission to hospital so you can see that's quite quite a big basket of drugs so we've still got quite a lot more to do round about that area so that's another area we're focusing on this year. There's national therapeutic indicators and we've used the same principle implied that in borders and looked at where practices on specific drugs look like an outlier and gone and talked to GPs about that. We've also looked at wastage which is really about focusing round about the dose we give a patient, the actual use of prescriptions and actually how a patient stops medication as well as looking at the use of nutritional products. We've got dieticians in helping us so in the case of orders a lot more work to be done round about GP prescribing and we're taking that forward over the next year. If I can maybe just finish off in terms of the four areas I was looking for previously where there's pressure I can come back and confirm this cancer by gestive disorders ophthalmology and rheumatology so just for the record. The other thing that would add to Paul in terms of IVA catheter which is a drug for CF funded through the rare medicines fund and in Grampian we have a higher instance of patients who require CF treatment and IVA catheter drug for us about £2 million as a current annual cost. We've predicted that that will continue to be funded through the rare medicines fund through 1415 that's the assumption made in our plan. Beyond that there is an uncertainty as to the future funding for that we've made an assumption that will have to continue within our financial budget. Within the SMC new drugs you didn't ask how much we've set aside, we've set aside £1 million in 1415. As we go beyond that there's a higher degree of uncertainty as to you know how that will flow through in future years but we expect that it could go up to between £5 million and £10 million that's the degree of uncertainty we have over the period of the next two to three years. So there's a degree of uncertainty there that we'll have to build into our budgets but we're waiting further and as Paul says we're waiting further information and guidance and that will further inform the budgets from 1516 onwards. It's really really helpful. In terms of benchmarking and rolling out best practice elsewhere I'm reassured that there's still savings to be made. I know rising cost but savings within those those rising costs so that's good convener. In terms of Mr James talking about prevalence and clusters and of various conditions befalling certain regions of Scotland and others the risk share scheme that's interest I'm sure that's something the committee might return to and indeed the new medicines I'm sure that's something we'll return to as well. However just one final question convener in relation to pressures on acute hospital prescribing I'm wondering how much work around that can be done further how much of that is is due to prescribing due to unscheduled admissions for older patients how much of that could be tackled via preventative work within the community in other words is some of the ways in dealing with acute prescribing should we just expect that will increase that's how it is or is there work to be done in terms of if you have a smaller cohort of patients in hospital in the first place because they're not coming through A&E or they're not they're not having unscheduled care at hospital because social care is stepping in to take the burden is any information about how that could be reduced or should we just expect that's a significant and increasing part of the prescribing budget I suspect that it'll be similar across all health boards conveners that maybe one or two replies to that so my colleagues will want to come in and ask additional questions I'm sure. If we're seeing the rise it's larger than the very specialist drugs which you know are really available for very small groups of patients they're the ones where we're seeing the greatest pressure I think if I look back over the last few years whereas the biggest rises it's largely through not the volume growth in terms of activity but largely through the increasing prevalence of very specialist drugs that do have a benefit but a small number of patients we've seen that with the new SMCA drug approval process again the expensive patients but will have a difference for a very small and select group of patients who have particular cancer conditions or other conditions that can benefit from these drugs there is no doubt that in terms of the integration of primary and secondary care there's further work that can be done and I acknowledge that that work is ongoing to try and reduce wastage to try and make sure that people are giving appropriate medication there's a danger that we can overload patients sometimes a medication so the polypharmacy is very much geared towards that and sure that when patients are giving changes in medication that's reviewed in the context of the entire package of medication that's been given to them because many of the older patients have multiple conditions and some of the drugs can have counter effects so the polypharmacy is very much focused on trying to make sure that we're doing the right thing for patients and giving them the right bundle of medication to make sure that they have the best outcome as well as the most effective in terms of prescribing cost I just wanted to say I absolutely agree with what Alan has just said but I'd like to throw in an additional statistic that we recently did an analysis of our medicines and identified that something I think it was 80 or 90 percent of our medicine spend was on chronic conditions so sort of in answer to your question although the growth I think is is certainly in these areas there's a big block of spend which is on chronic conditions which is which is in both the acute sector and also in GP land and and I think so your point is is right in a sense if we can if we can address the chronic conditions issue if we can prevent those conditions then I think there is significant saving to be had and I would imagine it's not to be fair not just the medicines bill which is being incurred on chronic conditions I think it's also a lot of the the GP bill and the acute bill which is being spent on chronic conditions as well and the community bill so the question is whether and it's a big question whether or not real impact can be made in reducing the number of people who have those conditions and I'm afraid that's one I don't have any meaningful comment to give the committee on but I think it's something that is worth exploring I think I've got a couple of bits yes Richard and Dennis you went back in again very very briefly I'm trying to understand we've got 14 health boards all doing this work with individual practices and all managing their acute budgets but on the other hand there are two things one is what support are you getting from the centre the health improvement Scotland and JIT to make sure you don't reinvent wheels in other words if Glasgow has had this very successful program of reducing per capita costs on on GP prescribing which they have to a level which given the health problems in Glasgow you know is significantly lower than all the other health boards per capita how much of that information comes out as to how they achieved that you know how they set about dealing with it that prevents you from spending endless time in committee reinventing wheels is the joint improvement team or health improvement Scotland dealing with it that's the first question the second question is some of the things now we've got you know the big difference in Scotland's healthcare system from england is that we've got these managed care networks so that in cancer which is one of the growth areas for costs in this in in respective drugs there are only three managed care networks so how how is that costing working you know how do you determine there's a managed care network in the west of scotland for example which covers fourth valley lannochshire ashore now in our gael i'm bit of our gael inclined how is that actually managed in terms of budgeting because the the expenditure is by the clinician at the beatson on behalf of patients in fourth valley in ashore now in lannochshire so how how is that actually worked and is the system we've got one that is sustainable given that that is going to be one of the big pressure pressure areas i can kick off if you like but i'm not sure i have much to say on the managed care network point in terms of the role that health improvement scotland play i'm not very sighted on that but i do have a pharmacy team who provide the support to gps and do the visits and that team does have input to other health boards so i do think there is a level of sharing of best practice and of knowledge now i'm sure there's always room for extending that and improving on that but it's not something that's completely operating in a silo within glasgo so i'd just throw that in and i think that's worth worth developing i think that's something that we've talked about before in terms of the the managed clinical networks i'm not really sure that i can comment because ideal as you will understand on the budgets that are incurred by the beatson so that's where my focus tends to be and we tend not to set a budget at that sort of mcn level and just add a little with that i mean you you have now got satellite units from oncology and you're going to have a new one in monkrens for example who incurs the budget for the prescribing that is going to be made in monkrens is that Lanarkshire or is that you i think in terms of what operates in Lanarkshire i think that will be that will be Lanarkshire i will need to check that but uh into the majority of the budgets operate through our regional services directorate which is in our acute division which is run by jonathan best and so his budgets would be would be what i would be dealing with right i mean i'll come back to it maybe under the enrack because i don't think this is properly dealt with under enrack either i think that some of this the central boards of grampian edinburgh and Glasgow which are the three cancer networks i'm not sure they're properly funded and maybe that's a separate discussion that could come back to us on in writing if there's more information do you want me to comment on the two issues yes yes yes certainly when we're talking about prescribing a lot of our support has come from something called quest numbers look at my notes what exactly quest stands for but one of the work streams is roundabout prescribing and so we we use quest to support us in in our our programme of work and i should also inform the committee that there are networks across scotland whether they are pharmacy networks medical networks or of finance networks where we actually do share information about successful schemes on your issue roundabout mcn's certainly from borders we've very much linked into the scan the scan for the scottish cancer area network and in the southeast what what we do is any any new drugs are considered by scan for all the boards within that area and they also give us advice at the start of the financial before the start of the financial year and give us a forecast of what the likely uptake is linked to the new drugs that are on horizon scanning so we do work on a on a on an area basis we also design protocols which individual consultants follow again right across the whole network so we are working together in a number of areas i get a bill for any drugs because we have been shared we share the care of patients if a patient is seen in NHS loading which is normally case in borders loading will bill me for seeing that patient and for any high cost drugs that have been prescribed associate with associate with that individual convener it was a point that mr gray made on i think you mentioned that that you're dealing with a growth in population and you've also mentioned you touched on this of integrated health and social care is the growth in population then are you are you projecting that that growth then needs to be met through your prescribing budgets on the acute side because i would have thought actually with the integrated program that's going on some of the prescribing and actually have gone down to primary care rather than the cute and i'm also interested within ophthalmology it's a very strange one that grampians may be different from other health boards because i mean i can understand again the aging population and if you're treating wet matter the generation for instance with the centre fine but are your numbers that different from other health boards I guess in terms of come back to come back with some formal written response i think in that i can't it was me to comment just now because i haven't seen other boards and where we compare but if i could come back to the committee with a written response in respect to the query as to why we are different from other boards in terms of assumptions i will do that in a way to explain some detail that was helpful to you in terms of the the integration i think there's no doubt the integration of services both within the NHS as well as between the integration of services between the NHS and local government over time will assist us in terms of managing the kind of chronic illnesses that are contributing to our costs not mind prescribing in terms of overall health costs so there's no doubt that we were seeking to pursue and continue to pursue different ways of managing that activity growth there's no doubt that we cannot continue to provide the same configuration of services or the same type of services given the population growth that we certainly predict within our own board area so we'll have to look at different ways of supporting people look after long-term conditions and also take preventive measures to make sure that people can live longer at home without need for expensive interventional health care and how you've actually come to that conclusion i don't know what the exact population growth on gambling will be only can only base it on the number of developments are coming forward for approval in terms of housing developments in terms of the buoyant nature of the local economy so i don't i couldn't honestly said i know what the population increase we know from the activity flows to the hospital that in certain situations we're seeing a certain rise in activity we're minding that as best we can through our efficiency programmes and productivity but there is a certain a continuing pressure in terms of both the growth of the working age population in gambling as well as the the elderly population it's mainly the working age population that's where we are seeing the greatest growth thank you may be opportune then just to pick on you know the efficiencies that have been expected over over over the period and with noble exceptions you know it was around that 3 mark and there was an expectation that boards in the main not all but in the main would achieve but what is the expectation of efficiency savings for the boards from the discussions of the scottish health department and scottish government 3% still we are expected to achieve apply to glasgo and others as well yes it does yes that consists of what we would call cash releasing savings and also productivity savings but yes absolutely let the efficiency versus cut things stick to the law but i mean in terms of some of the the efficiency savings boards have reported to us in terms of how they would attempt to achieve these efficiency savings glasgo suggested that 65% of its savings would be from services a grampian expects to achieve considerable efficiency savings through workforce equivalent to 13% to 32% of the savings and borders large extent through non-clinical support services in the state facilities and again borders grampian ortonies are talking about some hr and other shared services drugs and prescribing and what would you like to speak to any of these areas where you've suggested you know in glasgo how are we going to achieve the 65% of that 3% efficiency through from services what does that what does that mean i think it's always difficult to categorize savings whether you're talking about services or workforce redesign the majority of our costs are obviously people and if at the end of the day we're looking to provide 3% savings some of that as i say would be efficiency so we're looking at a cash releasing target of 1.6% in 1415 so that equates to 32.9 million for us and we're getting 18.9 million from our acute division we're getting 6.5 million from prescribing we're getting 6 million from our partnerships and there are some other bits in there but those are the main numbers now the reality is that of those figures i've just given you yes there are there are reconfigurations in many cases reconfigurations of services so that some are some are relocating from one area to another to make better use of our existing space and the facilities that we have some of them will be due to skill mix redesign where we're where we're saying we don't need somebody quite a senior as for that role and we can use somebody more junior that was a whole mix of complicated things that are done and we've got 10s and 10s of different schemes all of which have these descriptions against them so i don't think it's easy to say i don't want to leave an impression that you know we're we're cutting a specific service that we desperately need the reality is that we have a 6% staff turnover ish in Glasgow and if you're looking at a 1.6% cash releasing target you can see that if you can redesign your workforce and if you can look at skill mix and if you can look at relocation then you have the ability to achieve that without making people redundant you have the ability to basically not replace some people as they leave but you're doing that alongside a redesign so i'm afraid that's a rather that might sound like a woolly answer but i think that is the truth of the way that it's actually done within Glasgow if if our if our staff turnover were lower or the figure were higher it would be more difficult to achieve that and so you know when we get up to sort of 4% cash releasing savings i think the the 6% staff turnover figure would just not work i think we are looking as a committee about some of the thinking that that that takes you to your projections on savings i mean i can see the new southern general the co-location of coming out old buildings from the sick kids or a relocation down there i can see you know these are so when so the new southern general what what you have massive investment what savings do you expect back from that and in terms of the wider services in in Glasgow Clyde which is a bigger one rather than the non replacement of whatever and you know that would that would achieve some thousands of pounds that the business case for the for the new hospital was written several years ago and anticipated some very significant savings coming out to cover also some of the capital charges that will of course occur on the new hospital when it's when it's finally handed over in our 1415 plan we do not have any major assumptions for the new hospital because the new hospital will not be handed over to us until the end of january and then there's a commissioning period and there's the transfer of patients so really the major impacts of the new hospital will be in 1516 not in 1415 so in my current plan you will not see much in relation to the new hospital at all business plan there's no longer valid anticipated a number of you suggested that that was a historical document that may have picked you up but all you can find for it but the business plan assumed a number of savings do they still stand or not I think I think the business plan would need to be um revisited now because some of the savings that were anticipated when the plan was originally written we have since that time reconfigured services so Glasgow doesn't look the same as it did when the original business plan was written so I don't think I all I'm really trying to say is that savings have been made bed numbers have changed and and and the whole picture is different from the way that the original business plan looked but but I think the new hospital will deliver on its you know on the intention around which it was built I think that's quite clear but I don't think what I'm really trying to say to you is I don't have any good figures in my 1415 plan that I can put on the table for you this morning because we're what we're really talking about is 1516 and beyond with the new hospital when we close sites such as the Victoria and you mentioned the sick kids so those sites will be closed services will be centralised in the new hospital I think really around and it will probably be some of the more expensive services that are likely to be centralised in the new hospital so some of the specialties so we actually create centres of excellence for Scotland so I think I think the whole picture has changed in Glasgow since that original business plan was written I'm sorry that that's no I think that's the reality that I would concede that it's difficult whether by the prescribing budget or or any of the other budgets that a lot of of the presumptions you would like to make are you know in terms of prescribing that's decided by pharmacists doctors acute sector that can drive all of this it's just interesting to you know to try and get to a point about how robust these projections can can be when all of these variables come into play you know I don't know how much more that's leaving politics aside and local campaigns and we all plead guilty to that but you know leaving that aside it must be very difficult to get robust projections and identify areas for efficiencies and savings I think that's and that within that within that context I think that's fair but I would say that you know the new hospital is delivering on its anticipated budgeted cost in terms of the capital cost and and I think you know those projections were made a long time ago and the contracts were let a long time ago and the new and the new hospital will be there almost smack on budget um early next year and I think that's but you mentioned the capital charges they've increased over the piece haven't they well the capital charge were anticipated when when the business case they haven't changed no no because we knew what the cost would be um so so no I think I mean I think I think quite genuinely that is something of which we are genuinely proud in Glasgow that we will deliver a hospital and it will be on budget it won't be massively over budget um in terms of the the future operating costs as I say that those really are I think a bit more for the future I think we're looking looking at 15 16 16 17 before I can really come back to you with some useful information on that okay let me just pick up the fact that it's helpful to acknowledge the fact that the health business is a very complex business it's quite dynamic there's continuous changes I think one of the things from a finance certainly from one board's perspective is what makes it work is the close working relationship we have with the services so as a finance team we don't work nicely we work very very closely with the services throughout the year so setting a budget is the this part of an ongoing process that you know once we set the budget we're still working with staff because things change from the first of eight percent of April things changed throughout the year so it's the importance of building that relationship such that we're working with staff and services all the time so staff leave at a post we're looking at opportunity to redesign through skill mix through changes so part of the we can make predictions of our best estimates but how we deliver them is through the very close relationship we have with staff clinical staff non clinical staff out you know I've got to say I'm very proud of you know in fact the health service does work very closely together I'm very well supported by the staff they understand the fact that got to operate within the resources allocated to the boards but staff do work very very closely and come up with them very good and innovative ways something that's small scale sometimes larger to ensure that we can continue to operate and provide level service when it's barred to do so but within the resources that are available to us. You're suggesting in Grampian that you achieve considerable efficiency through workforce equivalent to 32 percent of all savings so as a different environment you're not a clinician you deal with figures so how many how many people you know how many people do you need to move along shift along when you can figure to get your 32 percent of your total savings out of that must be a figure somewhere. I remember going back to what Paul says we have a turnover of staff every single year so it's because some of that remember that's not all that's saving some of that's efficient some of that's money will put back into the system so the difference between the three percent. I'm not suggesting you won't put it back into the system we've left that aside whether it goes back into the system because that would take us home all morning we probably will be you know cuts versus efficiencies where it goes back into the system but you've presented a budget that says that workforce equivalent to 32 percent of your savings what does that mean in terms of how many people work for Grampian now many people will work for Grampian at the end of the year is that how many jobs will go to meet that saving. In terms of we employ 16,000 staff we've turned over between six and 10 percent depending on which year so about 1,000 staff will churn through our system every year so we'll look to ensure that we can act so that's not necessarily loss of jobs it could be a change in the skill mix in terms of using especially doctors supposed to consultants using a different grade of staff to deliver the service so not all of it's a loss of staff you know I'm very keen that we maintain the staff numbers as best we can but there's a turnover of 1,000 a year not all of those will be replaced not all of them that's that's correct so how many will not be replaced well I don't know I can't give you that number because I don't have that number to hand in terms of your budget we yeah but we've set as the budget I haven't set a number of posts that require to deliver that we'll have to work through our plan throughout the year to ensure that we do deliver that level of savings I don't know how many staff are going to change I don't know where they're going to change but we know there will be changes in our workforce throughout the year so just as these changes happen we'll look to then redesign the services that are affected by the change in staff or where there's a vacancy so I can't tell you for exactly how many and what services but your budget doesn't work unless there's unless there's less credit well unless there's less or less or something it could be less staff it could be less prescribing budget it could be less in terms of supplies and services the important point I'll let my colleagues in the important point is as as for us I think when these figures are presented how did you arrive at that and how robust they are what what sort of thinking what what what what sort of buy-in do we have with these partnerships I mean we all know that um that in our our world and everybody else's world it's easy to sit down and discuss these things in the general it's much more difficult to get people to accept the reality of that decision and the delivery of that program whether it be hospital beds whether it be a number of clinicians a number of nurses or whatever whatever but budgets are being presented with savings on them that require less people I don't know if it helps by you know and evidence here that we we feel unable to say that out loud you know and when when it when it's in when it's in the budget in terms of either on the budget or it's not the way the budget set is not set but it's set in with our services so in terms of the budget setting process we go through each year we're very detailed exercise where we go through with each service what the budget allocation is likely to be versus the budget the cost of the service and there will be a gap each year and we require the services to come up with plans we review these with them both as a finance director as an executive team to make sure that these are deliverable they're underpinned by plans that can be achieved and we're reviewing challenge of that as part of the budget setting process we come up with the numbers here it's not there's not been written by the finance team in isolation of discussions with services there are very detailed processes that's behind this that all that discussion and hard decision making that's going to you can't give me a number this morning it's either it's here or real but it's not yeah maybe I could come in and describe the process in borders just to give you a flavour of how we arrived at what I call efficiency programme the numbers you've got in front of you that's made up about in in the case of borders about 30 different projects so it's not just one project there's lots of little projects and how we identify those projects is we look at the national programmes I've mentioned that already around request we benchmark our services and look where there's potential room for improvement there we work both at a regional and national level looking at opportunities we try and make increased use of technology and we also engage as Alan said with our staff patients and services and so as I say as a result of all of that engagement we do identify individual projects each project is actually approved by something we call the clinical strategy group which is made up of clinicians managers and partnerships we get by into the individual schemes obviously there are always risks associated with each of these schemes and in our returns we put a risk rating associated with those and just to pick up for board there's some that you mentioned particularly as we have a focus round about estate rationalisation and we've set ourselves a challenge and target of reducing our estate by 20 percent and that's partially linked to some of the challenges we face round a bit capital but also trying to reduce our revenue running costs so to take that forward we did a space utilisation exercise and we looked at our underutilised accommodation we've relocated service and linked accommodation to actually working practices so if you were a community-based service you needed less accommodation than if you were an office-based service the other one you picked up was round about non-clinical services and again we've set our non-clinical services our back room services a 20 percent challenge where we've looked to ask them to increasingly use technology to streamline their processes and use functionality of systems so again as a result reduce costs associated with some of our non-clinical services so that did give you a flavour and how we actually get that buy-in to our individual projects. I think we got through a very similar process in Orkney and I think to address the point about staffing numbers if you look to our workforce plan the staffing numbers for NHS Orkney will be broadly the same in March 15 as they are today but actually if you delve down into that what you'll actually see is quite a few changes in the composition of those staffing numbers so for instance we as we were speaking about earlier we are recruiting additional radiographers to manual CT scanner we are recruiting additional nurses for our outreach service within the acute sector and we are increasing some more of our medical workforce so all of those areas will go up so given that we're remaining broadly static other areas must come down and that's the way it will be so part of our drive in looking at what we've what we call the earthshared services are really good exemplars of that as we used to have a laboratory manager on island who's now left us and we've now went into an arrangement with Shetland but we now share the laboratory manager and we share the quality manager so on rough headcount I'm down one but I have the exact same service coming into laboratory and actually I actually have an increased service in terms of quality management in there a big piece of work for this this year is we're looking at all over estates and facilities staff and by the facility staff I probably mean the domestics, the porters, the catering staff so we are looking at they are in conjunction with our HR colleagues that we're just about to engage with their area partnership colleagues in terms of this is probably in preparation for the new hospital coming along in four years time we're moving towards a generic worker so no longer will we have a dedicated porter and a dedicated domestic and dedicated estate staff we'll be looking for a generic worker who can actually swap between all three of those those areas what that will allow us to do and again what you would look at in a rough headcount is we will probably end up with maybe five or six less at the moment we've got eight porters 10 in estate staff and about 28 in domestics I'll probably end up five or six less than that at the end of that period but exactly as Alan has said that will be achieved by the means of turnover as people leave the system we won't replace them what that allows us to do then is do the reinvestment in other areas we've got a whole range of other services areas where we're looking at as well and we're looking at we're using the national workforce tools to make sure that our staffing levels are appropriate in all of our clinical areas where we are doing a bit of work this year is and where we're probably a bit behind the times in terms of it goes linked to technology we need to do a lot more work in relation to our rostering systems to make sure we've not got duplication on shifts and overlap on shifts and that the shifts are actually starting at the optimal time both for the delivery of the services and from a finance point of view so that's the process we're going through big area for us this year and it's been the use of locums in going into 14-15 because my financial plan allows for a particular recruitment pattern the consequence of that is that we will have to use locums to fill the gaps and obviously a big area for us then is to try and accelerate that recruitment to try and minimise the expenditure on locums so similar to Borders we probably have about 20-25 schemes and just pick up your earlier point some of those will end up in us not recruiting to post which we have in the system but overall our overall headcount between April 14 April 15 will remain broadly similar but I'd say quite quite a different skill mix then if you actually drill down below it that answers the question about award and they've been the only board not planning efficiencies through the workforce but just in terms of planning efficiency through the workforce you know it's opportunistic it's not necessarily planning is it if you know in terms of if an opportunity comes up because someone's leaving rather than you know seeking opportunity for for for changing delivery because you you can't go out and say well that department there we would like to change that we would like to lay people off or whatever I know compulsory you've done the same place but for each of those individual projects I refer to there's a workforce assessment done and from that we can quantify what the workforce impact is and as Jerry said it's not just about reducing your workforce because across here you've potentially got areas of service development investment so our workforce plan takes both reductions in staffing linked to efficiency but also increases in staff linked to service development or service redesign so you have to bring the two elements together and our workforce plan does that. Paul James can I just comment on the point about is it planning or opportunism I think I think on the whole it's planning there would of course be some opportunism and people leave and people take the opportunity to do some sort of redesign of the workforce but the vast majority of the of the pids that I've received in the business cases I've received for the savings that I look at talk about things like skill mix changes they actually are planned skill mix changes if I look at the new hospital we've created around 500 jobs with the new hospital if I look at the investment that we made consciously last year in nursing to reflect planned changes on nursing ratios we've made an investment in that so I think there's much more planning than there is opportunism I don't think it's I don't think it's one or the other but I do think there are some very significant aspects of planning and some new job creation as well which I've just given a couple of examples of. I think we need to move on but it was you suggested that the turnover was the big big factor in terms of efficiencies there's a difference between workforce planning and development where we're not seeking to achieve any efficiencies really as described in the budget whereas on all of the others we're we're attempted to achieve efficiencies through staffing levels which is sorry can I just can I just if I misled the committee I apologise what what I meant to say was that the six percent turnover figure enables us to achieve those planned savings I didn't mean it drove those savings in other words if somebody comes up with with an intention to redesign a particular part of our workforce then that is achievable without redundancies because we have a staff turnover that was my point I apologise if I didn't express it very clearly. I've experienced this person at the Beatson where you redesigned the the daycare service and it meant that 10 staff were redeployed so it's actually about you know if the opportunity arises with someone leaving you can actually then try to redeploy staff as part of service design of another service so I think there is a fundamental point and that is that the whole service in Scotland saw a really quite a abrupt decline in the number of nursing posts it was up at two and a half thousand at one point and we were certainly being you know expressing quite considerable concern about that reduction in nursing staff it's now back down to 500 it's really it's gone down and come up again and it's quite difficult to see how that was part of a planned operation and we interestingly have your comments on that I mean it almost every health board showed a significant decline in posts you know so these were actual losses in workforce which seemed to be part of an efficiency drive reduction in budgets which has now been substantially reversed I'm glad to say but I don't think I can make any of us can make much of a useful contribution I think your observation is correct that the numbers went down and the numbers are now in a sense going up but to say it wasn't planned is just not correct because all of the directors and managers who we engage with as part of our budgetary process have produced these plans now the fact that they've reversed some things I mean it doesn't necessarily mean that they've actually reintroduced staff in the same place as they had them before you know you've made the point that they have at the Beatson you gave an example of a service redesign now I think I think you know there are lots of those redesigns that go on some of them require more staff some of them require less staff and of course that's put in a context of an overall financial challenge yes but I don't think it's fair to say that doesn't mean there's any planning around the place I think actually the majority of my directors and managers would absolutely strongly object to that what's the planning that you need to make two and a half thousand on the voluntary basis those those nurses who presented you with the opportunity volunteered for redundancy and were paid redundancy and pension packages now it seems a long way round you can make it virtue out of it now but they're not necessarily back in the places that we wanted them but sure there's a better way of doing it rather than making a lot of people redundant out of one door in another door and put them in another ward or in the community which is effectively effectively what's happening I'm looking at you know all I can say can read it is I think I think that the health service in Scotland clearly is undergoing redesign and there have been many many initiatives some of them large some of them small and they involve staffing changes I don't think I honestly don't think you can draw any conclusions about the just a lack of planning I mean the reality is there are major redesigns going on all over the place and and what you see in our budgets is is a small reflection of that and so I just don't I don't link the two I mean I accept that the staff numbers have gone down like except that they're going up a bit certainly that's my experience reduction and it's strange to see that very sudden reduction and then the increase I mean I'm delighted with the increase again but and I'm sure there are different posts but you know it does seem strange planning that you actually saved two and a half thousand nursing salaries three years ago and now you know you've actually had to increase it again I just I don't follow the planning mechanism that actually got those posts two and a half thousand of them away and they weren't replaced immediately by other posts in new design services which is what's now happening not going to get Bob okay alien first alien info thanks can I actually I think the discussions probably moved on because the supplementary that I wanted to ask actually for Alan Gray was around the extent to which Grampiam is using the mandatory workforce planning tool to help make sure that you've got you know the appropriate staff for the right skill mix in the right place at the right time. Lead nurses in each of the sectors to tell us what the predictive tools would would tell us in terms of the nursing resource they require to manage the services that they deliver and clearly for Grampiam there's a gap between what the workforce tools would say so what we're going through is a second exercise to actually prioritize actually what would what we'd need in terms of immediate priorities because a part of the application of the workforce tools is the professional judgments to be through an iterative process of reviewing challenge with the second nurses with a view to making some changes in nursing workforce over the next year we're due to meet as a board I think sometime at the end of the summer to look at output of that process and then make some decisions around further investment within the nursing resource informed by the workforce tools. We'll not be able to match the full resource but certainly work in order plan over the next few years as we receive further enrack additional worries to use that as best we can to to address gaps to service one of which is an nursing resource. Actually convener the question I'd want to now ask was around the the preventative spend aspect and the potential savings that you anticipate from the various initiatives and projects that are part of your preventative health programs and I'm keen to know more about the extent to which the boards are assessing the potential long-term savings from preventative spend and any modelling work that you are maybe looking to do perhaps in collaboration with others to help with that assessment and future financial planning as well as any progress that you're able to try and make and trying to capture the impact and performance of preventative actions. Now I note from the responses received from the boards that we have reported to the committee that appear to be some difficulties in the modelling the savings with any degree of precision and there has been reference to the potential usefulness of national work in this area. I know certainly Borders had mentioned in their response the possibility of using for example the Scottish public health network or some other appropriate collaboration so I'd welcome some comments on that. Please. We have said in our return that there are not very many savings anticipated in our financial plan for 1415 from preventative spend and that's what we said last year and I think that's what we'd say next year. I think the reality is that we make investments in certain aspects of preventative spend and I gave the example earlier of Sephospavia and we mentioned the Hep C drug which I mean this is a cure so it's clearly a preventative spend but do we know the savings that will result from that investment that we're making and when they will occur? I don't think we do and I don't think we've made any significant attempt to reflect those savings in the plan because if I were to put those savings in the plan I would then have to be saying I could reduce the number of acute beds that I need or reduce the number of prescriptions that I would expect GPs to issue in the future and the reality is I don't expect those things to be reducing in the near term and that may be because there is a demographic challenge and it may be that all I'm doing with preventative spend is stemming the growth that I would otherwise find very difficult to handle. So I always struggle with this question, I know the committee likes this question but that's the reality of our financial plan and I think we would be, I would certainly be unwise to have reduced my budgets to reflect some savings that are coming in. I think the reality is we see a level of demand, we spend all the money we get meeting that demand and we'd like some more please but you know to say that we can then just reduce the budgets because we're spending money on sephospobia or smoking or something like that is it just doesn't feel true to me sitting around the table and that's an honest answer to the committee. It may not be what you'd like to hear but it's an honest answer. I think I agree with that, I think we recognize the importance of taking preventative actions to help, support the prevention of long-term illnesses and chronic illnesses within the population. It's something we'll certainly have to do if we're going to manage the kind of demographic challenge we face going forward. The challenge we face as financial professionals is equating that to a budget setting process and setting that context of savings, reduction in budgets, reconfiguration of services. There's no doubt that preventative spend is in preventative actions. We almost want to see preventative measures being an integral part of all health service interactions, whether it be a GP visit or a hospital visit actually and also in our schools that there is a concerted effort to educate and to assist people to manage their care on a longer-term basis but the reality of that, reflecting that on a budget is very very difficult for us to predict. So I suspect there's further work that could be done in terms of modelling in terms of actually what could be achieved over a long period of time but we're a bit away from that in terms of reflecting that in a five-year plan. So it's an important point, it's an important point we have to address but it's a significant one for us to address as part of our budget setting process. Since I mentioned at my return it shouldn't have just come in but to absolutely agree with what my colleagues have said. We do try and measure the success of preventative spend linked to outcomes which we can measure which is more about increased best feeding rates and increased immunisation uptakes, those sorts of things so we do actually know we're having success and as Alan said that very much links to a healthier population that'll help us potentially deal with the demographic challenge we face. Round about the modelling which again colleagues have mentioned that it would be supportive of taking forward for this really to be honest doesn't have the capacity or potentially the skills but I think there's a real opportunity there to do longer term modelling. We tell us about outcomes in the longer term but also might help inform how we actually design our services going forward. You know the treatments that we have to give based on some of the preventive spends changing the actual referral patterns in the future so certainly something I would welcome but I think needs to be done on a national basis. I probably don't have a lot new to add to what my three colleagues have said. I mean I think going back to and Carol mentioned the quest the quality improvement efficiency support team I think is the type of a they have recently established the health economics network is another sub set of quest and I think all boards have signed up to that and that's certainly in the discussions I've been having with my director of public health is where we see we are in the same situation we don't have the internal capacity or the skills if I'm being absolutely honest about it to do the modelling that's required to actually assess the impact that the the preventative spend has had whenever relate to to Orkney we have got particularly particular issue or not in relation to alcohol related admissions but we do spend a lot of work through our local drug and alcohol partnership with the third sector and putting a lot of preventative measures in place but could I sit here today and tell you how many bed days of admissions that has prevented no I couldn't but I think it's somewhere we need to get to just to understand it but I think I would totally agree with with Paul even if I could then come up with a figure whether it be 100 days 200 days 300 days I don't think that would ever lead me to the point where I would be taking saying I now can take a bed out of the acute system because what we did was saying well that would be replaced it would give us the opportunity to replace that bed which is getting used for that particular treatment at the moment with another treatment but I think the important point is exactly as Carol says we've got to get to a point where we just really understand all these flows that are going through the system but from a purely financial point of view I don't think we're where we're probably even close to the point where we can actually start planning financially as to what these impacts would have but it has got to come. Bob. In fact I'll just very briefly come in I think Eileen might have moped up slightly in our supplementary it was in relation to the workforce planning tool and Dr Simpson's questions in relation to budgets and nursing number trends over the years it's just to get an assurance that the workforce planning tool the new emerging workload management tool and the bed management tool agreed in partnership with unions and government that they are used and followed and then the budgets that you then set are underpinned by whatever the outcome of those planning tools are so rather than looking at having a debate about nursing numbers three years ago versus two years ago or one year ago what I need to be sure is that you're planning planning your staff headcount going forward that they are using those agreed planning tools to inform yourself because I agree with you that it will undoubtedly have been planning in previous years but clearly in my view perhaps not careful enough consideration was given through that process and then your planning tools changes the landscape by which you make future decisions so clinical decisions infrastructure decisions and then the budget decisions that you're responsible for so do you use these planning tools on an active ongoing basis and has it changed how you do your planning? I can respond on the nursing one because that's the one we use. My directive nursing uses the planning tools and I know they continue to come out with newer ones that cover different areas but we do that exercise on an annual basis and we build in the results into our LDP so certainly from the nursing perspective some of the other ones you mentioned I think are just emerging so I couldn't comment on that at this point in time. I would agree we're using the the nursing workforce tools on an annual basis and we have just in the last weeks run the small wards tool we've got a particular quirk in Orkney because we have neither a medical ward nor a surgical ward so we actually have a combination of both so we have to work with that just to decide which one we take of that but in terms of output from that that is all taken through our area partnership forum and that underpins all our budget setting exercises as well. Can I just agree with my colleagues I mean that I think that's right the nursing tool is the one that's more advanced and in current use than the others and I think as I mentioned earlier on we made an investment last year in nursing and that has continued because of the expectation of nursing ratios and the nursing tools and that's all under the control of our nursing director and it does indeed impact on our financial plan. Okay quickly a couple of issues that are on our horizon which we have dealt with in the integration of health and social care the change fund has changed the integration model we've thrown the cat among the person we've caused a lot along you may or may not have heard that they just want to cap your budget a wee bit and take a bit of that because you're not handing over any and sharing that budget you don't share the vision of delivering these services I'm acting in the role of COSLA at this point to see if I can get any reaction from the the the directors of finance from the health boards but there is you know a you know buy in right across the board that we that we need to be delivering more in the community and there is a a frustration maybe expressed very strongly we caused a lot about about how we're going to make that happen and how we're going to share and get that integration going your views yes um the we have a meeting in Glasgow of the six council directors of finance and myself and a few other colleagues there's a lot of work going on on integration but in relation to to finance I think there is some in some councils I think there is an expectation that there'll be a significant shift of money from the acute sector into the community sector and I'm not convinced that we know whether that will happen or not yet because we have to see that things like delayed discharges and the problems around delayed discharges will be sold because they clog up acute capacity and therefore incurred cost we also have to look at things like the average length of stay within acute to see whether or not that is going to be reduced as a result of shifting people through the system more quickly and then back into the community where they need the appropriate care so I think we've yet to see whether or not in reality there will be meaningful reductions in acute in cash terms that can then be transferred to the community I do think what we will see under integration is people taking a look at the community health services and the social care services which have come from the partner councils and health boards and seeing whether those can be provided more efficiently on a on a common basis which is what integration helps achieve so I think there are three parts to that equation there's the acute bit there's the community health bit and there's the social care bit and I think by putting the community health bit and the social care bit under one chief officer in one hscp we can expect to see redesigns coming through in future years so I think that's something that we probably will see happening but I think just to come back to the point I made earlier about the the shift in the demographics the reality is that hits all three parts of that equation it hits community health it hits social care and it hits the acute sector and if we're saying that we expect to see you know increasing numbers of people living longer and and therefore requiring community health services and social care and acute I'm not sure that we're yet clear that one part is going to you know be substantially reduced in order to to shift the funding around I know that's the agenda part part of the agenda but I think that merely to stem the stem the increase in acute would be a real achievement and I think for the health and social care partnerships to take their responsibilities in terms of delayed discharges in particular and make sure that we're actually get able to get people into into the community in the right setting would be a real achievement. Suggesting that there any extra money is there and it can be achieved through efficiencies in the delivery of local government services rather than I'm saying that if you combine community health and social care for getting acute sector for a moment then and you run that as one team of people addressing the needs of a local community there should be some efficiencies and emerging from that how do you do that we haven't seen the plans for that yet but at the moment in our community health and and care partnerships our CHCPs which are already integrated that that work does already take place and I think that that work will continue to take place under integration but it's right I think to look at the the needs of the population across the piece and to look at integrating that pathway and the needs and the demand on that pathway and making sure that we've got some cross-system perspective on the thing. The local government representatives are saying we need the efficiencies that we're creating now just to maintain the services because our budget is unlike the health services not protected. I'm not disagreeing with you I think I think that I mean we're all colleagues around the table will have the same view I'm sure that you know we're all under financial constraints it's a challenging time for us there is austerity across the UK it affects councils it affects health boards and I accept you're right that councils seem to have taken a larger brunt of it in percentage terms but there's no doubt that we're all under financial constraint and I've tried to describe some of the future issues that we have I can't get away from that that's just the economic reality of the world we're in. I think the important thing for me in terms of that integration that is a strategic plan we need the plan and the coming together of the health and social care initially gives us a great opportunity to put that plan together together. There's certainly things we can do almost immediately around better integration of services not just between health and social care but between a primary and secondary care services there's no doubt that we can make some really early roads in terms of you know efficiencies and benefits but I think we need to bring the plan together and that plan will take a bit of time to put together but it'll set out for us the journey about how you make that transformation in the way we deliver services that does potentially release capacity from the acute hospitals but company of that plan doesn't exist in a form that would give us confidence that resource can be released very quickly. I think over time there's no doubt that we have to invest differently and look at the reconfiguration of services possibly with more in the community but we need to do that together and I think for me the integration but it's about actually this is a great opportunity to come together to jointly plan. We both face very difficult financial circumstances we've always predicted as we went towards 15, 16, 16, 17 we'd all start to feel it very difficult and for health we will feel it very difficult in these two years but that doesn't mean we've got to stop when I think the integration agenda is but coming together I think a mutual understanding of each other's position but a real focus in actually making integration happen. Supporting the people on the ground at loving services who want some help in terms of just bringing things together I think there's a lot of progress we can make without necessarily shifting resource by better integration that's the theme for me is about how to bring the integration agenda together and then look long term at how you change the configuration of services and the way the resources then deployed. That would be my thoughts in terms of what health and social care integration offers both immediate and long term. Really to us I think health and social care integration is an opportunity and we're just really maybe at the start of that. There are 837 beds today blocked if you like by the delayed discharges and the number of bed days occupied is something like a third of a million and I mean these are these are big figures and yet the council budgets are as you said under greater stress because they've had no protection no increase and they're expected to take that up with the new targets of four weeks and two weeks which are coming in. I mean I just failed to see really I should declare an interest my wife is in charge of health and social care in a council and she just doesn't see how then heaven's name with a cutting budget they can actually begin to to deal with that or those sterling has dealt with it. I want to ask a question really about the use of planning tools in relation to joint health and social care integration. Since 2009 we've had the integrated resources framework. I'm quite surprised that's not publicly known that's not widely known because it allows you to do benchmarking how much she's spending on care homes how much are you spending on GP prescribing hospital prescribing how much are you spending on your your readmissions you know what's your rate of the spada data etc. I mean it is a fairly simple framework that each of the community health and social care partnerships for each local authority have to have available if you're going to plan and yet do they all have them have each of the Glasgow chscps or that are about to come into being or the shadow ones are they have they got that data does each of the boards give that data because it's the data that comes to the board not to the council and is it a tool that's useful yes I'm just to answer for Glasgow I mean yes they all have access to that data I do think there's work to be done on developing the data and to understand useful benchmarks particularly on community health activity because I think we tend to have more useful benchmarking on the acute side than we do on the community side so I think yes they have access to the data but I think there is room for improvement in the data as we move forward with integration and I think that's something that I don't I think all the information systems director I'm not sure ISD so I'm fully aware of and I'm trying to develop that database so that we do get more meaningful information to support planning. I think that ISD is a great start I think it's the follow-up to do to give us confidence in terms it's a very high level it's very helpful in terms of it allows us to look at spend for instance by GP practice in terms of various services so I think it's a useful start point it's great I think we need to start to use it I think that's a key thing really not used it together and I think as we come together with the joint strategic plans which you'll need to have in place as we start off the new integration arrangements that has to be part of the information that informs actually where we might make changes or potentially could make changes and then how that would be transacted through a service change process. Yes, we do have an integrated IRF model which is actually run by a joint post between the local authority and myself and both organisations have access to that data and we have been working to improve the quality of that data particularly around about some of the community information in it. To date we have used it you know information sharing across both organisation it's also been used as part of some of the change fund projects it's currently coming into it's forward particularly around about the strategic plan that we're we're writing jointly as part of health and social integration so it's something we've developed there's more to do but certainly we're picking that up as we go forward on the integration agenda. I would just add to what Carol said we obviously only have one partnership so the data is available but similar to Carol we've used some of the change fund money over the last three years where we have actually have a post which is dedicated to the partnership who is responsible for actually collecting and validating the data both council and health data so I would recognise and appreciate that we've got further to go but we are using the data that is available for planning purposes and that will underpin the strategic plan which I totally agree with Al and is key over the summer months to develop in terms of how we move forward in the agenda. One in terms of a view on the Glasgow Clyde and Grampian here on the NRAC former about the robustness of that model and the assessments that were made and I suppose the balance of need is there any comments on that? Alan Gray thinks tempted. I guess we've accepted the NRAC formula is that the current basis for allocating resource within the health system Scotland is a population base adjusted for mobility life circumstances so it's a model I guess we have accepted. I guess position in Grampian we find is that we're probably the board furthest away from NRAC parity albeit we've now agreed a three-year plan that we'll in the next three years will move towards to be within 1% of parity by 2016 to 2017 assuming our population doesn't continue to rise so we find ourselves at the beginning this year 35 million pounds under NRAC parity. The double challenge we face in Grampian of course is that even when we get to parity because of the healthy state of our population if you like we don't get funded so the population in Grampian something like 10.7% of the population of Scotland but when we're at NRAC parity we'll get 9.7% of the resource so even once we reach parity Grampian's overall allocation is less than a percentage of the population because adjusted for the you know the various mobility life circumstances of the Grampian population so the NRAC formula we have accepted we're working very closely in terms of the plan over the next three years but at least now get certainty around the NRAC additional money we'll get over the next three years that does present a challenge for the board and Grampian in terms of actually how we continue to manage all the requirements of service delivery but with a resource that is less than the NRAC sum that we're I guess entitled to under the formula so that's the challenge we face and it's a significant challenge every year because it does mean we have difficult choices to make about what we can do and we cannot do and the level efficiencies we've had to achieve have probably been higher than most board in Scotland because of that relative funding position. Is the balance between the population and need the correct one? It's a difficult one to answer is a healthier population do they require less health I'm not sure one could argue that you know they've probably similar demands or different demands depending on you know for instance we're back the cancer services you know the healthy state of our population means that you know they can probably go through fairly aggressive forms of cancer treatment so you know our ability for population to access also you know a more middle class population also can access service in a different way so I'm not sure the need and it's linked around the NRAC morbidity life circumstances calculation I'm not sure there's any less need for us than any other board in Scotland but that's the situation we have to work within so then we've agreed to that we're working with that and the formula itself can be adjusted and remember the formula is subject to regular review so it's not a static formula there is subject to review and refinement and that has had some benefits to Grampian over that piece in terms of there's a remote and rural factor added in and that was advantageous to us it recognised within Grampian and within some of the more rural boards there was a higher cost length to the remote and rural working so the NRAC formula has some flexibility I'm part of the group that reviews that on a regular basis so I'd have to say that we do work with that formula it has the potential to be adjusted over time to reflect changes it's an ongoing process it's an ongoing process there are the formulas re-run then of course then to get to parity position as you can't then suddenly move to the position we've we've heard this morning from Mr James that 40% of those with hep C are in the board area I presume that we could predict that they'll have a significant number majority of the cancers in Scotland the majority of strokes in Scotland the majority do you feel that meets the needs of Glasgow Clyde as it's currently structure I think the group that that Alan refers to is the technical advisory group for resource allocation it meets I sit on it others do too and it is indeed a dynamic formula it is re-run occasionally the major influence on the formula is population and so if population is wrong then the formula comes out with you know a different answer population is based on the census the census mid-year estimates are updated by NRS and we found after the last census that there was a significant shift from the previous mid-year estimate of the previous census and the 2011 census itself as a result of that the notional allocations for funding for boards changed ours changed by about 20 million I don't know the figures for the other boards but they all changed Lothian changed quite significantly so this distance from parity the amount of funding that we get compared to this notional allocation that comes out of the NRAC formula shifted because of the census so you can always criticise a population-based formula because it relies on population figures at its heart and if those population figures shift then clearly the funding that we would all expect to get shifts so I think it suffers from that flaw but you know can you think of a better model and you have to you have to find somewhere funding the boards so I think that there's there's sort of a level of acceptance of the thing does it reflect things like the risk share that you've just referred to that I mentioned earlier so phosphopy no it's not I don't think it's responsive enough to do that quickly enough you know when we when a new drug comes out the funding the funding plans for boards are normally published fairly well in advance and you can normally predict where you are and you know where you stand it's not going to respond quickly so we need to find other mechanisms to deal with those sorts of issues and for me therefore a risk sharing arrangement that the chief executives of the health board sign up to in that particular example is for me the right approach to deal with that so you have your funding but then you say well here's my 25% share that funding but actually I've got 40% of the cost of that particular thing let's share out that other 15% surplus amongst you so I think I think you have to have a combination of funding mechanisms some are a bit long term like NRAC and some are more short term that deal with things like the risk share requirements do things like the the age sex distribution work I think that probably does work reasonably well because I'm assuming it's based on known population numbers but do the excess cost of supply adjustments and the morbidity and life circumstances adjustments which are the other two adjustments work well I think probably you would say excess cost of supply should pick up the sephospobia thing so you know again it's longer term it doesn't pick up sephospobia so I think I think it's it's good for what it does you'll never get it dead right and arguing over to the nearest penny is got to be a mistake on a funding formula I think but we need alternative mechanisms I would say to deal with those sorts of risk share type problems I think thank you very much for the time you've given us this morning and engaging with the committee we appreciate your attendance here today and once again thanks very much thank you for bringing this session to an end while we await the we're now reconvene and move to agenda item three which is the committee's inquiry into teenage pregnancy members will recall that the committee published this report in June last year and the Scottish government response was received in September can I welcome Michael Matheson minister for public health Felicity Sung national coordinator sexual health and HIV Gareth Brown head of blood organ donation and sexual health team and Collins no sorry I've got I've got Gareth Brown as well here on my script and as Gareth is at the back well you're there if we call on you and I've got to Colin Spivey learning director team leader Scottish government welcome to you all minister you wish to make a short opening statement thank you for that thank you convener I'd like to take this opportunity to welcome the committee's efforts to highlight teenage pregnancy as an area of further focus I appreciate the recommendations that the committee has made within their wide ranging report and I'd like to see your dialogue in this area to continue it's important that the committee are engaged in this work relating to teenage pregnancy that we're now taking forward across government but most notably the teenage pregnancy and young parent strategy the data shows us that the rates of teenage pregnancy have reduced in all age groups over the last four years as I mentioned when I gave evidence previously to the committee it is a significant achievement and I'd like to pay tribute to those who have worked so tirelessly to support young people and thus achieve such results some might say therefore why do we need a teenage pregnancy and young parent strategy the improvements made in sexual health have had a major impact on unintended pregnancy amongst young people this priority and investment will continue as part of our sexual health and bloodborne viruses framework but as the committee rightly acknowledged it is the wider determinants and interventions that we now need to turn our attention to in policy terms a great deal of good work is already ongoing in this area as made clear in evidence submitted to the committee so some of the work that we need to do it will be to simply bring these elements of best practice together this is true in policy terms as well as the work taking place across local government and NHS boards in the third sector we are delighted that Professor John Frank of the Scottish collaboration for public health research and policy has agreed to chair the strategies steering group his vast experience will be invaluable particularly in looking at the wider the wider determinants around teenage pregnancy and issues around health inequality we intend that the strategy will focus on three key aims to continue to reduce rates of teenage pregnancy to respond to and support young women who become pregnant and to support positive outcomes for young parents we don't underestimate the breadth of work this represents however we are confident that those partners who are part of our steering group provide the range of expertise and enthusiasm that's needed in taking this forward effectively and positively and we're not happy to respond to any points committee what to raise. Thank you minister we now move to Bob Doris for the first question. Thank you convener one of the things that struck me in doing our teenage pregnancy inquiry was a visit to one of the schools in Glasgow whose name actually periodically escaped me that's Smith Smith Croft secondary that we've visited and what a positive contribution the the the the young mothers unit made there for the for the wider benefit of the whole school actually but also for the lives of the of the children and the mothers within the unit the reason I mentioned that is is twofold firstly obviously depending on where you are in the country that kind of provision will or won't be available so I'm just wondering if the Scottish Government's get a feel on how how local authority should take forward those kind of high quality specialist units as opposed to I suppose if you like for lack of a better exception mainstreaming provision within secondary schools for for teenage mums but secondly my experience is that some of the people who are best informed on how to take forward a relationship and sexual health strategy are young mothers themselves that have been through the process. My second question would be speaking to questions in there convener would be what role you think young mothers that have been through the life experience of fallen pregnant and getting on with the job of being a mum but also being a teenager at the same time but they would have to inform a sexual health and relationship strategy minister. Okay like a number of the committee members I visited Smithycroft in Glasgow which supports young mums from across different parts of Glasgow though it's based in the east end of Glasgow itself and it was I was very impressed with the quality of work which the undertaking intensity of the work that the programme undertakes with the young mums the approach that we're taking as we discussed at our last evidence session is to look at how we can normally build on the work that we've done to reduce unintended pregnancies amongst teenagers but also how we can also support the young parenting aspect for those young women who do become parents because we know that they can experience certain barriers etc and accessing services and what we can do to try and make sure that our causal local authorities who are working with us in this area are doing that much more effectively and Smithycroft is a very good model of an approach that can be taken and part of developing the new strategy will be looking at how we can build on exactly the type of things that we can learn from Smithycroft and how that can be used in our local authorities. Although the steering group will decide on what will be in the actual strategy itself what we're not intending to do is to propose one model that has to be applied across all local authorities to allow that flexibility. There are key principles here around the services that should be made available and that those principles should underpin the way in which services are designed at a local level. So the new strategy will intend to work on the good progress we've made around reducing unintended teenage pregnancies but also look at what further measures should underpin the work that's taken forward at a local level between local authorities or health boards and our third sector colleagues in helping to support young women who do become parents in supporting them and we know there are certain factors around that. So for example one of the key aspects of Smithycroft was about maintaining young women in education because there had been a tendency for young women when they became pregnant while they were still of school age and dropping out of education and there are consequences that they developed from that and if we can make sure that we provide them with the right type of support at that particular point to make a positive choice and to go into a positive destination that not only helps the young mother but also it helps to improve the outcomes for the child as well. So it's not about one particular model but that's one model that I think highlights the very good principles that should underpin the way in which services can be delivered for young parents. Minister, I agree with that and I'd written down flexibility and choice at a local level. Smithycroft is an excellent example of what a local authority has got the planning of the support services for teenage mothers right and also that they're excellent at promoting positive parenting with the children there but I had mentioned how the experiences of mothers that have been through that experience, how that could be fed into any refreshed strategy, I mean with a lot of talk previously about how you know relationship education in very early years when primary school for example and a variety of factors that then leads to people making informed and uninformed choices later in life and the mothers we met loved their children dearly they're making a wonderful success of it but it's also to learn from what maybe they thought did or didn't go wrong in terms of their experience, their wider experience, not just their educational one but the wider relationship experience that they had with maybe youth services locally and that kind of thing. So will there be a feed-in, I mean if it's maybe something you're still thinking about great but do you think there will be a mechanism to feed in from those direct experiences of teenage mums? The steering group that's been headed up by Professor Frank has a range of different individuals on it including a representative from Smithycroft who's involved in the delivery of that service to use some of their experience to feed directly into it and the steering group will determine what's the best way for them to gather the evidence that they require, who they engage with, we're not prescribing that to them but what we have put together is a very wide-ranging steering group to allow them to start that process and that will take place over the coming ones. I have no doubt that they will want to engage with young parents directly themselves how they facilitate that would obviously be a matter for the steering group. Once the steering group have actually drafted their paper there will then be a consultation exercise before any strategy is actually finalised as well which again would give an opportunity for some individuals to be involved and I'm more than happy from the government's perspective to look at when we're consulting on the matter how we can make sure that we build into that process an opportunity for young mums who have experienced some of these services to be able to comment on what's contained within the actual draft strategy. So we have some individuals I say from Smithycroft, an individual from the Smithycroft project who was involved in the development of that project, involved in the actual steering group that will be taking for development of the new strategy. Can you come back in later on? Let me call you in for some questions first and come back in later. First of all can I welcome John Frank's appointment I think an excellent appointment I'm sure you do a great job for the government and for Scotland on this issue. Minister you'll know that one of the things I cap on about is benchmarking and variation and in our report we did talk about trying to explore two things. One was to have outcome data at local level. When I visited Oldham on behalf of the committee I was extremely impressed by the fact that the disaggregation of data down to individual schools actually set those schools a challenge some of them thought they were doing extremely well until they saw their data and when they saw the data they were horrified and the pressure both from the parent teachers association and the governing boards of the schools meant that they actually developed policies and were very responsive to the support they were getting locally. So my first question really is about the disaggregation of data and the local localization of target setting. I mean in terms of just even the outcome data of a teenage pregnancy or repeat pregnancies because again Oldham was interesting because it was well below the average in England on the initial data and the government minister actually went out to visit and caught the group together and said look you've got a big problem here we need to see you moving towards the average and they then you know explored how they could support them as an area and they did and Oldham moved up to the average which for an area with considerable deprivation was exciting and developing. So my question really is what are you doing about disaggregating data so as an individual school knows the challenges that they're facing over time and the question of the local authorities or the new community health and social care partnerships having a challenge in terms of the outcome data of pregnancies and repeat pregnancies but also the other things like long long acting contraception there are a whole series of measures that Oldham had to measure themselves against. So one of the aspects I think is important with the new strategy is that the work that's taken forward in the new strategy is evidence-based and data plays a very important part in establishing that and as well we are taking some work I'll bring Felicity in maybe to explain a bit further on some of what we are doing around data we are taking forward some work at this present time to look at how we can disaggregate the data down to a much more localised level and trying to manage some of the potential unintended consequences that can come from that when it gets right down to a school just to make sure there are issues around confidentiality and managed etc so that we can get much more focused in where we need to take action where there are particular issues. For example you know there are there's also the important element of making sure that we then utilise that data effectively and that we learn from that experience in other areas so for example in Lothian they've been doing some work in looking at the history of young mums who were in school and looking at the amount of time that they had not been attending school and there's a clear pattern there in terms of when someone's level of attendance at school drops a certain point is that there was a clear link not directly causal but there was a clear link now what we need to do is to make sure once we've established or we've identified that type of issue in data is to then make sure that not only is that being acted upon in Lothian but it's also been acted upon in Glasgow in Dundee in Fife and in other areas as well so part of the work is to make sure that we not only get it down to that level but how we then utilise that and with the new strategy I'm keen for it to be to have targets set within it at a national level that can then be utilised at a local level but also that it's very outcome focused and I think access to data is extremely important in doing that let's see can maybe give you a bit further information on some of what we are doing around disaggregating the data so one of the things that we're doing to make sure that our strategy is based on the right outcomes and being able to measure those right outcomes is a logic modelling process and whereby you look at the outcomes you're working towards and what activities you might do to achieve those outcomes now part of that process is to look at what data you would need to measure and to to work out your progress against achieving those outcomes so that's a piece of work that we're doing at the moment and that's really it's a really good piece of work because it gets all your stakeholders involved to talk about what you want to achieve also how you might measure it and what resources out there what tools are out there that are available to measure that data and it's also about saying well actually there's a gap here and we need to think about how we might go and look for the statistics or evidence that we need to be able to measure that gap so you're not just measuring the things that you can measure if you see what I mean and part of that we'll also be looking at once we've got those statistics and we know what we want to measure is what level we can take that down to as the minister says we do have to be careful about when data become disclosif and how we measure that process but I know that some areas are already looking for example NHS Tayside and the local authorities that they work with are looking at data at school level and community level and they've found that an extremely effective way of of looking at their local rates and outcomes and so on so we'll be not only doing it through our modelling process but also the experience of other areas that have been effective already in reducing local rates so it may be worthwhile actually making contact with all them and finding out how the individual schools coped with exactly the point that you are making about confidentiality and not wanting to create problems but it did seem to work there I don't know why it worked or how it worked because I recognise the dangers you're talking about but it may be worth doing that I have another question but I'll maybe wait to come back in later Can I just respond to that point? We're more than happy to take that particular point away Alison Hardley who was the expert involved in the strategy in England is a member of the steering group which would and I would imagine she would be involved in the oldham at work in some way either directly or indirectly so we can we can clearly flag that up to the steering group Causial factors and other things and you referred minister quite rarely to the progress that's been made and the figures that were reported after you know the committee's report the ISD figures which show the significant drop in teenage pregnancy in the under 16 age group between 2009 2010 and and it showed that the rate reduction was from 7.1 per cent to 1,000 to 5.7 per cent per 1,000 616 pregnancies to 492 now that's a past the national target you know so what was it that happened in that period of time do we understand what happened in that period of time to show that dramatic reduction in you know the under age 16 group you know what lessons can we learn from that that that can be applied and going forward as I'm sure you appreciate there's no single factor a whole range of factors that have been taking place over a number of years because the figures have been the downward trend for the last four plus years around teenage pregnancies where I think there's a number of factors that you could probably highlight one is part of it will be around some of the education work that's been taking place around positive destinations for young people contraception advice and access to contraception as well the type of advice and support that's available within schools as well are all factors that contribute towards this trying to isolate one particular factor is probably not going to be possible but these are all areas where there has been a much greater focus in this agenda which I've got no doubt have played a part in the reductions that we've actually seen these figures. We recognised and as a committee we recognised the direction of travel over over that years but that is quite a significant drop in that period of time you know that that you know from you know 616 to 492 from seven over seven percent to around five percent you know that there's something happened in that period of time yeah has there been any work carried out to try and find out whether there was something that was significant going on at that period of time that would give us a drop like this or do we expect falls like this to continue do we expect of all of you know 100 nod next year or whatever is this the trend yeah there's a well there is a trend there is a downward trend but there's been a a step mark there from from what you're referring to and there is a I'm not aware of any specific work that's been undertaken to look at why there was a a particular drop over the course of that year or so other than it is part of that downward trend but I think the three areas that I've mentioned are probably all the main contributory factors there is also an element where when you are coming from a slightly higher starting point is that you may see step changes like that with different policies being taken forward once you see a reduction the challenge is sustaining that reduction as you go forward to get it as low as you would wish it to be so there is an element where some of it is coming from a slightly higher point to going in a lower direction which is the right direction we wanted to go in but I'm not able to pinpoint for you an exact particular issue or I mean that was between 2009 2010 do we have any update figures that show that that is that positive trend is continuing at that level the next set of figures come out at the end of June 24th of June which will give us an update on where we're at with that okay thank you Richard Lyle thank you can you actually have two questions minister can I turn to a question I know you've been you've been asking you've been considering um and you can maybe give me an answer in regard to roman catholic schools the committee drew the Scottish government's attention to the dispute between NHS Greater Glasgow and Clyde and Glasgow catholic education service in response the Scottish government said that would engage with SCES and NHS sexual health promotion specialist network to refresh the education circular two stroke 2001 which governs a conduct of sexual education in schools following the enactment of the same sex marriage bill can you update the committee on the outcome of this engagement has a dispute in Glasgow been resolved and what progress has been made in refreshing the circular following the enactment of the same sex marriage bill we have engaged with the catholic education service and we've also engaged with the NHS Greater Glasgow and Clyde on this matter and there's been a revision of the guidance however the differences remain between the catholic education service and NHS Greater Glasgow and Clyde at this particular point so we've revised the situational bring calling and maybe just to expand a bit for an educational aspect of it and it may be in my view is it may be that the the views of some of the individuals within NHS Greater Glasgow and Clyde will not get to the point of agreement with the catholic education service on these matters and sometimes these issues have to be respected is that there's a a defensive opinion between them in these matters so it's not for it's not for me to force the catholic education service to accept a particular viewpoint from NHS Greater Glasgow and Clyde there are some officials within NHS Greater Glasgow and Clyde to believe certain things should be provided in catholic schools which the catholic education service are not supportive of but we have engaged and we have revised the guidance to try and address some of these issues Colin, do you want to make a mention a bit more? Yes, thank you. Just to update you on the revision of the guidance, we did undertake a six-week engagement with stakeholders on what was a draft of the guidance and that guidance was available on the Scottish Government website and also sent out to two key stakeholders. We received approximately 60 six zero responses from national organisations on the draft guidance and also about 10 individual responses as well. The main issue that came out of the consultation or the engagement exercise was around the parental right to withdraw children from specific sexual health lessons and views were very much polarized on this between various organisations. The position that we're at at the moment is on the basis of that engagement exercise and the comments on the draft we are moving close to having a revised document which ministers will be considering shortly. The intention is that we will issue that guidance before the end of the school year. You referred to the specific issue of the Scottish Catholic Education Service and Glasgow Health Board as the minister has said. Unfortunately, it's not impossible to resolve those differences during the course of the engagement process, although we officials have met with both the Catholic Education Service and with the health board as part of the engagement process. I have a question. Along the same line, sexual health and relationship education committee recommended that the Scottish Government should undertake a full review of the provision of sexual health and relationship education, but the Scottish Government rejected this call on the grounds that two reviews were carried out in 2008 and 2010. Sponsor also stated that the review showed provision and training was patchy. Went on to say that the Scottish Government believed it was likely to be the case but it did not believe a further review of provision would add to the evidence base. Your response highlighted that it was a matter for local authorities, head teachers to decide what was provided in schools and what training was provided to teachers. Are you aware of any improvements in this consistency and quality of the sexual health and relationship education given the autonomy of local authorities in this matter? Will the delivery of this be variable and what can be done to improve the consistency of what is actually being delivered? Though there hasn't been a review, there has been a revision of some of the guidance and the code of conduct for use within schools around this particular area, which has been taken forward. There has also been an updating of the education material which is available to schools and for teachers use as well in this particular area, and the intention is that the code of conduct is there to help to support a greater consistency of approach and how this education is taken forward in schools. Again, Colin will be able to maybe give you a bit more detail on how we have taken that forward in practical terms. Given that there were two reviews in the fairly recent past, it felt that a full review wouldn't be appropriate at this particular point, but the revision of the code of conduct and the guidance should help us in addressing some of the inconsistencies that do exist there and the new material, which has also been provided as well, should allow us to make sure that staff within schools have the necessary material in order to take forward a relationship and sexual health education. Colin, do you want to mention a bit about the actual process that was gone through in looking at this? Okay, thank you. Yes, I think a number of points there that I would refer to. As the minister has referred to, the code around the conduct of relationships, sexual health and parenthood education is in the process of being revised and we're very near to the conclusion of that exercise. One of the things that has become clear through the engagement process is that there are concerns out there around the consistency. There are still concerns around the consistency of what is being delivered and that is in line with the messages that we had from the 2008 and 2010 review and we recognise that there is a need to do something about that. We believe that the revised code will be the jumping off point for us to be able to relaunch something on that facet of the curriculum. In particular, when the revised code is launched, it will be launched in conjunction with a packaging of the materials that are currently available. Education Scotland will be pulling those together into a coherent package and doing a joint launch at the same time as the launch of the code. They're also looking at holding an event at the start of the next school year, specifically focusing on this. In broader terms, there is representation from learning on the strategy group, which has been referred to earlier, and we would expect that the strategy to consider the issue of educational materials as well as one of the key things that might impact on this area. It's also worth mentioning that since those reviews in 2008 and 2010, we've had the introduction of curriculum for excellence and also the health materials, the sexual health relationships and education materials have been revised as well and are out there. It seems very busy and you haven't been around since 2008 and the job you're currently doing, so it's not a personal attack in you, but that sounds very busy. The question that Richard Lyle asked there was not disappointment for the committee because I view it as agreement with the committee because the committee found in 2013 that the educational experience and the involvement was patchy. The Scottish Government then was in 2010 carried out a review and found it was patchy. It found it was patchy in 2008, so we don't need another review because we're all agreed that the delivery has been patchy. Why has it taken since 2008 and the committee inquiry in teenage pregnancy to get to 2013 and we're all agreed that the delivery of this service for young people throughout Scotland is not as we would want it? They were two different reviews. The review in 2008 was for secondary school provision and the 2010 review was for primary school provision, so they were dealing with two different parts of education. I can understand that may be in your brief, but Mr Spivey said on both these occasions and indeed the response from the Scottish Government in September 2013 agreed with the committee. We don't need any more reviews, the Government response said. We know that we can't add to the knowledge here because we know it's patchy. There's no disagreement here and there's no hiding in one review against another because that was the response. When one of you in 2008, 2010, committee report in 2013, we all agree that it's not good enough. Why has it taken since 2008? Well, I can't obviously comment about what happened in 2008. I wasn't in a position on that. I don't know if Colin was in a position. He was involved in that process and he can maybe comment what happened at that particular point. I can't comment on what happened in 2008. What I can say is that over that period, 2008, 2010, up to the current time, there has been, it's not as if nothing has happened on this issue. There's been a number of things that have happened. I refer to the review of the health resources around education. There's been the introduction of curriculum for excellence and I think that is a key and important element here in the sense that one of the things I know this committee had concerns about was the kind of relationships versus biology question in terms of what should come first and curriculum for excellence very much placed relationships has been the important thing in this area of education. So there has been progress and things have happened over the time and obviously reflected partly and possibly in the reduction in figures that have been referred to. However, it's quite right that we should continue to listen to stakeholders and we have done through the engagement exercise around the review of the guidance and they're telling us that it's still patchy and this committee is telling us it's still patchy and I've kind of indicated that what we are intending to do as the next steps around that. Before any of our impacts those young people and those that educational process you know it's a launch in 2015. Sorry. You've had the committee review and the response in 2013. We're working through the situation we've had weeks and months talking to you know various people we're bringing various groups together but we expected to launch a more coordinated report next year did you say? Sorry the guidance is being launched at the end of this school year so it will be launched by the end of June 2014. Yes this year you may be referring to the strategy which will be launched next year and it's also worth seeing that the strategy will be considering this area as well and what aspects within the strategy should help to reinforce the aspect around education so it's a strategy in 2015. The other area where there wasn't as much agreement was the involvement of young people themselves because at the heart of this and Richard Lyle's question was what is the experience of this education line what support is there biology versus sex education what's relevant and there was a call from the committee to actually involve younger people get their views and that because the views as they were given to us maybe it was forever thus but what wasn't a great experience and the Scottish government I don't think were as in full agreement with that they should maybe qualify in how we would involve young people themselves and the type of services and education that they feel is relevant at this point in time. I think there may be a difference of views here because at committee I think I suggested the possibility of the if the committee felt it would be useful at possibly auditing young people's views on how sexual health services and relationship services are offered in schools and as a government we're looking at how that can be taken forward in order to harness young people's views so I'm we're very much with you in this matter run. Referring to the written response to the committee's report which was maybe less than enthusiastic we may have moved on with with you minister about how we would go about this auditing young people's views which the committee seemed quite supportive of how would you mechanically do that? I would imagine that we would probably work with that a third sector organisation to take that work forward for us and to work with young people to through a questionnaire programme and an interview programme to get their opinions and their views and to use that to then feed into how we then take forward policies so When is this planned for? That's a piece of work that we're taking forward just now to look at how we can develop that further so we're very much in favour of young people being able to inform and to into guide a policy in this area and to use their experience and I think an audit is a good way of actually going about doing that finding out from young people exactly what their views are of what happens in school whether it works what does work what doesn't work what would help to improve matters. When will that information be available to the committee? I don't think we have a time frame around when it will actually be available to the committee. Has the work been commissioned yet? No it's not been commissioned yet, no. Richard No it's not, it's Gil Paterson followed by Bob. Maybe if I go in a slightly different direction minister. I'm actually in favour of babies and pregnancy that's where I'm coming from here and it will be better just say just in case the Daily Mail says I'm in favour of young people and children engaging in sex that's not what I'm saying not a long fact I think we should carefully and meaningfully educate children at all ages that's that's my preference but I was fairly taken on I think the committee was fairly taken on with Harry Burns a before we had taken any evidence this it was in another session entirely and Sir Harry was explaining about the pilots on the feminist partnerships and how that was rolling out and I wondered if you could tell us how you see the family nurse partnerships engaging and what impact it's having that would be my first question how it's impacting on young people after after the pregnancy and after they have a child we had the good fortune this committee to meet some young women I'm guessing ages 16 to 18 who had the baby and had been supported unfortunately there was no males there which would have been interesting to hear what they had to say so my first question is what impact it's had on the program and how it's the family nurse partnerships being rolled out in this regard throughout Scotland is the second question okay well we obviously we've got a commitment to rolling out family nurse partnerships to all of our territorial boards so far and family nurse partnerships are in place in seven of our territorial boards there's further rollout planned in another two of them and following year they'll be rollout in the other board areas I think the end point we're hoping to is by 2015 is to have all of our boards providing family nurse partnerships I like yourself I've met with the staff involved in it the range of parents that are involved in it different parts of the country and it struck me how valuable they have found it given it is for a very specific group but how valuable they have found the input we're now with some of the early family nurse partnerships we're now at the point where parents have graduated from the program and some of the evidence has been gathered from their individual experience to help to inform how some of the other family nurse partnerships in different health board areas can actually learn from their experience so those that were actually ahead of the game in the family nurse partnerships t-side in particular which was one of the first areas to family nurse partnership have built up a a considerable level of experience and we can use that experience to help to inform the other board areas that are actually setting out in development and having family nurse partnerships so I think there are very positive way of which we can work with young mums at a very early stage in their pregnancy and then through that two year period as well to help to support them not just for them as an individual mother and for their baby but also to help to support them and their family and to look at what other support measures can assist them to help to whether going to education whether going to employment we're looking at other challenges that their family may be facing around housing bringing together our services that can help to support them the collective way in which the family nurse is able to is able to work with them and to guide them there is also a randomized trial taking place just now on family nurse partnerships in england which is due to report at the end of this year which will be very interesting and once we have seen the outcomes on that particular randomized trial we'll consider how that how we should use that to help to evaluate the progress that we've made in Scotland as well and where there's further work that could be done here in Scotland around family nurse partnerships I think they've got a positive contribution to make they're not the only model but they've got a positive contribution to make and from the parents that I've engaged with and the staff I've engaged with there is a clear feeling that they have a real benefit to those who have engaged in the programme it's also worth keeping in mind that the the level of attainment within the engagement of family nurse partnerships is very good in that we don't have lots of young mums and families dropping out of it so remaining engaged is a key part of the programme and how effective it can actually be and an experience in some of our health both areas has been very good in maintaining that. There's a question in the back of that also minister I think there's been viewers expressed that the provision of the health visiting service has been impacted negatively in that to recruit nurses for the service itself has left a kind of gap so you know it's taken resources away by you know the provision of the family nurse partnerships one if you have any views on that if you could you know maybe clarify it and do it with my needs. Well a couple of things one in terms of the roll-out within our health boards is to try and manage that at a pace that doesn't allow that to try and avoid or minimise that from happening where it can the other area we're looking at is considering who can be a family nurse within a family nurse partnership to see whether there's scope to extend that further from what has often been seen as being a health visitors who have been attracted to it so we're doing that just now to see if we can if we can look at extending the range of individuals who could actually become a family nurse in a partnership is well and we're in discussions with those involved in the family nurse partnerships around how that can be achieved but an important part is the pace at which we actually roll out the programme to try and help to manage any change that can happen around staff who do choose to go in to become family nurses to allow that to be managed within the health boards staffing levels for health visitors and other nurses. Are you comfortable? Is there any worries in the background that any concerns or are you comfortable with the kind of shape that is taking and the movement from one to the other? Is it leaving a is it leaving a draft behind or is it under control? That's basically what I think there will always be there will always be um there may always be an element of short-term challenges that can be created when you if you have for example if you have a very experienced health visitor who chooses to become a family nurse just recruiting another health visitor doesn't necessarily fill that gap because you're losing that experience as well. So there is a there is always the potential for it to to create some short-term challenges in areas but I think it's about trying to manage the pace in a way that allows that to happen in a managed manner rather than just saying right you've got to have your family nurse partnership by next month irrespective as to the impact that may have on your health visiting capacity. So to try and do it in a managed way but you know I wouldn't be naive enough to think that you know if you if you have a health visitor of 20 years experience who chooses to move into a family nurse partnership and then expect to have that pose filled by a health visitor who may be newly qualified it's going to be difficult for that new person to to fill that gap because you're losing 20 years experience as well so it's trying to do it in a managed way to avoid causing any instability that could occur at a local level but we're not that's important for health boards to manage and to and to do that in a planned way and that's why they're being rolled out and over a number of years to allow it to happen in a planned way. I want to return again to a little bit about sex education and relationship education in schools now in some schools particularly in secondary schools that that might be delivered by a pastoral support or a guidance teacher some schools will have a everything will be a frontline guidance teacher they will put on that pastoral responsibility so there are various skills mixes particularly in secondary schools in relation to the delivery irrespective of what the the guidelines are and in primary schools of course it's it's the teacher that you get that's going to deliver that that kind of relationship advice now i want to focus on relationships again because the ability of any educationalist who is exceptionally good at teaching physics or chemistry or history or whatever maybe a different skills mix required than to teach relationship advice within schools so i appreciate the patchy nature sometimes of of provision but it's about driving up standards and capacity building with staff and the way i would monitor that i i suppose would be i would be asking education scotland to take a view in the quality of of education within schools and i'm not suggesting that every school in the country should immediately have the inspector in to to inspect all these things of course not but perhaps i'm just giving for two areas where there's clusters and maybe higher prevalence of teenage pregnancies and and pregnancy young mothers of of school age that that might just be an area where we just touch upon with education scotland when they're doing routine of inspections of of schools in those areas just to kind of you know just just to get a flavour of the quality of the the support that staff have been given to be able to give effective relationship advice i think this committee would agree its relationship advice with the clinical and biological aspects of it as required to make informed decisions i think we all agree on that so it's your view on that would be helpful but also your view on something else i think he says as a former teacher that maybe sometimes teachers get a hard time young people spend a variety have a variety of relationships in life there and the most positive ones are not always at school as well for some of them and those most at risk of of having unplanned pregnancy those that may be disengaged from schools and i think again that's about good quality youth provision and so in primary schools yes early intervention and good relationship building but when you get to those most likely to have an unplanned pregnancy in secondary schools they may not be engaging particularly extensively with with the school and their wider network but they may be engaging with good quality youth provision so has the government given any thought about how again we can identify the areas where young people are most at risk of having an unplanned pregnancy and bolstering good quality youth provision in communities that includes funding of course and how we monitor and map out some of that so hopefully that's a helpful question but certainly something as a former teacher I'm sure it's not lost the committee it is called relationships sexual health and parenthood education and relationships being in front of it for very specific purposes in terms of how education provision is made i'll obviously been calling in to maybe mention some of the specifics but if we've highlighted one is about the materials that teachers have also the the guidance and the code of conduct for teachers as well and been able to in the provision of this area of education is extremely important there are those teachers who may be more given to this area of education than others my view is it's more important to have good educators delivering it rather than forcing reluctant educations to deliver it because you just have to do it so it's about how that's managed within an individual school setting and the leadership that's shown within a school and how that's taken forward they're extremely important so they're important elements on it can I can I pick up on the point you made though about for example youth working in schools where there may be a where young people who may have disengaged from education being at greater risk etc and I think this goes back to a very important point that Richard Simpson raised and that is about the use of data in this particular area and part of the work that I mentioned earlier on about the disaggregation of data is whether we can get the data down to a level that allows us to much more effectively pinpoint there's an issue there is an issue within that particular area because the rates are higher what do we then need to do is to look at what's happening in that particular area and what action they need to be taking forward at a localised level so if youth group work is one aspect of it is it an issue around how education has been delivered within that particular school is it about what you call is about how health and social work and other services are engaging as well and other measures that can then be taken once we have that level of detailed data it allows us to then look at what's the best approach to try and address the issue so we can be much more focused on our approach some of that may be educational maybe health maybe getting third sector organisations involved that would really be determined on the basis of what was happening in that particular area youth work could be part of it a part of the solution but allows us to get a much more tailored response where there are particular issues and that's where we can then make sure what we're doing is evidence based rather than just putting in something which we think might make a difference but we don't really know and if we put something in as it were there in a position where we can effectively evaluate that and measure its impact is there a change over the next you know two to three years as a result of the actions that we've taken is that type of sustained input that will be necessary and in the point Richard made earlier on about getting data down to that level will be crucial in helping to support that type of work at a localised level that will require a multiagency response it will require health it will require local authority third sector and in some cases it may require national government response as well so I think your point is well made and I think the data will be key to helping to unlock where we need to take some of that concerted action and then to look at what that action should actually be it will probably be in a better place to give you some more detail around the type of things that are available for teachers and the work that's done with teachers specifically in delivering this within schools. Yes thank you I think there's a number of things again I'll pick up on the first first one is that you mentioned the the appropriateness of perhaps you know certain teachers delivering parts of the curriculum so I think you mentioned physics teachers or whatever who I understand that but I understand the point that you're making I think one of the fundamental things about curriculum for excellence and why it is such a different and huge step in terms of education is that under curriculum for excellence health and well being is a responsibility of everybody who is involved in learning so be it the physics teacher be it the guidance teacher be it the catering staff in the school or the janitorial staff or whatever they all have a responsibility for health and well being and delivering that a key part is around relationships and it's changing the mindset so that that is true and that that works that's one of the key things about delivering improvements in this area but specifically to move on to the education Scotland's role in this which you mentioned education Scotland as part of their inspection programme consider or look at health and well being and the delivery of health and well being as as one of the the core things that they look at in each school inspection and one of the things that they report back on whether there's an opportunity to to to make a bit of a closer link is something that possibly we could pick up in the discussions around the the strategy I don't think education or education Scotland on the the strategy groups so that's I think that's an interesting and useful suggestion to take forward. I suppose in terms of who delivers in schools it is down to local authorities and and to schools and that's consistent with our general approach in terms of of learning and I wouldn't say it's wanting to be prescriptive in terms of saying it should be a particular teacher with a particular responsibility for a particular area that delivers something it is often down to who is most comfortable and who is best placed to to to deliver this type of education and I think that that's probably quite right. Thank you for raising the issue of health visitors. Minister you remember in answer to a parliamentary question I submitted you estimated that when we've rolled it out out of 350 family nurse partnership appointments, half of the number of people who have been when we've rolled it out out of 350 family nurse partnership appointments, half would be health visitors. I have to say to you I've done an FOI to the health boards on the training of health visitors and I am concerned that we aren't actually going to be replacing them even with more inexperienced people than I take your point very much that it's not a like for like replacement. Can I ask if if you would in the on that topic if when the workforce plans come out in June if you could update us on that because I know that the health visitor training is a matter for the individual health boards and I'm not convinced that they're actually looking at the replacement in a way that they should do. But my question chair was actually very very short one which is on contraception and when we discussed the issue we were raised the issue of eulopristal along acting emergency contraception and you indicated that you had a short life expert working group looking at that they'd make the recommendation and I wonder if you could just tell us where we are with that because that is now eight months since it was actually generally approved so. Just on the the first point as well that Richard Simpson raised that the cabinet secretary has set up a mustn't advisory group to look specifically at aspects around health visiting and that is due to report in the near future which should hopefully address some of the issues of concern that Richard Simpson raised but I do recognise the concern that is raised in the importance of health visitors to this. Specifically on the issue around the medication that Richard Simpson referred to, Health Scotland commissioned an expert group to look at this matter. They considered a number of different issues and they have since reported and we're in discussions with the community pharmacy on that. It would be helpful and more than happy to get a full detail breakdown of the outcomes from that particular expert group and the recommendations which would allow the committee to consider it in more detail rather than just giving you a quick run through the key bullet points but there is a draft national PGD being taken forward as part of the recommendations that came from that but I'm more than happy to give you a much fuller and detailed breakdown of that that would be useful. Dennis Robertson and it's a very brief summary in relation to what Bob Dorris was asking and maybe an early point from Richard Simpson on the data. Minister are we aware if there's a shifting trend in young people becoming sexually active and if so do you know what that trend is and is there a geographical difference? There are some areas of research that have indicated that young people are being exposed to information at a much earlier stage than may have been the case in the past largely through being able to access information much more readily than was available in the past so there are so there is research that does demonstrate that the children are being made aware of these things at a much earlier stage. There are particular areas in the country where we know there are issues around teenage pregnancies and we know that from the present national statistics that we do gather and some of the specific work that has been taken forward under the strategy present has been focused in these particular areas so we do know where there are particular areas and getting the data down to an even further level will allow us to be much clearer in those individual areas where specifically are there issues that need to be addressed more effectively. So is the data exposure in itself actually impacting on young people becoming sexually active? No. The question was about do we know the age range of young people becoming sexually active? I'm not aware but Felicity may have if she's aware of some specific research in this area. We have some information from the Health Behaviors of School Age Children survey which is an international survey but for which we have a Scottish sham that does give us some information on young people's sexual activity and it's shown really and I'd have to go away and get the specific figures that that level of particularly young people under 16 hasn't changed notably for some time but obviously it's very difficult to get specific information on young people's sexual activity and it also depends what you actually mean when you're talking about sexual activity. So that data is quite difficult to come by but we can look at other proxy measures which might give us that information and as the Minister says that's something that we can look at further because there are some interesting data out there particularly from the Health Behaviors of School Age Children survey that can give us some useful information. Thank you very much. I would think there's any further questions. Can I thank you Minister for your attendance in this session along with your colleagues. We have sought, we need your final agreement but we've sought behind your back that because we were delayed your attendance here by about half an hour from the expected time and the committee members have got pressures about other meetings that they've got to go at this time. We are suggesting with your agreement that we would not proceed with the next session and postpone that for another occasion quite soon if that is agreeable to you and we would end the meeting at this point. Thank you very much. Thank you once again for your session this morning. It's very interesting. Thank you. Okay. Thanks everybody.