 Good morning and welcome to the 10th meeting of the Health and Sport Committee in 2019. Can I ask everyone in the room to ensure that mobile phones are off or on silent? Agenda items 1, 2 and 3 are consideration of an instrument relating to the European Union withdrawal act 2018, the cross-border healthcare EU exit Scotland amendment regulations 2019 in draft. The purpose of this instrument is to amend the NHS Scotland Act 1978 and the NHS cross-border healthcare Scotland regulations 2013. The changes remedy deficiencies in retained EU law relating to cross-border healthcare in certain circumstances where the UK leaves the EU without a withdrawal agreement in place. This instrument provides a mechanism for ensuring that there is no interruption to healthcare arrangements for people accessing healthcare through EU directive 2011-24, after exit day, in those EEA member states that agreed to maintain current arrangements with the UK for a transitional period until the end of 2020. We will first of all consider the categorisation of the instrument. Members will be familiar with the basis on which this is done. The Scottish Government have laid the SSI under the mandatory affirmative procedure. Legal advice suggests that a SIFT should have been applied, but had it been applied, the affirmative procedure would have emerged in any case. Ultimately, the practical effect would be the same. The Delegated Power and Law Reform Committee considered this instrument on 19 March and agreed that it had been appropriately categorised as medium. The committee draws the attention of the Parliament to the instrument under the general reporting ground on the basis of a minor error and calls on the Scottish Government to collect this error at the next legislative opportunity. As I say, it has been assessed as medium because of the way in which it is the impact of it. Are members content with that categorisation? If we are all agreed, we will therefore move on to agenda item 2, which is an evidence session with the minister and his officials on the instrument. Once we have had our questions answered, we will then move to agenda item 3, the formal debate on the motion. Welcome to the committee. Joe Fitzpatrick, Minister for Public Health, Sport and Well-being, along with John Brunton, senior policy manager and John Patterson, solicitor from the Legal Directorate of the Scottish Government. Welcome, gentlemen. Minister, I believe that you want to make a brief opening statement on this. Thank you, convener. I am pleased to join you this morning to discuss the regulations. It is the Scottish Government's clear position that the interests of Scotland will be best served by remaining within the European Union and recent events in Whitehall have only served to strengthen that view. However, as a responsible Government, we have a duty to make necessary preparations to ensure that the Scottish statute book remains operable to help to mitigate the considerable damage that a no-deal Brexit would cause. At present, under the European Cross-Border healthcare directive, European economic area citizens have the right to obtain healthcare services in other EEA countries. However, the treatment must be the same as or equivalent to the treatment that is provided by the state in their country of affiliation. The patient pays for the treatment up front and may claim reimbursement, limited to the amount of the treatment that would cost had it been provided by the state at home in Scotland on the NHS. As health is devolved, the national health service cross-border healthcare Scotland regulations 2013 implemented the directive in Scotland where necessary. The regulations provide a legal basis for NHS to apply the need for prior authorisation for expensive specialist treatment. They also limit the amount of reimbursement to the actual cost that the NHS had the treatment to be provided here. Importantly, the home state retains responsibility for the healthcare that it finds on a cross-border basis. If the treatment is not available on the NHS in Scotland, you cannot use the directive to receive it in another EEA country and claim reimbursement from the NHS on return. The cross-border healthcare EU exit Scotland amendments, etc. regulations 2019 are taken from powers in the European withdrawal act 2018. The correct deficiencies that arise from the UK's withdrawal from the EU without a deal by modifying the 2013 regulations. England, Wales and Northern Ireland are introducing similar regulations. The instrument protects patients in a transitional position and enables continuation of cross-border healthcare arrangements in those countries with whom the UK has established continued reciprocal arrangements, maintaining the provisions in the directive that gives EEA citizens the choice to travel for healthcare. Maintaining effective access to cross-border healthcare abroad requires basic reciprocal agreements to ensure that the existing EU framework is maintained in participating countries. Therefore, the instrument terminates access to cross-border healthcare with countries where there is no longer a reciprocal agreement. As reciprocal healthcare arrangements are applied on a UK-wide basis, the Secretary of State for Health will maintain a list of countries that reach agreement to maintain the current reciprocal arrangements with the UK until 31 December 2020. The instrument protects, so far as possible, key groups of patients in a transitional situation on exit day irrespective of any reciprocal agreement in place. For example, individuals who obtained prior authorisation for planned treatment before exit day but have not yet obtained treatment. Individuals who accessed healthcare abroad prior to exit day but have not yet completed the treatment or sought reimbursement and UK state pensioners from Scotland living in other EEA countries who need to access healthcare provided by the NHS while in Scotland. Those time-limited measures aim to prevent, so far as is possible, without reciprocal agreements, a sudden loss of overseas healthcare rights for Scottish residents and pensioners and from Scotland residing in the EEA. We consider the amendments to be technical for the most part. I hope that members will agree that, as part of the Scottish Government's overall programme of legislative contingency planning for Brexit, the cross-border healthcare EU exit Scotland amendments etc. Regulations 2019 provide necessary changes to protect Scottish residents' rights to access cross-border healthcare in other EEA countries as far as that can be achieved. Of course, we are happy to answer questions. The cabinet secretary mentioned continued reciprocal arrangements with other countries in the European economic area. Is it possible to update the committee on which countries the UK Government has made progress in reaching such agreements with? We are not aware of any formal bilateral agreements as yet, but I understand that some EEA countries have agreed in principle to reciprocal agreements. I think that Spain is the only country that has made that public and, as I understand, have drafted regulations. However, it should be made clear that the European Commission has said that it considers discussions in the second phase of negotiations to be the appropriate way to reach agreement on the future of reciprocal healthcare and, as indicated, it does not encourage bilateral agreements at this time. In spite of the fact that there are indications from Spain in particular, there could be a hiatus at that point. The cross-border healthcare amendments regulations will protect Scots who have travelled for treatment but have yet to receive it or who have received treatment and are seeking reimbursement in that intermediate period. In relation to the European Union, in the expectation on the EU's part that there will be a withdrawal agreement, it is understandable that the European Commission does not wish to promote the concept of bilateral agreements at this stage. Given the absence of an agreement, which is clearly a possibility against which this regulation is designed, in the absence of an agreement, immediately on exit day, whichever day that might be, those arrangements that currently exist would cease and, therefore, bilateral arrangements would be required for UK citizens abroad. I think that there is clearly a willingness from Spain that that should happen. As I understand, as I said, I think that the regulations are already drafted. However, the view from the European Commission is irrespective of what the outcome is that any reciprocal agreement should be pan-European, so I think that there are maybe two different views coming from Europe just now, which is why I think that it is important to be put in place. Understanding that point and recognising that the EEA includes a number of countries such as Norway and Switzerland, which are not members of the European Union, presumably progress on bilateral arrangements with those countries, has obviously been very important to Scotland from an oil industry perspective. Reciprocal agreements are a reserved matter. I understand that the UK Government is attempting to get reciprocal agreements in place. Until recently, we have not been given terribly much information around that, but I think that we are starting to have a bit more information about the discussions that we are having. Do you want to add a little bit about that? Can I just add that the UK Government has entered into agreements with Switzerland, Lichtenstein, Norway and Denmark already, so there will be reciprocal agreements with those countries? Thank you very much. It would be helpful to have that confirmed, as in when there is a formal, presumably at the point at which formal arrangements are reached, that will be made public. On the legislation in front of us, the minister, can you indicate what guidance will be issued to NHS boards and potentially to individuals in relation to the operation of this instrument? Currently, in terms of the implementation of the directive, we have the European Cross-Border healthcare national contact point, and it is our intention to retain that contact point. That was established when the directive was transposed into domestic legislation back in 2013. Our intention is to maintain that and to update that to include the provisions in the amendment regulations that are unpinning those regulations in the guidance that will be issued to NHS boards. To give a bit of elaboration about what that looks like, it is a web facility maintained by NHS Inform. Obviously, the information arm of NHS 24 provides information for patients who wish to use cross-border healthcare routes for treatment overseas, and it also contains contact details for cross-border leads within each of our NHS boards. That would be maintained, and I will update it, obviously. Thank you, convener. Good morning to you. I am interested in the fact that there are patients that want to make a specific request to use the directive under article 8, so patients have to make that specific request. Does the minister know how many Scottish residents are currently awaiting treatment under this directive in another member state? Currently, the figures on patients would be collated on an annual basis and published in April. Last year's figures will be published in April. The latest figures that are available would give an indication of the sort of numbers that we have from 2017, so they were published last April. In that year, there were 29 people. Relatively, small numbers of folk, and we reckon that the cost was around £50,000. I have a list here of the countries that each of those 29 people came from, but there would be a danger of me identifying the individuals because you are talking about two people from one country, five from another, one from another, one from another, one from another. There is one country where there were 16 people, but mainly small numbers of people making that choice. That is the latest figures from 2017 and in April. Next time, we should get the numbers for last year. Yes. What happens is that we get a questionnaire every year from the European Commission. It comes into the UK Government. We then go out to NHS boards and they provide the information that we need. An additional question would be that. Are patients seeking healthcare from—who live in Scotland, but might be going to Spain, for instance. Would that include patients that are seeking dialysis that are maybe wintering over in Spain? That is a really good question. That would not be covered by this. Currently, that would be covered by the EHIC card in the menu. I think that it could be covered by this, but that would be covered by the EHIC card. I think that what you are asking is a really important question, and I do not think that there is a particularly good answer for people in that circumstance. The regulations do not replace the EHIC card. Recipital arrangements could do that, where we get them, so that would be dependent on what kind of agreements we could get. I think that that is an important point. Whether it is Brexit day 28 March 12 April or some other time into the future, wherever it is, it is important that people make sure that they understand what the implications are for them. Individually, for most people travelling, it will be about having insurance that will cover them for all eventualities, but you are talking about a particular group of people with medical conditions that might be difficult to get insurance for. Did you want to add in to that? No, not really. That would be something in the short term if somebody was looking for healthcare for dialysis when they were in Europe for maybe two or three weeks. We might ask an NHS board to pick up the bill for that, and there are basic equality considerations, but that would be down to individual boards, whether we prefer to fund that or not. We need to make sure that people are really clear and understand what the reciprocal process entails. I have had a constituent myself who came from Cyprus who needed dialysis in Ayrshire, and it was really complicated to try and organise that. I think that the point that you are making is some of the details that I think when people voted a number of years ago in the referendum, that sort of detail was never discussed in. What you are making is a really good case for why we need another people's vote. Emma Harper makes an extremely good point on that particular issue. I personally would be surprised if the e-hickard covers dialysis abroad. Within Scotland, the minister will have figures for the amount of EU nationals who received dialysis under the e-hickard. I would be surprised if there are any substantial numbers on that. Perhaps the minister will not have that to hand, but could he ask health boards if they could provide us with some information? That seems to me to be on the terms of the... I do not think that that information would be available, but the e-hickard covers pre-existing conditions, which include dialysis. The idea that you break your leg in Spain and you go into a hospital and you get reciprocal healthcare is well understood. The idea that you go into hospital in Spain without any pre-authorisation and, as for kidney dialysis and the e-hickard, I would be very surprised if that is done on a regular basis without lots of prior authorisation. You would certainly want to make sure that you are aware of what support you are going to get. That would definitely be safe to ask, but it does happen. On the reporting minister, health boards in Scotland that are providing care to EE citizens under e-hick need to communicate that back to you in terms of the work that they have carried out. Obviously, we are not looking at the regulations about e-hick. I did not raise e-hick, but you did. It was you that raised the point, which is why I am just trying to confirm this. Do you have figures on that? Can you ask your boards to give a return on how many patients have you got from e-hick? Thank you very much, convener, and good morning, everyone. Minister, you mentioned in your opening remarks about agreements and consent in regard to England and Northern Ireland. I have great concerns having read the letter that was sent to the committee from the cab segment on 21 March, in regard to the fact that the Scottish Parliament and, obviously, the minister and this committee do not seem to have the consent or an agreement from Westminster as to how that is going to work. I could just give you a couple of quotes when the convener had asked some questions of the cabinet secretary about why we do not have delegated powers in that consent. The minister mentioned the fact that Wales and the Scottish Parliament and the Scottish Government placed great importance on the protection of its devolved status and legislative competence, and they had written to the equivalent minister in Westminster. We have a perfectly reasonable request, but the last paragraph mentions the fact that the UK Government has, however, rejected this reasonable demand and is a little prospect of a reversal at this time, which is due with legislation and this Parliament being given delegated powers in regard to this. Do we have any follow-up from that, rather than a memorandum of understanding, or will this come back to the committee? It is worrying that it went through the House of Lords, what Westminster is a devolved matter, and yet we are not given the legislative powers in this Parliament to deal with it. We are absolutely clear that we think that the powers of this Parliament and the powers of devolution should be respected at all times. To say that the Scottish Government is not happy about the current arrangements would be an understatement. It is really important that, when we are talking about devolved matters, the powers of this Parliament—it is not about the Scottish Government, it is about this Parliament being given its place—should be respected at all times. We were very disappointed that the proposals that came forward, which would have guaranteed the powers of devolution, were not accepted by the UK Government. That said, we have to make a decision about what is in the interests of the people of Scotland, and that is why we are taking a pragmatic approach here with those orders, which is about protecting a small number of citizens who could find themselves in a difficult place if we did not do that. I just have a small follow-up, thank you. In that respect, we understand that we want to make it smooth, seamless, but we do not know even at this moment in time what is happening in regard to Brexit whether it is going to come about or not. Can the minister give this committee or the Parliament some form of guarantee that, if they do not have this power, we do not—the Scottish Parliament has this power—exactly how we are going to protect those people? Would we write letters again, or would we ask them to come from Westminster to give evidence to this committee as to why we are not getting the powers? Obviously, it is up to this committee to decide how you want to do your business. You can be rest assured that the Scottish Government will continue to press the point to protect the powers of this Parliament. However, you are right, there is a huge amount of uncertainty that remains around the whole matter of Brexit. However, what we are discussing today is arrangements that would only come into effect in the event of a no-deal Brexit, so it is that worst-case scenario and making sure that we have provisions in place for that scenario. Whether it is 29 March, 12 April or some other time that we get to that cliff edge, that is when that would come into effect. It would come into effect before Brexit. Thank you very much. We will certainly, as a committee, consider these matters going forward. One last question in just in terms of some of the statistics that you mentioned, the last numbers you had were from 2017 on 29 people going one way. Do we know what the numbers are going the other way? I am not aware of any patients from other EEA countries using the directive to access treatment in Scotland. As far as we are aware, the directive has never been used in that way. I think that you may have partially covered that, convener. Can I just minister ask you about transition agreement? I think that my colleagues probably raised the fact that the directive is very rarely used in Scotland. We are not talking about the S1 or S2 routes, but the scenario that you will know is that if a Scottish pensioner living in the EEA countries, and just for the record, that would be the 28 community countries plus Iceland, Liechtenstein and Norway, just for completeness, plus Switzerland. If someone in that situation has had prior agreements to get treatment in Scotland, as you know, there is a 12-month period where they are provided free of charge in Scotland. Have you got contingency to cope with that, minister? I take it that the numbers will not be high, but if there is suddenly going to be a surge, health boards need to have capacity to do all this. Can you tell us a little bit more about the transition arrangements? I am not understanding how there would be a surge, so this is maintaining a transition of what is there just now. I do not see how it would ever get higher than what is there just now, if you understand. Maybe I am not understanding the question. The position just to clarify, minister, is that you will be familiar with it, but under the transition agreements, where a Scottish pensioner, just to give you an example, who is living in one of the eligible countries, has had prior arrangements or prior permission to have treatment in Scotland, during the 12-month period after this goes ahead, there is an agreement that healthcare will be provided free by the Scottish health service. That is in the regulations. Do you have any idea of the numbers that will be using this over the 12-month period? I do not think that we do. However, the alternative would be to potentially leave some of those individuals with no access to healthcare anywhere in Europe, so I think that it is pragmatic that we take this in the regulations. The regulation says that, if they have agreement, they get free treatment in Scotland for a 12-month period. That is laid down in the regulations that we are proving today. Can I just add that pensioners are coming back to Scotland? We do not have numbers for them, we do not know how many there are going to be, so we will be monitoring the position. Obviously, it is for a year that England has already done this and Wales is considering doing it as well. So, to follow the throttle of other countries is probably sensible for Scotland to do it too. I am sympathetic with the minister's comment that he is not, and the minister is not expecting a surge. However, of course, if you do not know the numbers, you do not know if there is going to be a surge or not. All I am getting at is that we need to give some understanding to our health boards that there will be additional pressure on NHS resources in Scotland for a 12-month period, because of the regulations that we are agreeing today. It says that, if you have had prior agreement, you have a right to get healthcare in Scotland if you live in one of those countries that you have just mentioned for 12 months. You are saying that you do not know how many people will access this, so it is difficult to know if there will be a surge or not. My assumption is that there will not be a lot of pensioners who are going to access this, because the directive is not widely used across the EU. All I am saying is that, for good planning of our health service, surely is she trying to find out the figures involved? I think that your premise of it is not a huge number is probably correct, but I think that that is a point that we will take on and just to check if there is acclamation making. Thank you. Brian Whittle, do you want a brief note? I do, actually. If I could give you a good morning's comment, I have been listening with your point. Can I mention that we move on shortly to the debate, so if it is a point rather than a question, then I would suggest that you leave it to the debate. Okay, I will leave it to the debate. Okay, thank you very much. That allows us to move on to agenda item number three, which is the formal debate on the affirmative SSI, which we have just heard evidence. Remind members that we now no longer put questions, we may make points in debate, and officials also will not take part at this stage. Can I invite the minister please to move the motion S5M-16442? Formally moved. Thank you very much. I see Brian Whittle. Thank you, Kibira. I know I'll kick off. I think that I've been listening to the questions from the minister with great interest. I'm going to declare an interest here that my parents lived in Spain for 10 years, and both of them had, while they were out there, had serious conditions that were treated both in Spain and in the UK, and there wasn't any problem. One was Cairns, one in a back operation, and I think that we are trying to create problems here out of this. Politicking round this table, we're creating problems. The reality is that, as it currently stands, you can get treatment in a new country, and if you come back here, you'll get treatment here as well. That practically happened, and there weren't any barriers to that, so I don't know where we're going with this particular, what we're trying to get out of this, but it really is starting to irk me here that we're trying to create problems that aren't there. Thank you very much. Any other contributions to the debate? I see none. Minister, would you like to speak? Just to wrap up, I think that Mr Whittle is absolutely corrected about a system that works really well across Europe just now. What those regulations are about is putting in place protections in the event of a no-deal Brexit. If we don't put in place those protections, then there could be people who are currently in the process of using the directive to access treatment in another EU country who would potentially be left high and dry in the middle of that process either just prior to receiving their operation or just after receiving the operation prior to receiving funding. I know that we've talked about a number of matters around the table, and I understand that the committee likes to do that, which don't relate directly to the regulations that are before us, but the regulations before us are a pragmatic approach to deal with a no-deal Brexit. Any other scenario, they wouldn't necessarily be required. The question is that the motion S5M-16442 be agreed to. Are we all agreed? That is agreed. Thank you very much, Mr Miller. I'll adjourn for a few moments to allow the minister to part. Always check the technology before you begin. We will resume the meeting and resume at item 4 on the agenda, which is consideration of a negative instrument, the national health service, superannuation and pension schemes, Scotland miscellaneous amendments regulation 2019. Colleagues will recall that we consider this instrument at last week's meeting and agreed to write to the Scottish Government for further information on a number of issues. We have now received a letter this morning from Kate Forbes, the Minister for Public Finance and Digital Economy, in response to the questions that we asked. I invite comments from members. Thank you, convener. Recall that I raised this last week. My concern about this is the jump in the player contribution by 6 per cent next month. Many members will have received correspondence from GPs, particularly. This will affect them dramatically, for example, on the costs of their own staff like receptionists. This may end up with redundancies in the longer term. It may also affect some GP practices who cannot continue and go back to health boards, which, obviously, is a worry. There are particular issues in rural areas that will affect retention and recruitment of GPs. There will also be an issue in non-NHS employees such as the hospice movement, and Chaz wrote to us recently—a number of members have also raised this. Chaz has mentioned a customer of 350,000 a year, which is nine full-time nurses. I have seen the letter from the minister. Obviously, those are primarily reserved issues, but, on top of the lifetime allowance and the annual allowance, those issues are hitting GPs and consultants in particular. They are all reserved. I do not think that we can do anything but accept the instrument today. However, I do think that it is important to put on the record my great concern that I am sure is shared by the committee. The effect that this will have unless there is a Barnett consequential to try and remedy what is going to happen to GPs particularly. It is just to put on the record the concerns about retention and recruitment of GPs, in particular. Indeed, I think that that is a very important point. Sandra White Thank you very much. Conveniently, I have also had concerns in regard to this, and I had raised it earlier also. Dave Stewart is correct about not just the GPs that affect perception, etc., but it can also affect charities too. That is when I have great concern. I know that it was raised at the health committee as well in this Parliament in regard to how it could affect the education committee. When I checked with SPICE in regard to this, SPICE was not aware of it either, which was last week. It is something that is coming through that a lot of people are not aware of, but it can have dire consequences on the services. The big worry is that, if the Westminster Government, because it is a reserved matter, does not give in money either consequentials. I do not think that it fits into the part of consequentials in health, because it is not just health that is affected as other areas as well, but I would like that to be clarified if at all possible in that respect, but it really could have dire effects on front-line services in the health committee and throughout. Although I understand and I have spoken and asked advice that we cannot stop this from going through today, I wonder whether the committee would be minded to follow through in some of the concerns that myself and others have raised in regard to this. Perhaps right to the minister again, Kate Forbes, for clarification on where the money actually is going to come from or whether the Scottish Government is going to press the UK Government for these extra funds. It is them that have raised this pension funding. Therefore, it should not be incumbent on us, the Scottish Parliament, who does not have that power to make up the shortfall. It is a worrying trend, if that is a trend. That is just one of many that is coming forward. Thank you very much. Emma Harper. Thank you, convener. I just want to raise my concerns also and I agree with Dave Stewart and Sandra White about different aspects of people working in GP practices, whether doctors, nurses, receptionists or admin staff. I represent a rural region and we already have recruitment challenges for our GPs, so I want to make sure that we continue to monitor this and make sure that there is no negative impact from those changes. I think that that is absolutely right. It is important to say a couple of things first of all to Sandra White. It is open to us to stop this instrument today, but clearly if we do so that is to annul the instrument and therefore it would go to the chamber this week because it is due to come into force on 1 April, so I would have to be dealt with by the Parliament in time for it to be. So that option is available to us. In terms of the question around funding, I think that it is worth simply reminding colleagues that Kate Forbes is very clear in her letter failure to fully fund these costs will have a significant and detrimental effect on the delivery of essential frontline services in Scotland. Clearly the Government is continuing to engage with the Treasury on that issue, but it is important to note that. The minister also says that the Scottish Government will take the appropriate steps to disperse additional funding if that is received from the Treasury. She also says that if there is a shortfall in the funding from the UK Government, the Scottish Government will consider how that shortfall will be met. That seems to me to imply that the shortfall will be met, but I think that it would be worth our while even if we agreed to approve this instrument. It would be worth our while to write back to Kate Forbes and ask for confirmation that that is the intention that will come what may. The shortfall will be met and there will not be the impact on GP practices, hospices and others that members have raised. Are members so minded? Very good. Thank you very much. Is the committee therefore agreed to make no recommendations on this instrument? That is agreed. Thank you very much. We now move on to agenda item number five, an evidence session with NHS Lanarkshire, part of a series of evidence sessions that the committee is holding with territorial health boards. Let me therefore welcome to the committee Nina Mahal, the chair, Calum Campbell, chief executive of NHS Lanarkshire, Dr Linda Finlay, medical director, South Lanarkshire Health and Social Care Partnership and Ross McGuffey, interim chief officer of North Lanarkshire Health and Social Care Partnership. Dr Jane Burns, medical director, NHS Lanarkshire and Heather Knox, the deputy chief executive and director of acute services. Can I welcome you all to the committee and thank you for the evidence that you have submitted in advance of our consideration today. Clearly, one of the first areas of consideration for the committee in scrutiny of boards is the fundamental issue of financial balance and being able to achieve your many objectives within the envelope that is available to you. We noted in looking at your financial plan and also at the annual audit by Audit Scotland that it was anticipated that you would be facing a £26 million funding gap for the current year, the year nearly finished, but that you have now achieved something or a break even with some on some recurrent efficiencies required. It would be useful to have a brief summary of that and also an explanation given that the funding gap was significant only a few months ago, an explanation of what you have done in order to close that gap. First, I thank you to the committee for giving us the opportunity to present evidence to you today. In relation to financial balance, I will ask the chief executive to give more specific details, but you are correct in saying that we are aiming to achieve financial balance at the end of this year. We have done that for a number of years. It has been very challenging, and we can talk about some of the challenges as we go forward. As to the reasons why we have perhaps been able to do that, I believe that in the board we have very tight management of our financial situation. We have good oversight and scrutiny from the board right down to individual teams. The finance team is very well known throughout the organisation. We have also a very joined-up approach, where we engage with our clinicians and our staff through the area partnership forum and the area clinical forum when we discuss our savings. We have a very structured approach to how we consider savings. We do quite a lot of horizon scanning at the board. We are able to identify risks quite clearly and early on, but we have to have that balance between finance, performance and not compromising on quality. The approach that we have taken in Lanarkshire has been helpful in ensuring that it is forefront in everybody's minds but without compromising on ensuring that we also maintain performance and quality. In relation to the specifics, I will turn to our chief executive, who can maybe talk a little bit more about some of the challenges that we have going forward. The chair touched on it. The first thing that I would say is that we have a particular approach in Lanarkshire. I cannot speak for other boards, but certainly we have a very gifted director of finance and finance team in what we do is take a risk-based approach. Although schemes come forward, we actually risk assess every scheme, so we do not automatically presume that it is going to be 100 per cent successful. We work through that with general managers and clinicians. The second thing is that we challenge any cost pressures. We do not just accept that a cost pressure is the automatic solution on behalf of the fund. If I give you a practical example of that, we had challenges in our mortuary. The good case comes forward with that we are getting larger as a nation, so we require some bariatric additional capacity in our mortuary. The estate team pulled together. It was a very good business case. It came to £0.25 million. If it came across your desk, you would think that it was well thought through and logical, but because we work as a team, the head of procurement actually looked and you can buy bespoke units for mortaries for the larger individual. In effect, that £0.25 million cost pressure became a £70,000 cost pressure, so it is to try and look for innovative solutions. I would also touch on prescribing. The reality is in the past that we have maybe not been the best around prescribing. We have had a prescribing quality efficiency programme, and we are sure that it will come up later on. The discussion over the second highest per head of weighted population in Scotland is now below average in that sense. That is using prescribing quality efficiency. It is not just cost savings, but the emphasis has been on quality. To get that £26 million down, we have made savings in prescribing, we have made savings in procurement, we have reduced our agency and drug expenditure, but the reality is that there is over 100 other schemes that we have had to work through to achieve that. We will go into next year with some non-recurring pressures that are still required to be found. Thank you very much. Clearly, as a well-run ship in financial management terms, you will be looking at announcements by the Scottish Government providing brokerage to other boards, writing off brokerage and other boards saying that they may need future brokerage. What incentive do you have as a board to maintain that prudent and proactive approach to financial management? If I could maybe start off, it is extremely important that we recognise that this is about providing safe care for our patients. That has to be at the forefront of everybody's minds, but yes, it is challenging, given that we are a board that has not had brokerage or a bail-out. In terms of keeping our staff incentivised, it will be quite challenging going forward. As I said, it will be helpful if the chief executive can explain what some of those challenges will be going forward. However, we will endeavour to keep that tight ship, as you have indicated. The key thing for us is that we work very much as a team from the board right down to individuals. We absolutely are clear about our direction of travel. We have a strategic direction in terms of a healthcare strategy, working very closely with the IJBs. We know where we want to go. We know what we want to deliver, but it is going to be very challenging, given that we are not to use the word rewarded for the performance that we are delivering. With any allocation formula, there can be opportunities to improve it, but it is important that you have an allocation formula. Just to set the context slightly to be clear around Lanarkshire, we are one of the lowest GMS-funded per-head of population boards in Scotland. We have two PFI's because there was not capital available at the time when two of our hospitals were to be built, and that comes at a pressure of about £60 million a year. We do have good corporate buy-in because, at the end of the day, the board wants to stay in control without external influences as to how we go about things. However, the important point is that your question is very, very fair. There needs to be fairness, there needs to be equity, because the board is fundamentally there to do the best that can for the population that it serves. The people of Lanarkshire are, in many areas, a deprived population. We need to make sure that we get a fair allocation for them. Can I maybe put my question not quite the other way around, but from a different perspective? If it is the case that dealing with a large and, as you say in many cases, relatively disadvantaged population, you are able to deliver services within the financial constraints that you have, and you see other boards not able to do that. Is there a mechanism by which you seek to share your approach to financial management with other boards across NHS Scotland? Yes, certainly. If I focus on my director of finance, my director of finance frequently meets all the other directors of finance in NHS Scotland, and certainly the Western Scotland directors of finance, Eichol and myself and my executive colleagues have similar meetings. One of my favourite sayings is that I have never done an innovative idea in my life, but I specialise in plagiarism. We spend a lot of time looking at what others have done, and there is no shame that it is the highest compliment to steal shamelessly what others have done to be successful. A good example of that is that we were one of the last boards to implement script switch, which is one of the mechanisms through which we have made prescribing savings, but it has delivered for us. We do try and share with boards a weekly learn from boards. The increase in cost of medicines is one of the challenges that I think all boards face. Is it your view that script switch has enabled you to address that directly and will it be adequate going forward to keep those costs under control? I will maybe start and ask my medical director to say a few words. I think that one of the biggest cost pressures that we are going to face going forward will be the cost of acute drugs. The reality is that we will get up to 2.6 per cent uplift this year, but our acute drug expenditure will increase by around 16 per cent. Over the last five years, we have seen that expenditure grow by around about 60 per cent. That is a massive pressure that, to be honest, if we don't do something about it, we won't be able to sustain balance going forward. I don't know if the medical director wants to elaborate. I'm happy to do that, thank you. As Mr Campbell has said, one of the key responses to that across the whole organisation is a relentless focus on the quality of care that we provide. With that focus, we have clinical engagement and support for driving all those initiatives forward. As you know, safe care costs less, because we don't have the same complications in patient care to deal with. That is what motivates our clinical teams, and that will produce a sustainable methodology for us moving forward. However, there are some really significant outstanding challenges for us. In the past 12 months, we have had a quality approach to reducing variation and standardising our approach to antimicrobial prescribing in line with best practice stewardship as examples. We have reviewed high-risk areas of prescribing, and we have had a reduction in costs per patient below the national average when we look at the weighted cost per individual patient. That is now amongst best in class. The change in switch script gives us the opportunity with primary care prescribing to continue to offset the rises in primary care prescribing that we are predicting for the forthcoming year. However, the significant challenges are within the acute division. The acute division in the year 2018-19, just ending, is predicted to come in with a marginal overspender of something just under 1 per cent of the £51.23 million budget. That is despite a 6 per cent increase in costs that is largely due to increases in the treatments for lung cancer, myeloma and prostate cancer. We have managed that by a significant number of initiatives, so we have switched by similar agents with a quality approach, using nurse practitioners to support not just the change from one agent to another—a more cost-effective agent, but also reducing and, in some cases, stopping a patient's medication, where they have been on that treatment for a long time. We have managed to recruit some patients on some very high-cost medicines into research studies, and that offsets the cost to the NHS of paying for those high-cost medicines. We have increased the number of patients who are being managed by healthcare at home, where the medicine is delivered to the patient's home. That is produced in a new year saving of £2 million. In addition to that, we have had a range of initiatives across our acute hospital sites, with reduction in variation, looking at things like patients bringing in their own medication rather than re-providing extra dispensed medicines, looking at the consistency of clinical practice switching from intravenous medicines to oral medicines, which also has the benefit of reducing healthcare-associated infection, and also a real rigor by our hospital pharmacist looking at the costs of individual medicines as they can fluctuate throughout the year, depending on the supplier. However, looking forward to next year, as our chief executive has said, we are looking at a 16.6 per cent increase in our acute drugs costs. 54 per cent of that is expected to be in new cancer drugs that have already been approved by the Scottish Medicines Consortium, but a concerning area for us is about 22 per cent of that is medicines that are going through the new PACs to process. My concern around that process is for the drugs that are authorised to go through that process, but also those where we have been advised that we should put some medicines through that process, despite them not having approval from the Scottish Medicines Consortium, because it is a much more permissive way of prescribing. We previously had a senior clinical professional input in a broader-based panel to the decision-making around very high-cost medicines to support the clinicians making the recommendations to ensure that they are not deferring to undue bias towards the individual patient that they are treating personally, because it is often very difficult to tell a patient that you no longer have something new to offer that is going to be beneficial towards them. That governance process I would like into the sort of governance process that is used in multidisciplinary team meetings where if a patient was scheduled to have cancer surgery, for example, that would be a team-based decision to discuss the potentially effective treatments available for a patient, and then a patient would be given an opportunity to discuss that with their treating clinicians on a shared decision-making basis. The process that we have now got in place for medicines management bypasses that governance and that team-based approach, and that is going to give us a significant cost pressure in the coming year. Thank you very much. I have a brief supplementary from Brian Whittle, and then we will move on to Dave Stewart's question. I touched on an area that interests me greatly, especially on treatments and prescribing of medicines. I wonder whether, within the budget that you have, everybody would agree that prevention is better than cure, and that we are trying to move towards that preventative health agenda. Are you able to start to work towards that sort of early intervention that would maybe help to cut the treatment and prescription costs that you are currently talking about? There are absolutely additional measures that we will be rolling out as new initiatives but also as extended initiatives. One of the areas that we have really just started to develop a process for is addressing polypharmacy, so addressing the number of patients who are on a large number of medicines, who have often been on them for a long number of years and who cease to have any particular benefit and, in fact, may be contributing to harm because of the potential interactions, or because, over time, over a decade perhaps, of taking a medicine the benefit that existed 10 years ago is no longer of the same magnitude to the patient, so we are starting to get into looking at how we can manage that agenda in particular. If I could just use a very quick point on that before I go on to my substantial question. A number of colleagues here are very interested in diabetes. Brian Whittle and Harper himself all chaired the cross-party group on diabetes. I am very enthusiastic about preventative spend. As you will know, around 10 per cent of spend is because of diabetes complications. On technology, I have been very impressed with some of the continuous glucose monitoring devices at Freestyle Libra, and I visited yesterday at Dexcom, where we have the new G6, which is an absolute state-of-the-art facility. I do not have shares in this company. I hasten to add. The reason I was raising this is that we know that these devices can save money. We know that there is a complicated route. We are not in the medicines, but the technology approvals and some boards, including in my neck that is up north, were a bit slow before the final approval. The point that I am making is that sometimes you have to spend to save money, and certainly in diabetes, that is vitally important. In some countries, like Sweden, 85 per cent of type 1s are actually on a form of continuous glucose monitoring, which is phenomenal. The general point is that you can save money by investing in technology. Those devices are very effective. What can you do on your own board to promote not just pumps, which are very effective, but the stage before that is the continuous glucose monitoring devices? I completely agree that the preventative agenda in diabetes care is absolutely essential. It is an area that is well worthy of an invest-to-save approach, because the population benefits might be 10 or 20 years down the line, but the reduction in the longer-term complications for diabetes is one of the main healthcare challenges that we are facing. Our diabetes team work through a managed clinical network, and they support patients to move on to different types of glucose monitoring as appropriate to their care and when they require it. They do that in an evidence-based way, but sometimes the greatest barriers are being able to bring the patients in to actually give them the education to use the technology effectively. I have arrived from the convener, if I do not move on. It is just to say that what worked in the past is targets for pumps. As you know, there were real problems before that. My own theory from a meeting that I had yesterday with the DEXCOM was that what I think will probably work as a target for continuous glucose monitoring, because that is what boards respond to because you are getting the chief execs letters and so on. It is not one that I expect a political answer on today, but is that something that maybe your board can have a think about, whether that would work or not? Can I put that to the chair perhaps rather than to the committee? We are keen to look at all measures that will improve the health of the population, so I would be inappropriate to make a comment, but it is obviously something that we would go away and consider. We also have to look at some of the upstream work that we can do around health preventative measures to stop people from getting diabetes in the first place. It is the early interventions when somebody has diabetes, but we also need to see what else we can do, because that is all about investment as well, and what benefits those investments at that very early stage to stop diabetes can also bring. Thank you very much. I better move on to my real question, which is about staffing and sickness. Could you explain the reasons for the long-standing high sickness absence rates? I think that it is a number warning that was given in the Government's stats on this particular issue. Okay. Our sickness absence rate is roughly 6 per cent against the Government target. Again, we have a number of initiatives in place that are aimed at trying to improve that sickness absence rate. Again, we have very close management in terms of supporting people to come back to work where they can. In terms of the specific initiatives and some of the things around the long-term sickness figures, I will ask our chief executive to comment. You are correct. We have been challenged with our sickness absence. One of the jobs that I do as well as being chief executive of NHS Lancer is a help co-chair stack, and you will be aware of part of the pay settlement this year that has been the revised sickness absence approach. There is a win for Scotland approach with key triggers within that. Stack is the Scottish Terms and Conditions group, where I am the employer representative on it. We have staff side colleagues there. Part of the pay settlement for the NHS Scotland this year has been the fact that there are various work streams. One of them was on sickness absence, so there is a revised wonderful Scotland policy that is going to come forward with key triggers in that to make sure that we standardise it and try to drive that figure down. We do try to use our occupational health services best we can, but as a concern for us, that is as high as that present. As you know, members have had different left experiences where we have revolved ourselves in recruitment. Certainly as a general stat, I would always look at companies and look at turnover, sickness absence and retention problems, because sometimes they are a sign of a deeper problem. You have some vague issues as well, particularly in medical and nursing roles. Would you like to say a little bit more about that and what you are doing to tackle? If I could maybe ask our medical director to talk about the medical vacancies that we have. Our medical workforce is stretched across primary care and secondary care. I will not touch in detail on primary care medical staffing. I am sure that Dr Finlay could, if required, talk in detail about that workforce. Suffice to say, we, like most boards, are facing some real challenges in recruitment and retention of general practitioners. We have a sustainability plan that we are working through with our colleagues in the partnerships in relation to that. We are taking every endeavour to try and improve recruitment and retention. We relatively recently had a meeting with NHS Education Scotland to try to increase the number of training placements in general practice and to increase the number of training practices and the number of authorised trainers that we have to try to boost those numbers. We know that our workforce generally comes in a sustainable way from those who live locally and who want to continue to stay locally. The general medical council has good evidence around that being a significant factor in career choices for young doctors in training. In secondary care, we have had a large number of initiatives. We currently have a shortfall in our workforce of around 15 to 16 per cent, which is significantly above the national average. That varies by specialty. I can give you details of that if you wish to. However, the general actions that we have taken to address have been a whole system. We have looked at how we can widen access to medical training. We have developed relationships with the local schools. We run careers information services for the local school pupils to come and learn about not just medical careers but all careers in healthcare professions. We look to provide work experience for school pupils and specific work experience for higher school pupils who wish to enter the medical profession, giving them some tailored experience and support with application for medical school. At undergraduate level, we have improved the level of training and the quality of training that we offer for medical students coming out to our hospitals and our GP practices. Again, a positive experience as a medical student is likely to boost recruitment and retention thereafter. We have had some significant plaudits across many of our specialties for the quality of undergraduate training. We have also developed leadership roles in doctors and training and postgraduate training. We have substantially improved the quality of training for every single specialty that we have in NHS Lanarkshire. We have had a significant number of plaudits and we were voted the best hospital to go and train in recent poll of local graduates. We focus on international recruitment as well through the colleges for doctors and training. We also use that route for recruitment of consultants in very hard-pressed specialties, particularly in radiology and in mental health. We look at development for consultants to expand their portfolio into research and development, medical leadership and service redesign to make roles more attractive. We have looked at the whole system of the things that will improve our ability to recruit and retain, but it remains very challenging as a board that sits between the two large university boards—medical school university boards—despite our strategic partnerships with other universities to compete with larger teams where out-of-hours work is less frequent. That seems very sensible. Can you say a little bit about your strategy for attracting non-EU staff, because, clearly, if we are looking towards, none of us can read the in-chills of what is happening in Westminster, but on the basis that we are leaving, presumably focusing on non-EU medical staff in particular would be important. You might not have the figures in front of you, but can you also say something about the NHS surcharge? As you know, that was doubled by the UK Government, which is a cost that employers have to pay for non-EU staff over £30,000 normally. You will not have that in front of you, I am sure, but perhaps you could say a little bit about your strategy for non-EU, for example India, Pakistan and so on. The international medical graduate route has two different mechanisms that we utilise, one is the Scottish Government-sponsored international medical training fellowship, and those are posts that are for doctors towards the end of their formal training, so just short of consultant level. We have accessed that route to try and advertise for positions in emergency medicine and general medicine, so those are two hard-pressed areas for us. We have not had tremendous success in those areas, I have to say, because the expectations of people coming to work at that level in their training is that they will have a different experience from the one that we have to offer in terms of the service gap, which is not quite at that level. We have had more success with the Royal College-sponsored international medical training initiative, and that is something that many of our consultants came through themselves or have strong links with. We have a number of doctors who are graduates from India or Pakistan or who have family routes there. They have used their contacts to identify individuals who can be sponsored through the Royal College to come and work with us as international medical graduates. That is usually the middle grade level of doctor, which is exactly the area where we have a service gap, but we also have strength and training. We have a number of colleagues who have supplemented questions in the area, and we will start with George Adam. Good morning. Dr Burns mentioned one of the particular challenges that you have with recruitment of staff being the fact that you are in between Glasgow and Edinburgh. Can we maybe elaborate on what particular challenges you have in recruitment of staff, including retention of staff? Again, if I could just comment, we have the medical schools in Glasgow and Edinburgh, which Dr Burns can refer to, but we are taking a number of initiatives to try and make sure that we are an employer of choice and that we can also attract people to come and work with us, even though we do not have the medical schools that are situated in Lanarkshire. We are working very closely in partnership with a number of higher education institutions to look at innovative ways of attracting people. As Dr Burns said, once you have come and worked in Lanarkshire and trained in Lanarkshire, you are more likely to come back there for a permanent role. It is about getting Lanarkshire into the psyche of people, that it is a good place to work. As I said, we have a number of initiatives around higher education institutions and, at a very earlier level, with school leavers who can then see what Lanarkshire is like and contemplate that as a place of working. In terms of specific issues in having those medical schools, Dr Burns might want to elaborate. There are a number of different areas. The first one is that geography does not tend to be a huge issue because, at consultant level, most people are happy to travel across the central belt. We can manage to recruit, but we sometimes have difficulty in retention. That is usually because of the preferential work-life balance. I would describe it as that, with a reduced frequency of out-of-hours work and the larger teaching hospitals that provide the tertiary services. The fact that tertiary services are offered there, the more senior doctors in training have to go through rotations in those clinical departments in order to get all of the components that are required of the curriculum set by the general medical council for their full training. If they miss those opportunities, they would have to go back and do them again. That cohort of doctors rotates out for part of their training to Lanarkshire. However, those posts are general posts—general medicine, general surgery. There is less requirement for those posts to be absolutely filled by the trainees. There is no imperative for the trainee to have to come back and repeat a training allocation in a district general hospital if that is missed because, usually, by the time they get to the end of their training, they can manage to achieve all those competencies. That slot in the duration of a seven-year training programme is often the one where a doctor in training will choose to take time out of programme, as it is described. It might be a time when doctors in training choose to start or complete a family. There is maternity leave and paternity leave are things that impact our ability to show those doctors in training the benefits of working in Lanarkshire. That is a real difficulty for us and an area where we have a constant debate with NHS Education Scotland to say that we have to have those posts filled so that we can compete in recruitment and retention of our staff and give those individual doctors the experience of working in Lanarkshire so that they will come and work with us. That is something that we try to tackle. We have also created different opportunities for doctors in training who, at the completion of their foundation years, do not want to go straight into that lengthy seven-year training programme. The latest general medical council figures were that only 20 per cent of doctors went straight on to those training programmes, so we have offered different opportunities that allow those doctors in the third year of their training to go into medical education, simulation training, leadership roles, quality improvement roles, etc., and give them a different opportunity that helps them to stay in Scotland. I would like to ask about a specific issue that will probably declare an interest in the fact that I am a convener for the cross-party group in the multiple sclerotas. My wife is MS and there was a campaign about a year ago, two years ago, where she had no MS nurses in Lanarkshire NHS. One of the problems was that the previous nurse—and it is connected to that as well—the previous nurse had left because she believed that she was overworked because she was dealing with more than the recommended 315 patients per individual with MS. I believe that the cover for 2.5 MS nurses is available now, which is a successful campaign, if you ask me. However, at the end of the day, the question is for the future. I know that they are doing a review at the moment for services for MS in Lanarkshire. Where are we going for the future? What are we doing in Lanarkshire for those with MS in the nursing in Lanarkshire? How are we going to make sure that something like what happened previously does not happen again? I would like to pick that up as best I can on behalf of my nursing colleagues. I think that the future for services to support patients with MS lies in those nurse practitioners and providing services within the community, but also as a liaison service between patients and the consultant neurologists. Neurology is a very good example of a tertiary-level service that is actually provided by NHS Greater Glasgow and Clyde. Although we have created Lanarkshire-based consultant neurologists posts, we have failed to retain those individual consultants because they are more attracted to the tertiary centres, where there is a high level of research in that particular area of specialism. We will never be able to numerically compete with that because the numbers of consultant neurologists that we will ever have will be two or three at most, so that is quite difficult to sustain that workforce, so it becomes really important that other healthcare professionals such as advanced nurse practitioners help to support the service. Thank you very much. I remind colleagues that time marches on, so brief questions and answers if we can. I'll call Hamilton. Good morning to the panel. I'll try to be brief. One of the things that we have detected in our scrutiny of other boards and, indeed, other wings of the NHS is that when recruitment and retention are an issue, obviously there's a corollary to staff morale and the feelings that staff have of being heard, the faith they have and the systems that they can raise concerns through. Could you take us through your whistleblowing practices and the strata that you have within the health board to allow staff not just to complain or to raise concerns, but also to contribute their own ideas and expertise to the growth and development of the organisation? If I may start off and then I can turn to other colleagues to contribute, so from a board's perspective I think it's extremely important that we are connected to front-line staff and hear very much from the front line what the issues are, what some of the challenges are, but also what some of the good things are that need to be celebrated. So all board members, for example, participate in leadership patient safety walk grounds where we have an opportunity to go out and have quite a focus with staff to help understand from them what concerns they have. In addition, we obviously have the full whistleblowing policy and practice, which again our chief executive can talk through. We've also done quite a piece of work around psychological safety and a sort of culture, safety culture survey around cohorts of staff starting with our nursing midwifery allied health professionals, but also expanding to other areas, which gives staff the opportunity to give their concerns, to voice their concerns in that safe space, to tell us how they feel about being able to raise concerns either formally or informally and what we can do about shaping that culture. I believe that that's what's really important. You can have all the policies and practices that you want, but you have to have that open culture, a dialogue and the ability to go out and reach out to staff in various ways, but maybe Mr Campbell might want to expand on some of those initiatives. Just very briefly, I think that the chair touched on one of the key differences. We do the psychological safety questionnaires, and it was started off when the nursing staff has now progressed beyond that, where we actually ask people whether they feel confident and safe enough to speak out. In special, there's missed episodes of care. We want to be told that the chair touched on the fact that we do leadership walk-around, we also do patient safety walk-arounds, where you're walking around the place and it gives a chance for people A to get to C, B raise issues. The other point that we make is that we have an email link. If people want to email in anonymously to the director of HR to raise issues, that mechanism is in place. Thank you, convener. Good morning to everybody. I'm interested in looking at waiting times, improving waiting times. I note that the quarter two report was submitted to the board and it shows 11 key performance indicators, with either red or amber, 12-week outpatient appointments, 18-week referral to treatment, CAMHS, access to psychological therapies, advanced booking to primary care, detect cancer early and others. As I said to convener, I'll try to keep this brief. I'm aware that money has been released from the Scottish Government £146 million to help address waiting times, so I'd like to hear if you've heard a much NHS Lanarkshire's getting and then what do you propose to do with that. If I can maybe split the contributions in response to your question in two bits. If I can get Mrs Knox to talk about the waiting times within the acute sector and Mr Marguffy can focus on the CAMHS performance. Okay, thank you for the question. I think when it comes to performance, we do have areas where we have very good performance, so we're very proud of our cancer performance in particular, and that's something we really focus on within the acute team. We've also made great progress in our HSMR, hospital standardised mortality performance, and Jane can tell you more about that if you wish. Then there are areas as you rightly point out where we're working hard to put in place improvements within our performance. If we look at Lanarkshire's performance against the outpatient 12-week target, which is one of the targets that you mentioned, I'm really pleased to report that we've seen a significant improvement in that performance over recent months. Back in October, we had about five and a half thousand people waiting more than 12 weeks for an outpatient clinic attendance. As of yesterday, we've managed to bring that down under 3,000, so I hope you'll agree that that's quite a big improvement in quite a short period of time. For the treatment time guarantee patients, i.e. patients waiting for an operation, the comparative figures back in October were over 2,000, and they're now 1,430. For this performance measure, we're probably the most, in fact, I think we are, the most improved mainland board across Scotland. We also benchmarked well across Scotland, so the Lanarkshire population is around 12 per cent of the Scottish population. If you accept that around 2 per cent of our patients are going to be treated within Glasgow, you would expect our share of the overall weights to be about 10 per cent. Back in a few years ago, maybe 2015, 2016, we were sitting at about 10 per cent of the overall patients waiting over 12 weeks within Scotland. Our share of the outpatient weights has now fallen to its lowest in the last four years, and we've now only got 3.8 per cent of the Scottish share of those weights. I'm really proud of the progress that we've actually made. I know that it's still showing Amber on your report, and I know that there's more we can do, but I am pleased with the progress that we've made in recent months, and that's been a lot of work with the whole team to deliver that. We're keen to sustain that improved performance, and to do that, we need to put in place programmes of redesign. It's not just about having more and more patients being treated in the hospital sector, it's actually looking at the demand and looking at the pathways from primary care into secondary care, and looking to see if we can do some change management around that. If you have celiac disease, for example, you will now be seen by a dietician. You might actually be seen in your GP's practice, as opposed to being seen in the hospital, so that then takes away the burden from the consultant's freedom up to see other patients. Equally, we've put in place a lot of virtual clinics, so learning from other sectors, so if you're in another sector, take the banking service, for example. They've affected a change from face-to-face, telephone, virtual. They flipped that on its head, and that's what we need to do around many of our outpatient consultations, so moving away from that traditional, we will see you in our clinic when we have the paperwork and when it suits us. We could do a lot more virtually, and GP's are doing a lot of that work already. We've got virtual clinics now set up in a number of specialties where the consultants will just look at the patient notes. They don't need to see the patient. They can phone the patient if they need to, but we set that up as a clinic virtually, and we're seeing a big improvement in the numbers of patients that we actually have to bring up to the hospital as a result of that intervention. We're doing quite a lot of improvement work to try and change the demand on our services. I'm happy to talk for longer if that doesn't answer your question. We'll take Ross McGuffey and then we'll come in or we'll have him. The first thing I would say is that we've got a really strong performance culture within the area. If we take the health and social care partnerships as an example, we've got quarterly reviews that take place with each of the locality teams around performance. We've got quarterly reviews with the chief executive review on our performance. In North Ananshire, we've got both chief executives in place both through the NHS board and the council. We've got a really strong culture. In terms of CAMHS, historically, we have been one of the better performing boards, but we have, in recent years, become an under-increasing pressure. The service pressures faced demands doubled since 2012 coming through the service. We take just the last year. We've seen a 60 per cent increase in urgent referrals, which clearly has a knock-on impact in terms of the wider waiting list. There's been a really positive direction of travel around the funding coming in with quite a number of temporary funded allocations, which have been moved to permanent. In the year, we've also moved a number of staff from temporary contracts to permanent ahead of those changes to try to bring a bit more stability to the service. Staff demographics is a challenge for us. It's a really predominantly female workforce and quite a significant proportion of that in younger age. At the moment, we've got either off on maternity leave or just about to go off on maternity leave, 14 whole-time equivalent out of a service of 113 whole-time equivalents, so well over 10 per cent of the service off on maternity leave at one time. As we've picked up in previous questions, recruitment within CAMHS is very competitive and based on the central belt, which drives a challenge in terms of recruiting, but also in terms of staff move. We have undertaken a deep-dive exercise, which was led by our medical director within the partnership, and that's come up with a number of actions that we've taken forward either immediately just now or across 2019-20. We've identified additional peripetetic posts to cover off areas where we have got significant staff absence through maternity leave, etc. We have reviewed the number of team bases and we're looking to change the number of team bases across Lanarkshire to try best to improve the resilience of the service. There's really significant work going on around the neurodevelopmental pathway, which is one of the actions coming out through the national task force work. There's been a lot of national interest in terms of the approach that we're taking, but that will see the development of a multidisciplinary team. The north service will start off in May of this year, and that will see CAMHS, paediatrics, SLT, etc. coming together in one integrated team to provide a much more consistent service around neurodevelopmental conditions. The other key component here for CAMHS is early intervention. The national drive through the task force is really welcoming in that regard, and we'll be doing a lot of work through the two children's services partnerships in north and south, because I think that's an absolutely critical element in terms of CAMHS getting a much earlier level intervention in place to try best to provide much earlier supports. Thank you, everybody, for your impact. I'm just interested in that everybody's doing a lot of work around transforming care, getting people into primary care approaches instead of secondary care, getting people out of hospital, discharge planning, all of that. There's a lot of good work. Callum talked earlier about plagiarising or getting ideas from other health boards. Is active work being pursued to look at what other boards are doing to address their waiting times and sharing best practice? Yes. The reality is that Mrs Knox summarised her performance, and a lot of that is a fair degree of plagiarism. Just last week, we had the review of her orthopedic service, and there were representatives from a number of boards giving feedback on the day. Generally, it was positive, but there were some good things that came out from that. One of the challenges we had was that we could probably go further with our virtual reviews and that we're probably duplicating that because we operate on three different sites. They were saying, why don't you make your virtual centre one? There were some good recommendations coming from there, and I think that that was a consultant from Glasgow who was one from the boarders. We challenge ourselves in that sense. One of the important points to highlight is that we have a partnership agreement with—we're now a university board with Glasgow Caledonian and with UWS, but we've started to work now with Strathclyde University because one of the things that we've recognised as a fact is that we can't continue to go forward with the models of care that we've got, with the demographics that we've got, so the fundamental challenge that we're presenting with Strathclyde University is to say, how do we address health inequalities, as well as look at how we match our workforce, because we've got about 10,800 whole-time equivalents? I think that, given demography, we're not going to continue to rise in numbers, so therefore what are the models of care we will require going forward if we're fixed round about 10,800 but the demand in the service goes up, and that's a close collaboration with Strathclyde University trying to help us to answer that question and give us appropriate workforce planning going forward. I wanted to touch upon preventative health again to go back, because looking at some of the national trends, NHS Lanarkshire continues to have the highest prevalence of smoking within all of the health boards in terms of population, with 30 per cent of the adult population smoking and 19.2 per cent of pregnant pregnant women in Lanarkshire reporting that they smoke. I wanted to touch upon in terms of future smoking sensation programmes in Lanarkshire, but specifically some of the innovative approaches that the health board have taken to date, and I know that certainly the pilot project around paying people to quit was one that Lanarkshire engaged, so I wondered if you had any feedback on that and how you're looking to address the problem, which is still a high number of adults nationally. In 1718, Lanarkshire's target was to achieve 1,220 12-week quits in the 40 per cent most of private areas. Our final position was actually 1,273 quits, so above target. Lanarkshire's performance of 90 per cent against the Scottish Government target was the third highest in all health boards, and we've also extended the overall Scottish performance by 9 per cent. Along with that, the 12-week quit rate for 1718 in the most deprived areas in Lanarkshire is 2 per cent higher than the Scottish rate, and overall we achieved 2,361 quits at March 2018. In terms of wider tobacco control, we've recently developed the smoke-free Lanarkshire for you, for children, for ever, Lanarkshire tobacco control strategy, and that provides Lanarkshire with a clear action plan, which is in line with the direction of the Scottish Government's action plan. The vision of our strategy is to create a society for children, which is smoke-free, and where adults are positive anti-tobacco role models, whether they're smokers or not. Even if they can't quit themselves, they promote a non-tobacco use in our children. The key aim of our strategy is to protect children's health, to tackle inequalities and to reduce the prevalence of smoking in Lanarkshire from 21.8 per cent to an overall 11 per cent by 2022. We look forward to reporting that trajectory as we go forward. In terms of that work, specifically the high number of pregnant women who were reporting smoking still in Lanarkshire was of real concern. I mentioned already the pilot projects. Is there any other work that you're looking to do around that, or what success have you had specifically within pregnant smokers? Certainly within our family nurse partnership, which tackles people who will have health inequalities in the work very closely with young mums to take forward smoking cessation. I would need to go away and look for some more information on the rest of that. Thank you very much. Thank you very much, convener. Obviously, delayed discharge is a problem across Scotland, and we have come up against this with any examination of a territorial health board. Can I just ask, in this scenario, that we'll be familiar to many members of having constituents in hospital far longer than they need to be for want of adequate social care provision? What is the decision-making process, and who can knock heads together, if it were, between social care and primary care, to make that happen? I'll ask Mr McGuffie to talk about the delayed discharge process. Again, just to say, we knock everybody's heads together to make sure that this works, because it's absolutely important that we get people out as soon as they are ready to go home. Absolutely. It's a vital priority for us as a partnership. I suppose that I'm starting the fact that we have taken this on a really whole system basis, so we've got unscheduled care and delayed discharge improvement boards, which covers both North partnership, South partnership and acute sector altogether. That is the planning vehicle for all unscheduled care and delayed discharge work within the partnership. There has been a whole range of work undertaken. The headline figures are that, over the last year, we have seen a 12 per cent reduction in terms of delayed discharge bed days. We have seen an 18 per cent reduction in code 9 bed days. We are seeing some moves going forward. Specifics have been taken forward both in North and South Lancer partnerships have had their own home support strategies. There are new models of home support that have really tried to focus on much more reabilment and rapid response rather than on one of the mill packages. That is definitely starting to see an impact. The number of over three day bed day delays for home support has reduced really significantly across both partnerships as part of that roll-out. Ultimately, the real positive is that having a rapid response reabilment will have a much better impact for the individual themselves, because in the longer run, we are maximising independence right at that point and, hopefully, reducing the overall demand in terms of home support in the longer term. We have daily conference calls that take place between the partnership, co-ordinating complex cases and significant cases. Within the two health and social care partnerships, we have conference calls that do the same across health and social care to make sure that we have a site of every complex case in the hospitals and exactly how we are trying best to move those forward. Within the code nine patients, we have had quite a significant piece of work looking at the national protocol around that. That is a really significant impact. It would take probably 12 months ago. We would be sitting mid-double figures around—or mid-teens—around over 100 bed day delays for individuals going through the guardianship process. The national protocol is for that to take about 13 weeks, which is 91 bed days. Since doing a bit of work on that, it includes a number of escalation points for when things get blocked. At the moment, last week, we only had four over 100 bed day delays across the three acute sites in Lanarkshire, so that has been a big improvement. We are also now taking forward a test of change around guardianship applications, where NHS will spot purchase care home beds to put the individuals in a supported environment that is much more homely to living through that process, supported by the appropriate medical and MHO cover. We have been working in the acute wards around estimated data discharge. That, again, is trying our best to do that on a collaborative basis, so that we will get social work involved in the discussions much earlier. We have also undertaken in North and South reviews of intermediate care provision. That is a critical one—I think that one that we have started to get a real traction from. That is looking at the off-site beds and the step-down capacity, but we are trying our best to get a much more rehab focus and ravable focus in those sites. That allows the throughput back into a much more positive destination back into the community, but it also provides a step-down capacity that we require to support people stepping down from acute. The last thing that I will pick up is a recent development around the roll-out of integrated teams that we have in North Llanche of integrated rehab teams. That took some physio hours from the acute sites, the community assessment and rehab service, which was acute-based as well, disaggregated that into the localities in community, took the domiciliary physiotherapy and occupational therapy and social work occupational therapy into integrated teams. South Llanche has a similar approach in their integrated community support teams, and what that has allowed us to do is create a rapid response vehicle. Over the last three weeks in North Llanche, we have supported 20 early discharges home, so that was removing them from the process previously, where they would wait for OT physio assessment on-site to have been supported home with a rapid wraparound service, rapid access to equipment on the day to allow those assessments to take place in the community. The big benefit of that is not just in terms of bed days for delayed discharge but also in terms of the destination for the individual, because if we could get people home much earlier, the deteriorate much less than they would sit in hospital, and the assessment would be much more likely to be more accurate at maximising the opportunity to remain in their own home rather than ending up in institutional care. I think that just to try and set the context, I am going to ask Mrs Knox to say a wee bit about hospital home to put that in context, but it is important that Mr McGuffey talks about the reduction that we have seen in delayed discharges both in the north and south. That is because there is a strong partnership between the health board and both councils and the IGBs, but what we need to recognise is that our emergency admissions have went up and our length of statement down. We have already touched on the fact that we have a large deprived population to look after, so the system is under pressure but the performance is good, but hospital home has been a rule bonus for us, and I do not know if Heather could say a few words. I think that it is important to say that Ross McGuffey gave us some encouraging numbers, but the year-on-year figures show that the number of delayed discharges in Lannarshire in January this year is higher than it was in January last year, so the numbers have in front of me 3488 bed days in January 2018, 4211 in January 2019. I wonder if we could just understand the context of those numbers and how they contrast with the numbers that Ross McGuffey mentioned. The figures that I gave you were for March to January, which was our last ISD-reported figure, so they were the cumulative in-year total compared to the previous year over the same time period. I am simply comparing this time last or the exact same point in the previous year. I am doing a cumulative March to January position rather than just the January figure itself. Thank you very much, convener. I think that that is probably one of the most comprehensive answers that I have ever had to that question, Ross, so well done. Obviously, you can still share the convener's concerns about this year's numbers. On that, there is corollary to this story, which is the social care environment in your health board area. Can you tell the committee a bit about capacity in that? Whether part of the problem, as we have experienced in other parts of the health service, is down to the fact that we cannot get people out of hospital because there is not either local authority provision or private commissioning provision available to cater for the packages of care that they need? It is certainly a challenge across both partnerships in terms of recruitment. Again, the workforce issue in terms of home support can be quite challenging in terms of recruitment. I think that, although there is an impact there, the changes in models that we have been putting forward have had quite a positive impact. I think that the direction of travel that we have set around shifting that balance away from straightaway into direct service provision to a much more focused on an earlier intervention and rehabilitation approach will have the desired impact. We have done quite a lot of research, for example, around the discharge to assess models that we have been down to visit different partnership areas in England to review their models and the impact that they have had. What we have seen from other areas is that we can make quite a significant impact through a much earlier intervention. That is the direction of travel that both partnerships are moving forward with. If you take an example, it was picked up in terms of discharge to assess what we were looking at equipment. The learning that we have gained from other areas is the fact that, when we do get in a much earlier intervention, we get the individual out home on a much earlier part. While the equipment needs to go in on the day, which is a pressure for the system, what we find is that the number of pieces of equipment that are required shrinks quite significantly. There is a significant challenge in terms of the transition of that model, but we know that the longer-term impact of it will reduce demand, so that is the direction of travel that we are pushing. You have talked about early discharges up. At the same time, emergency department admissions are up. Is there a danger of people going out one door and in the next? I think that there is certainly an element here of building up the rapid response capabilities within primary care. The initial focus of us in both partnerships has been about developing that for use for the back door. In reality, what we need is those rapid response teams in the community being able to pick up the front door element as well. We need to have that rapid unscheduled care approach that is available in communities that will negate the need to reduce the number of people going to the front door. I might be able to suggest that this is not going to expand on what we are doing at the front door particularly to support that. In terms of how we use hospital at home, if I could pick up that point first that Calum mentioned earlier, our main focus is on patient safety and doing the right thing for that patient at the right time. We try to stick to that. That sometimes means that we have older patients who have dementia or have come in with an infection and have a delirium in our emergency department a bit longer, because we do not want to move them around the hospital to various wards because it is very disorientating for them. We have a service in Lanarkshire called Hospital at Home that has grown like topsy over the past three years. We have a team that can come in and take many of those older patients home with that support. It is a virtual ward environment, so they are actually having drips and infusions and a lot of care that they would normally receive in a ward. They are under a consultant that they are cared for in their own home. We now can support around 90 patients across Lanarkshire on any given day in that kind of environment. That is one of the reasons why sometimes we have people waiting a bit longer in ED, but it is the right thing for that patient. Equally our GPs. We were unique in Lanarkshire in what is called our ERC, which is our emergency referral centre. The GPs will phone into a single point of access in Lanarkshire when they want to admit a patient. That is unique across Scotland, so that is something that I was involved in setting up when I was a regional planning director many years ago, so that is quite nice to come back to that. They phone in and they are given the option of hospital at home at that point, so again the GPs can refer the patient straight into hospital at home, and our team will come out to the patient as opposed to the patient coming into the emergency department. It is not just all about the numbers and the eight hour waits and the four hour waits, it is about the patients and what is the right thing for the patients. Brian Whittle A simple question about the GP contract, is how supportive the GPs in Lanarkshire are of the new GP contract and all that that entails? Is Dr Finlay to respond to that, if she can? How much time do we have left? Dr Finlay As you will know, only 30 per cent of GPs voted for the new contract, and only 70 per cent of that 30 per cent voted for the contract. Across Scotland, we are dealing with very small numbers, and we can think about the reasons for that. Within Lanarkshire, we have developed some very good relationships with our GP sub, and they are very supportive and have signed off our primary care improvement plan. We also need to get round the GPs themselves, so we have cluster qualities, cluster quality leads, who are GPs who lead quality within a number of practices for their area, that we have very strong links with and are very supportive. I think that for GPs at the moment, there is that tension between sustainability and the old model of general practice towards what could be seen as the biggest change in general practice since 1948, so being much more involved with the managed service within their localities. We are working through some of those challenges just now. However, they have mostly positively embraced it. We are seeing trust with our GPs grow in that, where we have sustainability issues, people are coming forward at a much earlier stage to allow us to help them as a board. I wonder how the board monitor the performance of GP practitioners and practices and will the new contract change the way in which that is done? That is a big change for everyone. The cough that we used to use to monitor practices went in 2016 and was replaced with the transitional quality arrangements and primary care indicators. When you look at it on SPI, our board officers cannot view the primary care indicators for their own board, and that is something that stops us using that to monitor quality. Part of that was roundabout getting the trust of GPs and the quality leads such that their data can be extracted and used centrally to help them improve quality. Therefore, as a board, we are thinking about how the cough has gone and we have nothing else in place yet. How do we do that? Prescribing. Dr Burns has already talked about that. Certainly, that can be looked at per locality, per practice and per individual, so that can be helpful. Complaints, which we do not like getting, but we ask our independent contractors, not only GPs, but other independent contractors, to report on their complaints quarterly. The board will now mediate in complaints at practices rather than going straight to the ombudsman, although many times that often goes straight to the ombudsman. There is SPIR, which was touched on previously, and that is about extracting data from GP practices. Our GPs in the clusters are working with list analysts to look at the data for their areas, to think about quality. As a board, we can look at discovery, which is run by NSS, and that lets us look at things such as referral rates, read missions and emergency department usage. What we have done is set up one quality improvement programme around that in one locality, where the GPs in that locality have agreed to look at those indices and work with us to reassure us and help us to improve the quality there. We have, as I said, good relationships with our cluster quality leads and our locality lead GPs, so that helps as well. Of course, there are a number of enhanced services and GP practices that are monitored by the board. I was reading that primary care in Lanarkshire is receiving the lowest total payment for its population of all territorial boards. I wonder if you could expand on that. I wouldn't say yes, and if we can have more money, we would like that. Perfect. As Mr Campbell said, we use what we have got wisely. We have the GPs increasingly integrated in both IJB areas into the ICST teams, so integrated community support teams in the area that I work in, such that we are maximising the use of the GP because some of that work is picked up by those teams to keep people at home. It is really that full systems approach. I will let Brian in again in a moment. It has been suggested in the past that one of the issues in Lanarkshire is that people who, in other parts of the countries, might go to primary care and Lanarkshire might go to emergency departments. Is that still a feature that you would describe us as an issue in Lanarkshire? I think that it is a reasonable observation for people to make. One of the challenges that you have in Lanarkshire is the fact that you have three district general hospitals that are quite close to population centres and therefore access to secondary care in that centre is relatively easy. To make a comparison, if you take Aberdeen royal infirmary and compare the population use of Aberdeen royal infirmary for local authority in Aberdeen Shire and compare it with North and South Lanarkshire, the reality is that you are twice as likely to turn up at one in Lanarkshire, but I think that it is as much to do with the geography and the close proximity of the hospitals to the population that drives that. I think that I also had a deprived population at times, but I dare say that if we had more general practice then that would help it, so I think that it is a combination of issues. The other thing that I am really interested in within the GP is that that GP cluster is working in the multidisciplinary teams that are now developing. I wonder if I could ask you how you prioritise the locality of planning against health inequalities in Lanarkshire? Thinking about the multidisciplinary teams and how we are using them, we have moved to a position when we are rolling out the resource that comes with the primary care improvement plan that is allocated on a locality basis. We have taken the view that there will be a levelling up of services to try and start tackling some of those health inequalities so that the areas that are better resourced will get the additional resource later on. Within each locality, the locality lead GP, the cluster quality lead GP and the locality general manager are all involved in discussions about how that resource is best used within their locality, such that if there are practices struggling or where there is pocket deprivation then they would get the resource first and then it will level out over the three years. Underpinning the whole primary care improvement plan, there will be an evaluation. Part of that, our GP colleagues have asked us to make sure that there is a fairness of allocation across the pieces, I am sure that you can imagine, and they are working with us to develop that as we speak. However, it is a very new way of delivering general medical services, so it is almost that partnership working as we go along. With that fundamental, there will be a levelling up of services, certainly not a levelling down, so we have got a level playing field. If I could just ask one more question here. I unashamedly put my heart on as the convener of the MSK and Arthritis cross-party group. Within a multidisciplinary team, we know that but one in five people presenting at a GP practice is going to have some sort of MSK issue. We would also probably agree that, in most cases, a physiotherapist would be the best person to deliver that. There is a suggestion that there is a shortage of that level seven physiotherapy for GP practices or GP clusters and multidisciplinary teams and that they are moving from and from the hospital environment into the GP environment. Is that the case? The Robin Peter to pay Paul certainly is a risk. There is also a risk, as we have heard earlier, that you would train people up to level seven and then they would move to other boards as well. Within Lanarkshire, we are looking at a grow your career in Lanarkshire approach, such that within the primary care improvement plan, we would have a range of physios working within general practice and making sure that that is governance and safe, so that we are attracting people in, so that they can grow their career with us and ultimately have a career ladder up to that band seven. We are also working very closely with the enhanced service physios such that we might even work a rotational model. That is being worked up as we speak, so I cannot give much more information on that at the moment. People are retaining the experience not only within primary care but also in the acute care setting and back out. That, hopefully, will improve job satisfaction among our physios. We are also almost future proofing that service, because there is no doubt that if you have an MSK problem, you definitely want to be seeing a physiotherapist and those advanced physiotherapists, rather than necessarily going to your GP, where you probably end up with a prescription and maybe not much else. Do you have enough physiotherapists in the system? The short answer is no. It is one of our pressure areas. We had a conversation yesterday with the University of the West of Scotland and we will do some work with it to profile all the demands in physiotherapy and say that there are other professionals that we can use to offset some of that work, because physiotherapy posts are one that we are short of. It is on the back of Brian Whittle's question, because physiotherapists are needed for pulmonary rehab, and if you have so many smokers in Lanarkshire, that is going to have a knock-on effect for pulmonary ill health. I declare that I am the cross-party group convener for the lung health cross-party group. I have an interest in smoking cessation and pulmonary rehab and social prescribing for prevention of type 2 diabetes. So, tell me a wee bit about the success or benefits of social prescribing in NHS Lanarkshire and do you have pulmonary rehab processes in place to deal with your lung ill health? We have a programme in Lanarkshire called Well Connected, which is a social prescribing programme. That includes a whole range of elements from pulmonary rehab classes and wider fitness classes through things such as stress control, anxiety management, mindfulness, a whole range of different programmes that are available to GPs and also through Rhone Occupational Health Services for referral. It is an area that we are absolutely keen on developing within both partnership plans and within the strategic commission plans that it is here as we are looking at. I think that the tech agenda within this is absolutely critical, because there have been some great pilots in North Lanarkshire around home health monitoring. If you take respiratory, as an example, we have simple tech out with individual patients where they can use a pulse oximeter, text their reading back into the service and they will get an automated response. If it is beyond a certain value, they will get a text message back, give them some advice and ask them to take another reading in 30 minutes, so that they will send that back again. As required, they can get a respiratory nurse out that day to see them at home where they are required. I think that the tech agenda in terms of enabling that is really important. Other examples I could give around the development of making life easier, which is a portal that is used in North Lanarkshire, which provides self-management advice and also supported self-assessment and gives a range of options for individuals in terms of being able to order simple equipment for their own home, but really allowing people to take control of their own condition and to connect them into service where they are required, but not automatically. They really try best to support the individual to take control. However, in both commissioning plans in North Lanarkshire and South Lanarkshire, this is an area that we are looking to develop around supporting people to take control of their own condition. Thank you very much, Sandra White. I am pleased to know that I am not a cross-party convener. I know of any health so far, but I know of other cross-party groups as well. I am really impressed with some of the figures and what you have said, particularly in the integrated teams and people being able to go out and get in sport and so on. I would hope that other health boards might take that on board. I wonder if the convener would indulge me, perhaps, if you were able to send us some papers in regard to the delayed discharge and how you get people out and how you support them, because it is something that is really, really important. It is a personal matter for me as well. It is personal, but it is not a health matter. That would be wonderful. I want to go on to—we know of the pressures that are put on in one of the pressures in your own area—the new Monklands hospital. It is not just a pressure that comes in under capital projects and monetary terms, but it is obviously the morale of the staff, I would imagine, in retaining and keeping people there. I know that it is quite a sensitive subject. It is out to public consultation, so I cannot dig too deeply on that particular issue, but we have the two on board, Gart Cosh or Glen Mavis, in that respect, and our report was supposed to be put forward in February this year. Could you enlighten us on where you are at the moment, or is anything moving without— Maybe if I could respond to that initially, and then Mr Campbell can come in. The first thing to say is that you will be aware that an independent review has been commissioned by the cabinet secretary to look into the consultation process that we carried out in relation to a new Monklands hospital, the refurbishment or replacement of Monklands. The independent review group were due to report at the end of February, but have recently indicated that they will now not report till the end of May. Therefore, you will appreciate that there is limited information that I am able to share or that it would be inappropriate to say too much around that. However, I would like to say about the Monklands site that it is a key plank of our clinical strategy going forward. Having a replaced or refurbished hospital is absolutely part of that. The hospital is now over 40 years old. It is important that, if we are able to deliver our clinical strategy going forward, achieving excellence, notwithstanding all the discussion that we have had earlier on about attracting staff, enabling them to work in an environment that provides them with absolutely state-of-the-art facilities, having that new hospital is absolutely crucial for us. We have some challenges, and you talked about staff morale. I will ask Mr Campbell to talk about some of those challenges, but one of the key ones is about the physical environment of the building and the amount of backlog maintenance that we have. More important, it means that, in that environment, you cannot always deliver the services in the way that you would wish to deliver them. That is the key bit of it. It is not just about the physical environment, it is about delivering those services in a manner that you would want to. I think that, if you want to expand a bit more perhaps, you can come on. I think that to try and set the context, first of all, between 1516 and 1718, NHS Lancer took its backlog maintenance from about £53 million down to about £42 million. Broadly, that drop was because of the three new health centres, but of that £42 million that remains, over £31 million of that is on Monklands. There is a physical fabric problem on Monklands. I think that we are the only board that is moving revenue to capital to try and maintain that, so it is imperative. We welcome the fact that there is a commitment to replacing or refurbishing Monklands, but we really need to make progress with that quite rapidly. You would quite rightly make the point that one of the issues that we have is recruitment of staff. Our nursing vacancies are greater on the Monklands site than on the other sites. It is not attractive and the uncertainties make it more difficult to recruit staff. The functional suitability of Dr Burns wants to say it briefly on that. I think that that is right. There is a contributory factor on the recruitment retention of medical workforce at Monklands hospital. The functional suitability becomes challenged because of the old infrastructure within the building. I understand that I am not an expert, but I understand that the drainage system is not conducive to the appropriate level of run-off, and what that results in is the backflow of human effluent, which is sewage. That usually happens about once a year and that interrupts the delivery of safe patient care. That is extremely demoralising to staff working in those areas. Throughout the rest of the year, there are some real challenges with the fabric of the building and maintaining the appropriate HEI levels of hygiene that are required of. As the staff orias bacteremia rate in Monklands is marginally higher in comparison to our other two hospital sites, that could be the patient case mix. It could be that that is more to do with the renal unit that is there that contributes to that higher rate. Nevertheless, that is a consistent feature. All those things make it extremely challenging to maintain staff morale and the ability to deliver a high-quality service. I would like to assure you that we have absolutely got mitigating actions in place to deal with that backlog maintenance. Obviously, we are working very closely with staff, but to have some certainty going forward would be very helpful. I hope that we come to a conclusion sooner rather than later to serve the people of Monklands. It is not just the area that people have a great affinity for, where it is and that type of thing. There has been some controversy on how you went about the public involvement in it. In light of that controversy, which appeared in the press, unfortunately, would you approach it differently if you had to do it again? The first thing to say is that we will obviously learn any lessons that come out of the review. We welcome the review. It is important that we consult and engage with our communities that we want to serve with this hospital. On reflection and hindsight, it is always something that you would reflect on and say, could we have done that differently and could we have done that better? High insight is always a good thing, but I await the outcome of the review, and we will look forward to implementing the recommendations to try to take that forward. Good afternoon, everybody. My questions are around maintenance and infection control. Can you provide information on what routine monitoring is undertaking to test for contamination including water and ventilation supplies before patients become infected? Committee members may have seen our response in relation to the inspection of the Queen Elizabeth University hospital and the recommendations that were produced there. We have a long-standing Lancer Infection Control Committee that has a number of sub-committees that report to it, and that is the governance structure for our healthcare environment. There are a number of standard procedures that have been in place through those sub-committees to give assurance to the Lancer Infection Control Committee about how the process for in-line flushing, for example, in high-acuity areas, is managed and how the integrity of the environment is maintained on a regular basis. There is quite stringent assurance that is provided to the committee. Can I ask, as a health board, directly responsible for employing all cleaning and facility staff across all its sites? We have three sites, two of them are PFI, and the third munklin is not. There is a difference at Munklin's hospital where they are our staff, and they are responsible for the cleaning of the environment. As we have indicated, it is challenging, given the fabric of the building in Munklin's hospital. There are some challenges with recruitment of domestic staff in those areas, and the other two hospitals are PFI hospitals. It is an output specification that is required, and that is monitored again through our internal governance processes to ensure that that output specification is in fact achieved. I was going to come at how much involvement do your Infection Control staff have in monitoring maintenance and the different cleaning methods across all your sites? They are sensitive. Lastly, but not least, you see how much input the Infection Control staff and specialist engineers will have into the design of a new munklin hospital and the future maintenance contracts of it. We are going to have a high role. After the Queen Elizabeth issues, they will have a central role in it. I think that, similar to the point that the chair made around the consultation on Munklin's, whatever comes out from that, we need to make sure that the lessons are learned, we get the benefit from it, and we can give you that guarantee that we want to make sure that we end up with a real state-of-the-art hospital at Munklin's or to replace or refurbish Munklin's. Those design issues, whatever they are, need to be made sure that we are picked up with the engineers. That is very helpful. Thank you very much. Clearly, you will know the evidence that we took in this committee on healthcare environment hazards. One of the things that we heard from witnesses was that Infection Control doctors were not always involved in the design of new buildings. It is certainly very reassuring that you are planning to take that directly on board. I thank the witnesses for their evidence today. That has been very informative and very helpful. Thank you very much. There are a number of things where I think that you undertook to send us further information and look forward to that. In addition, we will also, on discussion, identify any other areas where we might want to ask for supplementary information, and if so, we will be in touch with you to that end. Thank you very much. We will now suspend briefly and then resume in private.