 Welcome to the First Meeting of the Health and Sport Committee of 2017, which will give everyone another happy new year. I ask everyone to switch off your mobile phones on to silent. It is acceptable to use mobile phones for social media, but it is not for photographs, filming or recording. We have already covered items 1 and 4 in private this morning, so we move on to Felly, we move on to agenda item 5, which is subordinate legislation. We have two negative instruments to consider today. The first is the regulation of care, prescribed register Scotland amendment order 2016, SSI 2016-16413. There has been no motion to anull and the Delegated Powers and Law Reform Committee has not made any comments on the instrument. I can invite any comments from members. No. Is the committee agreed to make no recommendations? Thank you. That's agreed. Thank you very much. The second instrument is the Cason's and Cason's Scotland number 2 regulations 2016, SSI 2016-16422. There has been no motion to anull. However, the Delegated Powers and Law Reform Committee has made comments on the instrument. They have drawn the regulations to the attention of Parliament on reporting ground, JAI. The instrument fails to comply with the requirements of section 282 of the Interpretation and Legislative Reform Scotland Act 2010, although that does not affect the validity of the instrument. Regulations were laid before Parliament on 15 December and come into force on 21 and 22. They do not respect the requirement that at least 28 days should elaps between the laying of an instrument, which is subject to the negative procedure, and they come into force off that instrument. As regards its interest in the Scottish Government's decision to proceed in this matter, the Delegated Powers and Law Reform Committee finds the failure to comply with section 28 to be acceptable in the circumstances following. If there are any comments from members, no. Is the committee agreed to make no recommendations? Agenda item 6, we have a session with the Scottish Public Services Ombudsman. Thank you very much for your attendance this morning. We have Jim Martin, the Ombudsman, Nicky McLean, director, and John Stevenson, head of complaints and standards. The Ombudsman has agreed not to make an opening statement, so we will just start with questions. I wonder if I could begin, maybe, by just asking you to very briefly explain your role and your experiences over the last year or so. The Scottish Public Services Ombudsman is the last protocol for people who have got complaints that we have undersolved about public services in Scotland. We have a very wide remit. We deal with the national health service, with government, local government, prisons, water and so on. We deal with health in a way that is different from the other public sector areas that we have, because in health we have the power to look at clinical judgment. That means that I have to take advice from professionals in all the different disciplines in a lot of the cases that come to me. That power does not exist in, for example, local authorities, and, for example, in higher education, further education schools. I cannot look at academic judgment in that kind of thing. In health there is a particular power that I currently have. As you have seen from the papers that we have given you, over the last year we have had a significant increase in the number of health complaints that are coming to us. It is maybe worth saying that people are not familiar with the Ombudsman office. People can normally only come to the Ombudsman once they have been through the complaints process in the public body concerned. So, if someone comes to us early, we call that premature complaint, what we would normally do is signpost them to the appropriate place and have them take their complaint through that. Once that complaint has been through all the process at the local level—so GP level, dentist practice level, health board level—if people are still dissatisfied with the outcome, they can bring it to us. So, as I said last year, we had about a 9 per cent increase in the number of complaints coming to us. Since I became Ombudsman in 2009, the increase in health complaints is around 75 per cent over that period. There are lots of reasons for that, which I am sure that you will want to discuss. The up-hold rate—the cases that we investigate and we find that there is something that should have happened that did not happen—is currently running for most public services in Scotland, coming to me about 50 per cent, and health is about 56 per cent. The worrying thing about that is that these are cases that have already been investigated at the local level. So, when investigations have been conducted at the local level, complaints have been not upheld by enlarge and brought to me. We have investigated in more than half the cases that we find fault. It is sometimes the case that a complaint may even have been upheld at the local level, but not fully to the satisfaction of the complainant. In some cases, we will look at these cases. If we find that the whole thing has not been investigated properly, we will look at it. If we find that it has and that there is nothing more that we can do for people, we will tell them and that will close the matter. The proportion of cases that we see overall that health takes up has increased over that period. Health is the fastest growing area of complaints that come to my office. It is now second behind local government, and I would anticipate if the rates keep continuing the way they are going, then health may well be on a par with or overtake local government in the next two to three years. I have to say that the cases that we are seeing in my opinion are more complex now than we are perhaps seeing in early stages, so that more and more we are having to send away for advice, maybe from two or three different specialisms, to look at a particular case. That is an issue of concern because you will see in the report that I gave you. This is beginning to sound like an opening statement. You will see that we have an issue over the provision of clinical advice where the parliamentary and health service ombudsman has decided that an arrangement—that is the one that deals with England—has decided that, after 23 years, they do not feel that they can give us clinical advice or access to their clinical advice any more, which I will say more about later if someone asks me the right question, which is leading us to having to create in Scotland our own bank of clinical advisers. Over the past year, convener, we have seen an increase in health complaints. The uphold rate is still quite high. We are having to rethink how we get advice to investigate cases, but we have also been working alongside the national health service to help them to put in a new complaint handling procedure for the national health service, which will go live in April. That will put the national health service complaints process on to the same standardised procedure as the rest of public service in Scotland. We have argued long and hard that, if we are going to have health and social integration coming together, we need to have one complaint procedure to go through everything. The social work complaints process will be brought in line with that from 1 April. From 1 April, we should have a user-centred complaints process, which is standardised. We should enable local authorities and health boards to work together to solve issues when they arise. They should also give the committee better information about the number and nature of complaints that are coming forward in health, but also in health and social care integration. That will then play Scotland in a better position than any other Parliament in the United Kingdom, I would argue, in Europe in that we will be able to look across the whole of our public services in Scotland and be able to see from a complaints perspective what is happening, what areas are leading to complaints from the public, how they are being managed, how different health boards, local government bodies, universities, housing associations and prisons and how everyone is dealing with that. The raw information that you will have at your disposal as a committee to help you to get underneath what is bothering the public about the provision of public services will be something that I hope that you will mine in the future. John Stevens, who is the architect of most of that stuff, will happily answer questions on it, and Nikki McLean will do the stuff with the numbers. I just do the blarney at the front. You are saying that 56 per cent of the health cases that you looked at were upheld, having already gone through an NHS complaints system. Is that an indication of an NHS system that is broken? If you look at the Scottish Health Council's report in 2014, making it better, it had a few concerns about the way that the health complaints system was working. It asked that the health service worked with us to put in place a better process for handling complaints, which will give us a new national complaints handling procedure. Areas where I think that the health service is improving but could go further, I am not convinced that the management of complaints is given the weight that it should be given in health boards in particular. In general practitioners, I am absolutely convinced that that is the case. If you look back at the Francis report into mid-staffs, part of what Robert Francis highlighted was his discussions with the chair of that health trust. He put it to the chair of the health trust that a lot of the issues that arose that led to the deaths of so many people had been flagged up in the complaints system, but the chair and the chief executive and the board of the trust had neglected that. Essentially, what the chair said was that there will always be complaints. We know that there will always be complaints, but they do not really add anything. Francis' view was that if you take that approach, you miss out on early warning and learning. I think that the national health service in Scotland is getting better and understanding that when complaints are brought, they are not necessarily something that should be looked at on the basis of potential reputational damage. When I came in to office, one or two health boards definitely saw my office as a threat to their reputations. It is not a matter for lawyers because, in my view, we are moving away in Scotland over the past couple of years, at least, from lawyers saying, for goodness sake, do not say sorry, for goodness sake, do not admit anything, in case that is zero point, whatever it is, zero four percent of complaints end up in court and we end up in litigation. We are moving away from that. I think that the health service is getting better at that, is getting better at knowing that they have to investigate complaints. I would hope that once the new processes are in, the new procedures are in, and the work that Nicky McLean is doing with health boards and others on learning from complaints, that the uphold rate that I see on my successors sees, because I will be leaving the office soon, that my successors sees will fall. I do see a willingness in the national health service to grasp this and to learn from it, but I have to say that the machinery of the national health service sometimes looks to me as if it has been oiled with treacle because things take so long to come through. In this case, I think that they move relatively quickly in the complaint handling procedures. It is still slow, but relatively quickly, and hopefully from the 1st of April we will have a better system in place. In terms of the culture and the attitudes that prevail sometimes within very senior managers within the NHS, in my experience representing constituents and who are both practitioners in the health service but also patients, it often appears as though there is a culture of closing things down and denial rather than an acceptance that there is a problem and a capacity within the health service at a very senior level to claim that white is black and black is white. Do you sense that that has been there in the past and is it still there, or do you sense that there is an opportunity in grasping that opportunity for real change so that we do learn from mistakes and are open about those mistakes and those complaints? I think that it is wrong to look at all health boards and suggest that they are the same, because I think that the culture in different health boards is different. In 2009-10, if you would ask me, I would not name names for the minute, if you do not mind, I will say why later. I would have said that there were a couple of health boards who would fit nearly the description that you were saying. The first port of call would be no, say nothing to see here, please move on. But also, this is paradoxical, where the national health service I think also in the past has been, and this is going to sound really silly, unprofessional, is that it has not been good in some cases at closing things down. On the one hand, I think I would have said five years ago that consultants in hospitals, for example, had far more power over what happened to complaints than they ever should have, and that the investigation within a lot of health boards was not up to scratch, particularly of working consultants. On the other hand, in some cases where it was in the best interest of everyone, families included, to close something down, the health service would attempt to go the extra mile, would drag a process out without coming to a conclusion, and would lead families to come to me and say, the national health service has been investigating this case for over a year now. When I look at the detail, I can see, no, they haven't. What they've done is, they've investigated it, they've got to the point where they can't take a decision, but they've tried to help the family by going and getting another bit of information, another bit of information, another bit of information and not going to close you. So, across the board, I think that in terms of handling complaints, it's been a cure its egg as far as various boards are concerned. I think that culture is changing, and I think that the Scottish Health Council deserves a lot of credit for, as we used to say where I come from, putting their foot in the ball in 2014 and saying, hold on a minute, what are we actually doing here? Because that has enabled them to look at what their complaints process should be, how they should go about investigating complaints, what the status of the people handling complaints should be, and in post Francis reports, Ness and the boards got together and asked us to help them with master classes so that non-executives and health boards understood the central role that complaints played in governance in the national health service. So, I think of the last two years, there's been that pressure from the boards down, there's been a move towards getting the procedures improved, and I think that will lead to a change in culture, but I agree with you, convener. There's still a bit to go in a lot of health boards, and in the case, for example, of your own area, we recently had to say to Lothian Health Board that we were not happy with the way that they were managing the complaints process generally, and if you look at the minutes of that board, you'll see that they're now grappling with how they can improve that. That might have been a fight five years ago, now it's, and I pay some credit to the chair for this, it's a case of we really need to get this fixed in the interests of patients and their families. Two questions. The first is to ask you about the reasons behind what appears to be a very significant rise in health-related complaints, not just over the last year, but as you said in your letter over the last five years. Secondly, to get your observations, please, on the fact that on page two of your letter, it's clinical issues and hospitals, which far outstrip, it seems, regularly any other issue. I just wondered if you could explore that for the committee. I'm happy to take that question. In terms of the rising volumes at SPSOCs, that very much mirrors the rise in complaints recorded within health boards themselves. I think we have to be careful about making the presumption that rising volumes in complaints in and of themselves is necessarily a bad thing. What it can mean is that it can be a recognition of an increase in confidence in a complaint system. I think that in and of itself a rising volume in recording of complaints, and John, my colleague, might want to say a bit more about that in terms of the complaint standards authority role, but certainly what SPSOCs is a reflection of what is happening within NHS boards themselves. With regards to your second question, I think that you're absolutely right that we see a relatively low number of complaints, for example, about GP services compared to the number of people that are accessing GP services. I think that part of that is about access to complaints processes because these are small practices that would not necessarily receive high volumes. I think that the processes for processing complaints within health boards will be more established. I think that there is potentially underreporting of complaints within areas such as the GP sector. Can I just add to that? You have to remember a number of things. The Patients' Rights Act came in and you can argue how much was in that act that actually changed, but what it did was raise the profile of people having the rights to do it. Since 2011, the Parliament has given my office—in fact, we were the first in the UK—to publish decisions. You will now see in newspapers decisions being upheld. I am particularly pleased that you see them in local newspapers, and I think that that is encouraging people to come forward. I think that that is important. When you start to look at underneath the numbers, it becomes difficult. I always ask committees to remember that I only see the tip of the iceberg. The cases that come to us, we see a relatively small number of the total number of complaints. You have to be very careful about reading strategically across from what we are saying. It is fascinating. There was a number of things just through the process that I want to touch on. I was going to ask about how many of the complaints were hidden. If you like that, you can answer that. I get the feeling that you do not really know how many are hidden in that. That will obviously develop over time. 56 per cent are upheld. Those complaints have been through a process within the health board and then come to you. Do you have data on what is happening within the health boards in terms of how many complaints they are seeing and what their metrics are in terms of how many they are dealing with or not dealing with and how many of those come on to you? We have data from the information services directorate of the NHS to say how many complaints are being received and recorded year on year. It is fair to say that there has been a rise year on year up until the last year when there was a slight decrease. One of the issues around the listening and learning report from the Scottish Health Council awards the consistent use of performance information and information about complaints handling. The main recommendation led to the development of a new procedure that Jim speaks about. One of the recommendations was to look afresh at the datasets being captured and recorded by ISD to bring it up to date, not only with the information that has been recorded across a wider public sector but to ensure that it is in line with the new complaints procedure. Moving forward, we will have a far more detailed, a far better understanding of the complaints that are being recorded by boards and by primary care providers, not only what they are about but importantly what the learning from those complaints are. I personally was very encouraged that, in working with professionals from the NHS, when we looked at performance reporting, they themselves identified the learning and improvement from complaints as the number one key indicator. You will find that the new complaints procedure that comes into place from April highlights that in the performance reporting that the number one issue to report against is the learning and recording from complaints. It is fair to say that moving forward, we will have a far better understanding not only of the number of complaints being received but of what they are about and what the outcomes are. To pick up on one other issue that you talked about, the hidden complaints, I think that perhaps not only in the NHS but across the public sector, there has been an issue of issues that are complaints that are not actually being recorded as complaints, so where somebody expresses some real dissatisfaction about a service that has been provided, historically at least there has been a tendency to certainly resolve that issue in a professional way but not record that it was raised and therefore if you do not record that you lose opportunity to learn, there has been a change in the NHS certainly and that maybe explains in part the rise in complaints numbers but also across the public sector to rigidly apply the definition of a complaint, which is an expression of dissatisfaction, and to record that so that the organisation can learn going forward. Do not have any data such then on how many complaints have been made to health boards, how many of those are getting dealt with satisfactory there, how many of those are then coming on to you and what that percentage is? In terms of raw numbers, we know that about 21,000 complaints have been made in the year 2015-16 and we can tell you how many complaints come to SPSO. That is about 1,500. 9 per cent are getting dealt with at the health board level. Of course. Just playing with that number for a minute. I have real concerns about how robust those numbers are, but if you look at the health number, which is about 21,000, the local government number over the same period is 62,000. I do not know how that feels to you, but that suggests that in health we are seeing 60 complaints a day and the local government is seeing 180 per day. What I am hoping is that once we get everybody on to the same system, we can maybe begin to look at those numbers a bit more scientifically and you have better data in which to begin to advocate policy changes. We are doing this 56 per cent. I am assuming that there is a spirit across different health boards there. I do not want to use the word sanction, but is there any kind of lead table measure kicked back to the health board to say that your percentage is too high, you are not dealing with that stuff upstream well enough and you are letting too much of it come downstream to us? Is that accepted as the way things are? No. I have intervened with a couple of health boards, one of which I mentioned earlier is Lothian. The way that we look at that is that we look at three things. We look at the rate of upholds that we have coming through and the things that they have looked at that we have looked at and we have come to a different conclusion. We have looked at the volume of complaints and whether, relatively given the size of that health board, that is kind of what we would expect or not. The level of premature complaints that people would come to us when they should really have gone to the health board in the first instance, and you do a wee algorithm and you come up with it a figure. If a health board gets to the point where they are around 70 per cent—I am upholding 70 per cent of a period—I will have an informal chat with them. If that number does not come down, I will have a formal chat with the officials. If that number still does not come down, I will have a very formal chat with the board. The last point that I want to touch on is that my background is in consulting and manufacturing, where that stuff is done to death and contains improvement is a way of life. If you do not do that, you do not survive. Listen to some of that stuff that was thrown back to 30 years ago to where we were in that environment. It is good to hear that you are saying all the right stuff in terms of where you need to go in terms of process improvements. I am interested to hear how many of the complaints that we move on to to become implementers of process improvements, but to move forward even the language of complaints about opportunities for improvement or improvement suggestions, etc. Is there a process that allows people to say that that could be better? I want to make an improvement suggestion rather than a complaint as such because the whole complaint thing is obviously tarred with the implication that somebody did something wrong rather than that there is a process thing that we could fix? In terms of process improvement, it is important to remember that the ombudsman initially was established and that the heart of the ombudsman service is about individual redress, so fundamentally our first priority is trying to put things right for that individual and their families. Saying that, 60% of the recommendations that we make through our case work are improvement related recommendations. I think that increasingly that is where we should be focusing our attention to make sure that you are getting as much value for money, as much improvement as you possibly can from those recommendations. Obviously it is very much back to health boards about how they use that to drive wider improvement, but some of the work that we are now doing through our learning and improvement unit is very much on encouraging and supporting health boards to ensure that they get maximum benefit from the recommendations that we are making. We do not have systemic powers to follow complaints and investigate more widely, and we are also seeking more powers to be able to share the information that we hold in regards to learning, and I think that that would be of real benefit. In working with NHS professionals over the last year, it has been my experience that they do aspire to be this open and learning organisation that values all forms of feedback. You asked of those other processes, so within the patient rights act at the moment, there is a requirement to record all forms of feedback, so feedback, comments, concerns and complaints. Complaints, you are right, have a certain connotation, but I know that boards and primary care providers are also recording concerns and comments and feedback and use that information to improve services. Thank you for coming to see us. I am very grateful for the existence of your office. I have referred a number of constituents to you when they reached the end of the line in terms of complaints, particularly with NHS Lothian in health circumstances. I would like to pick up on Ivan's last question about learning and application of learning. I had a constituent come to see me yesterday. His name is Dr Patrick Statham. He is a neurosurgeon from the Western General in Edinburgh. He was very concerned that he felt that the levels of cancellations in his ward due to the unavailability of beds because of the lack of ring ffencing in the neurology department was getting to the stage where his morale of his fellow surgeons was really plummeting because they kept having to turn people away. This is clearly a systemic problem that will undoubtedly lead to complaints to your office. It is clear that there is a mix of systemic complaints and complaints about individual practice or care. I just wondered if you could explore a little bit further about the application and recommendations that you make, how much you look to other health sectors that have solved those problems in the past. I say that because Patrick pointed to St Thomas's Hospital in London, which had exactly the same problem with the neurosurgery department, and brought in KPMG as a management consultant to look at how better to deploy those beds. They came up with a very simple idea that we ring ffence beds for neurosurgery. It did not really impact on the rest of the hospital, but it meant that people got seen for elective surgery. I just wondered if you could give us your reflections on learning from other places, because these problems are clearly not unique to Scotland. I think that it is fair to say that the complaints that we see are not complaints about systemic issues is the first thing that I would say. Neurology, we actually, I know that is not your question, but we do not see a high volume of complaints about neurology. In terms of our recommendations, our recommendations stem from the use of clinical advisers who are in practice. They refer to relevant sign or nice guidelines and other areas of good practice. What we are doing is assessing the reasonableness of the actions of the clinicians and other medical experts against national guidance. That is really where we take our advice from. We were at the local government committee the other day, and I was given the opportunity of my last annual report to suggest ways in which the powers that the ombudsmen have might be augmented to enable better sharing of information so that issues can be picked up. I am one of the areas—I have not used that term—that we look at. We see things frequently occurring. I can think of one hospital that we saw in Fife. A few years ago, we were concerned that we would have seen a number of radiography cases coming through with the same flaw. Technically, I could look at each of those cases on their own and come to a decision on each of those cases on their own, and presumably make recommendations about each of those cases on their own. Clearly, there was an issue there that was more systemic. I think that by enabling my successor to be able to share information with regulators, which we currently are precluded from doing in our legislation, we will enable us to take a more joined-up approach across Scotland where issues arise that the ombudsman sees that can then be tackled. If we were to operate simply on the letter of our act, we would not be allowed to do that. I think that that is something that various committees of the Parliament might want to think about when the local government committee, I hope, takes forward the suggestions that we have made about information sharing. The second question about my convener is about the split as to the complaints that you are handling in real time, as it were, as in their live and happening to people right now, and still happening to people or after the fact. I was reflecting before the committee started with the convener about the fact that, on a number of occasions, myself and other colleagues, parliamentarians, have had to raise individual cases on the floor of Parliament and embarrass ministers and the First Minister to get action, and that action is then taken the next day. I do not think that that is a particular way to run a health service, but it works at the moment for us. I just wondered if you could give us an idea of what your office can do. For example, in the case that I am talking about, there was a bedblock in case where it delayed discharge of 150 nights, the gentleman had been in hospital after being declared fit and had got nowhere with the health board, what he could have done to help in that situation and then speak to the split between real time and after the fact complaints. You got to remember a couple of things here. One is that the ombudsman is not a regulator. That is very important. As Nicky said earlier on, the primary role of the ombudsman is to deal with cases that require individual redress. The work that John Stevenson has done with the national health service to bring in the standardised complaints process should mean that complaints are defined earlier, investigated earlier and concluded earlier, we should then allow things to come to the ombudsman earlier. One of the things that frustrates my team in my office—a lot of good people get very frustrated from time to time—is that we see cases late. It takes a long time to come through the system before things get to us, so that should be there. However, we are not there to do the job of the health board. We are not there to do the job of healthcare improvement in Scotland. At the moment, as I said earlier, we are precluded from looking at systemic issues. Your gentleman wrote 150 nights in a bed. We could look at that, perhaps even while it is still happening, and come to a conclusion. It is far better if the more appropriate management routes are working effectively. I want my high horse. The one thing that my office is about is naming and learning, not naming and shaming. I think that one of the barriers to learning in the health service in Scotland has been the fear that people will be named and shamed and the reputational damage that comes with publicity around failure—inverted comments, failure. I hope that the Parliament would move to it, because I think that we are far more matured Parliament in many ways than our colleagues down south. It is understanding that, yes, it is good to highlight when things have gone wrong, but the most important thing is to get the learning from that and ensure that things do not happen again. The vast majority of people who come to my office, the first thing that they say is, I want to understand what happened here and I want to make sure that it did not happen to anybody else ever again. If you give me advice, naming and shaming does not enhance learning. On that note, I want to ask a little bit more about the learning and improvement unit and whether there is a systematic approach to feeding in what you have, the themes that you are getting from the complaints that you handle, into the bigger governance picture, such as the near misses and the details and things like that. I think that it is important to remember that previously the Ombus and Service has not been resourced to undertake that wider kind of analysis work. This year we have secured funding and going into the coming year we have secured funding to set up a very small unit of just three people to undertake some analysis work. As we have said before, we actually see a very small number of complaints proportionate to the whole of the health service. However, I think that there are opportunities to identify some thematic issues. One of the things that this unit will do is publish themed reports across the whole of the public sector. In March we are actually publishing a report around informed consent and some of the issues that we have identified in relation to informed consent. What we are looking for is areas where there is some space for us to add a voice and add some comment that is unique to what is already being said in that area. Another example might be an area like end of life care, where there is already a lot of research, investigation, guidance that is produced by other bodies. We need to carefully think about how we use our resource so that we can genuinely add a unique voice and a unique picture to that area. Other pieces of work that we are pursuing through that unit is, as we have said already, working with a small number of public bodies who bring high volumes of complaints where there are high upholbrates. For me that is very much around supporting organisations at that later investigation stage where things have become complex and intractable. I think that is where there is a skills gap and where organisations genuinely need support education guidance. Thanks. I wonder if you could tell me a little bit about how you do feedback. You feedback to health boards, do you, rather than to the place where the complaint originated from? When we arrive at a decision on an investigation, we report it in one of two ways. One way is that we will issue a decision letter that will go to the body, whether it be a board, a practice, a dentist, a pharmacist or whatever, and the person who is complained. In that, there will be the reason for the decision and recommendations for improvement, so that will be sure. If we find a matter that we regard as significant, either in the public interest or significant learning or whatever, we will issue that report individually as a separate report to Parliament. We issued 38 health reports last year to Parliament. These are significant cases where we see learning. Every month, we will publish summaries of all of these decisions. We will publish maybe 60 health complaints a month. We will draw it to the attention of the board. NHS Scotland draws other decisions to the attention of all the boards and where appropriate GP practices and others. By doing that, we are hoping to get learning from every decision that we take into the system. As an ex-teacher—not a very good teacher, but as an ex-teacher, I can tell you—you can have all the teaching materials in the world, but if you have a bunch of kids in front of you who do not want to learn, you are struggling. What I am so taken with over the work that John has done over the last couple of years is that the Scottish Health Council and the health service seem to be approaching this whole issue of complaints from the point of view of learning. In order to get learning through, you have to create an environment and a culture that accepts that learning will come from when things go wrong. To do that, you have to get to the position where when things go wrong, you do not just shoot people. The whole thing is a continuum. The work that Nicky is doing, what John is doing, I see the mission together to help the national health service to learn from the experiences that we see people having with their service. On the analytical work that you are doing, have you looked to identify a correlation between complaints and things such as budget pressures or demographic change or social economic factors? Have you done any of that work? You have got to remember that this unit has been in existence for how many months? Nine months. We are looking across all of the sectors and it is interesting that wherever we go and we talk about the learning improvement unit, we have questions like, do you think that you could maybe look at the correlation between this and this? I keep saying to people that we have three people, we have a budget for one year, it has been extended for another one year, we do not know if it is going to be there in year three. We have to colour cloth in the first instance. We have raised this point earlier as well. The data that the health service themselves will be required to publish on their own statistics. Because the volumes that we see are small, I am not sure how useful that analysis would be. I think that the analysis has to be of the wider health service complaints data that this committee will have available to them. As Jim says, that is a fantastic opportunity for Scotland that we will be the first country in Europe to be able to analyse this data across our public services and it will be available. I wish you well in your retirement. Can we put this in context so that I have got it and we do not paint a bad picture about the health service? Correct me if I am wrong. For every health service complaint that you get, you get three years about local government. We have received probably a couple of hundred more complaints a year about local authorities that we do about the health sector. It was across the NHS that we are looking at around 20,000 complaints, but those are recorded by the sector, not cases against the SPSO. That is the point that I just want to clarify. You said 21,000 for the NHS and 62,000 for local government. Every complaint is important, and I certainly agree with that. However, taking on board at the national health service, and this figure, if we will get it checked out, has at least a million appointments a year. Do you think that the number of complaints that you get, which are all important, I agree that I have got one complaint with you already? Yes, one. Unlike Mr Cole-Hamilton, I have only got one in just now. Basically, do you think that the number of complaints that you get is proportionally high to the number of activities that take place in the health service? Your honest opinion? I have had this put to me for the last four or five years. It is a standard line. We hear you, Jim, but there are a million contacts. Local government says that we hear you, Jim, but there are millions of contacts. That is absolutely true. If I were sitting with you sitting just now, I would say, okay, that is a given. The health service's own numbers, the ISD numbers that John was talking about, over the last four years, the increase in complaints, not to my office, but recorded by the ISD, over the last four years, has gone up by 68 per cent. Mr McKee was explaining earlier about his business experience, my business experience as well. If I was running a business nice or complaints were going up at that rate, I'd be saying, well, maybe I'd be better to look at that. It is important to get it in proportion. This is not an indication that the national health service in Scotland is failing or it's on its last legs or anything like that. What I do think it does show you is that there are a number of cases, very, very serious cases, which is increasing, both in the national health service itself and to me. But worryingly, in the cases that are coming to me, I'm upholding more than half of the cases which health boards have not upheld. So, if I were sitting on this committee, I'm up, teach my granny to suck eggs here, but where I'm sitting on this committee, I'd be saying, okay, if the ombudsman is upholding half of the non-upheld cases that come to him, how many cases weren't upheld by health boards in Scotland and what's the likely proportion of them where maybe the ombudsman would come to a different conclusion if that came through. That would then lead me to think, are we satisfied that even given the small proportion against the total number of contacts that the investigation of complaints is thorough, robust and at an acceptable level, and given the work that Robert Francis did on the Francis report and the risks there where the chair's view was, we always see complaints, there's always lots of complaints, there's nothing you can do about complaints, factoring all that in together, I would argue that it's not the only indicator the committee would have but a very important indicator where the committee might be asking questions of the relevant people. No, but there is something you can do about complaints, you can solve them before they're sent to you and that's the reason why I asked you the question and that's the point that in my experience that if you look at what a problem someone has and you sit down and I've had that same discussion with my local health board which is NHS Lanarkshire and basically if you sit down look at how people look and go into the depth and I agree with you all too often I think they just go no you know there's nothing we can do and then the people come to us to put the complaints in. Anyway I think I've flogged that enough. You made an interesting comment in your submission about the EU in Brexit, sorry to bore people with that word again, Brexit, you say there's something which we're currently mindful of but we're not clear what the impact may mean for the direct delivery of services and we will be monitoring this carefully. Do you believe that if and when Britain, hopefully not Scotland, but Britain comes out of the EU that laws will be changed which will affect your service in some way you may want to expand on that? Or not, can you? Or not? I don't know what the Prime Minister is saying just now, I mean she might be saying something that's of interest I just don't know. I think as far as my office is concerned the issues are you know what will the public service in Scotland look like post Brexit is that like to bring complaints to us until we find out what happens we just don't know but my successor I'm sure will be keeping an eye on this place and what committees like this think about Brexit and how that will impact on them? One last small question if you allow me. We're all talking about budgets. What is the cost of your service at this moment in time? Remind me and because of the increase in the level of complaints you're getting right across the board you know you don't just deal with health, you deal with local government, you deal with other complaints you know are you coping are you under pressure be honest? The budget I have is just over three million thank you for for the opportunity to run I'll try to keep it short convener. I have roughly the same number of people investigating complaints today as I had in 2009 when I came into the office at that time in the office we had cases sitting in my office which are three years old and older we had in fact when I went when I walked through the front door of my office we had 92 cases which were over a year old and another significant number above 91 sold we've turned that around we took on prisons complaints and at that point I went to see the presiding officer and said to the presiding officer I think my office has enough capacity to deal with that without increasing our staff and he said well done on you go we then took on water complaints and we had the same conversations and on you go but over that period the number of complaints I have come to my office is written by about 40 productivity is up 31 but when I go to the corporate body in the parliament and say we now need more people the answer is no so I think parliament has to work out at some point what it's going to do with bodies like the Scottish public services ombudsman and the information commissioner who are effectively demand led services financed by the parliament who are funded as departments of the the parliament in other words as if we were a finance department or an HR department with a fixed budget and over the years I've spoken to the chief executive and others about looking at different funding models for example you'll see in in the material we've given you we worked with nes to put together new training materials which 19 000 plus people in the national health service have used my argument was that we should license those training materials for use outside of scotland where they are being used for nothing I suggest that we should look at polluter pays systems because at the moment the Scottish parliament is funding the final tier of the complaints process for local government health prisons etc you are funding your funding their budget if we introduce polluter pays that would then put a sense of responsibility on to the body's concern I was very disappointed when I said in my strategic plan for the next four years that we should consider that the response from the chief executives and legal officers of local authorities was that one of the ways we should control demand was introducing a charge on people to access the ombudsman now that will only hit the most vulnerable and I don't think it's the way we do things in Scotland so I think that when my successor comes in I hope parliament will say to him or her what do you think you need to run this efficiently scrutinise that number you know play hard ball with that number but for goodness sake listen to them because if we do not have the resource all that happens is that ordinary people families were grieving very often face inordinate delay in getting decisions which are of real importance to them so you know parting shot is ombudsman you know going out the door is for goodness sake listen to my successor and please if you want an efficient ombudsman service be prepared to fund it and resource it thank you that wish you well in your return the opportunity with applause must be clear thank you convener and thank you panel it's been really interesting hearing your answers to uh fellow committee members questions um you very kindly there raised prison healthcare which is what I was wanting to ask you about um from the information that you provided to us in your briefing you see there's 137 complaints about prison healthcare in 2015 to 16 and you'll be aware that the committee is looking at conducting a short inquiry into prison healthcare could you tell me does that figure cover the entirety of prison healthcare so all of the services provided within there and also could you perhaps tell us what the most common complaints are that come from the prison healthcare service and so yes it does cover all of prison health complaints i think it's fair to say without and I don't have the details with me but the most common area of complaint is around prescription medication um and whether whether or not things have been prescribed appropriately sorry come here it's just another hobby horse can i if you indulge me for a minute if the committee are looking at this can i suggest an area that the committee might want to think about is how the aging prison population is going to be cater catered for i'm very very concerned that as we have an aging prison population something in groups which are not the most popular sex offenders in particular people are getting older all of the things that happen to people who are not in prison will happen to these prisoners we will have more dementia we'll have more mobility problems you know all the rest of it if we are going to be humane in our treatment of prisoners then there has to be a more close collaboration and strategic planning between the national health service and the scolish prison service particularly around areas like hospice care for people who are who are in prison and i hope if the committee are looking at i'm really really pleased that the committee the committee are that you test people's strategic thinking or how they're going to deal with this what i think is a little time bomb can i just follow up on the numbers for prison healthcare complaints i think it's probably notable to say that as a percentage of all the NHS complaints received in the last year prison healthcare complaints have gone down in terms of the complaints that come to SPSO they've gone down slightly and in terms of the numbers that we uphold they've also gone down slightly i think that working with NHS Tayside for example and NHS Odeon i know there are some good initiatives going on in prison healthcare settings to try and resolve complaints quickly and early and at the point of contact and it may be that some of that work is coming to fruition i was going to move on actually to that point because of the ombudsman had provided some information previously to the committee saying that since the healthcare responsibility had been transferred to NHS from prison services that there might actually be some barriers to prisoners making complaints and i was going to ask what what you've done in terms of making it easier for prisoners to access particularly your service when required i think in the early days of the transfer of responsibility from the Scottish Prison Service to the national health service and deal with complaints from prisoners there was a patchy response across the different health boards different health boards were interpreting the Scottish Government guidance on how to manage prisoner health complaints differently and we had a lot of chats with the Scottish Government about what we were seeing informally saying that we don't think things are working and eventually i think it was near share on the iron health board that we saw an interpretation of what the complaint guidance letter from the Scottish Government meant which we just couldn't match with what was happening elsewhere and that led to discussions around what does it actually mean for example in one case i can think of people were told in a prison that they couldn't make a complaint until they had formally given feedback on a form etc because that's the way it was meant to be and that's the way the Scottish Government wanted it to be whereas in other health boards this was not an issue in some health boards there were questions about whether the role of the Scottish Prison Service with prisoners whether we're receiving healthcare advice and that kind of thing i think that's largely been sorted out i think we're now in a better place and i see fewer things coming through which i think are systemic faults you will see the occasional thing that goes wrong i mean that that happens whether you're in prison or not but in the early stages i think it took a bit longer than maybe you should have to get over the teething problems but i think they're largely over them now okay any other questions no thank you very much for your attendance morning and i wish you well when you we've wanted to pass your new and thank you very much for the evidence we'll suspend briefly for the new panel the seventh item on the agenda is an evidence session with the care inspectorate can i welcome to the committee carne reed chief executive and paul eddie chair both of the care inspectorate can i invite carne to make an opening statement it's paul that's going to say that thank you morning care inspectorate chair are the scrutiny body that supports improvement and is responsible for inspecting and reporting the quality of care that older people experience and we were formed in 2011 with the merger of the old care commission and the old social work inspection agency with some duties transferred across from education scotland at that time we as well as inspecting and reporting on the quality of care we also highlight good care and we work closely with care providers to support them to improve to help them improve and when they're not prepared to do that we do have and their quality of care isn't good we do have extensive enforcement powers we also work with providers wherever possible to support innovation within health and social care delivery and we regulate and inspect across a broad range of services around 14 000 services are registered with us annually and almost nine and a half thousand of those are services for children and young people we work collaboratively with a range of other partners including education scotland healthcare improvement scotland audit scotland the police and the prisons inspectorates and the triple sc and nhs education amongst others we carry out joint inspections to see how well organised in local areas services work together to protect people and to make a positive difference in people's lives and joint inspections for example of children's services everywhere in scotland we carry these out and they bring together professional inspectors from care from social work from health police and education and similarly similarly we work with healthcare improvement scotland to jointly inspect the effectiveness of collaborative working between health social work and social care services for older people and their carers we also have a role in providing independent scrutiny of criminal justice social work across scotland and we're developing a positive working relationship with community justice scotland as the new model of community justice is being implemented almost everyone of us will use a care service at some point in our lives and we believe as a body that every person should receive high quality safe and compassionate care that meets their rights choices and needs we're also changing the way that we work we're building on our experience of and close working relationships with other scrutiny partners to deliver new models and new methodologies to focus on new statutory duties around integration and strategic commissioning and we're embarking on a transformation plan of our own organisation and over the next couple of years our priorities include consolidating excellence, changing our internal culture, building a competent confident workforce and collaborating with external scrutiny and care delivery partners and people who experience care their families and their carers we're also seeking to move from a traditional compliance based approach to a more collaborative approach away from a regulatory perspective to a more modern scrutiny approach one which acts as a diagnostic on which to provide assurance and also to target improvement critical to all of this I think is going to be the new national care standards they're going to be crucial in the way that care and scrutiny are delivered currently these are out for consultation and although their government standards the care inspectorate and healthcare in Scotland healthcare improvement Scotland rather have coordinated their development and they've been created in partnership with people who use care themselves which I think is to be welcomed once these are completed I think they're going to be the most radical standards anywhere in Europe perhaps further afield and they'll have the potential to really transform how care is planned and delivered they'll apply across all settings including how services are committed commissioned rather by integrated joint boards and it's very much a move away from the traditional approach of minimal or technical inputs and more of a focus on outcomes and a person's experience of care so with that share we're happy to take questions okay thank you very much Alex Vina good morning thank you for coming to see us today I have two questions firstly it is about self-directed support obviously this is something of an undiscovered country that we are still moving into the uptake has not been as great I think as people perhaps expected at first but it is still happening and with self-directed support obviously comes a great deal of very welcome choice and flexibility in the delivery of care to service users and that is in many cases directed by themselves how has the care inspectorate found the implementation of STS particularly in the way that the market has responded for things like care at home services how you regulate care and inspect care at home services and indeed a broader range of providers than perhaps existed before STS came in thank you I'll take that question what we have found we've undertaken 13 joint inspections of health and social care partnerships to date and what we found is as you say quite a variable picture in terms of the uptake of STS in relation to the care inspectorate's position we actively support people making informed choice and decisions about their care and in particular ensuring that the care that they experience meets their needs rights and choices one of the things that we are quite well aware of given the variable picture that we've seen from the 13 joint inspections that we've undertaken in terms of the implementation of STS is that we actually require to do more work so during the 1718 it's our intention to actually commend scoping a thematic review of self-directed support and I would welcome the opportunity to report back to this committee in terms of our findings thank you and the second question is relating to your work with other organisations you touched on that briefly Paul when I was first elected one of the first cases I took up with it was the campaign of a constituent I have in a care home who had been very badly burned in a bath in a in a different care home and that is not that was not necessarily it was partly a failure of the care that she was receiving but also a mechanical failure as well and I just wondered what your kind of links with the health and safety executive were and how how that read across and who holds responsibility for learning in cases like that and I do recall the case I think I responded to you on the specific incident which was tragic the first and foremost thing to say is that we expect every care provider to deliver safe compassionate and high quality care where that doesn't happen we work with a range of bodies the health and safety executive being one and in that specific instance we did work with the health and safety executive in terms of looking at the the details of the case what tends to happen is where there's a predominant focus on the quality of care then the care inspectorate would be the lead agency in terms of looking at any investigation around about that but we do of course bring in specialist support wherever we require that in relation to health and safety or it could be in relation to health for example so that's how we tend to work I think what's critical in terms of what you described though is the learning that came out of that incident so one of the things that's very different about the care inspectorate and indeed a new responsibility that the organisation had in its inception in 2011 is a statutory responsibility to support improvement so in relation to those types of incidents that you're describing what we would do on the back of that is actually work with the provider to see what's the learning from this and actually tell us how you're supporting improvement and making sure that the changes that need to happen to ensure that people enjoy good quality care across Scotland are actually in place I wonder it might be helpful certainly be helpful for me if you could maybe describe the the kind of process you go through where on doing an inspection so for example I'm sorry that we often dwell on negatives in order to exemplify our points but it's often the experience that we have with people coming to us but I certainly was heavily involved in the issue around the Pentland Hills care home which was a catalogue of failure ultimately ending in the closure of the care home and I'm really wondering how we got to a situation where the police were involved it was deaths when the dogs in the street knew that there was serious problems within that establishment and yet it took an age for to get to the position where that was closed down so I'm sorry to be to give you a negative example but it's just to understand how it took such a long period of time and also maybe in a more positive frame if you could describe the process you go through in terms of your inspections and what point do you involve different agencies the person who runs the establishment all of that kind of thing okay for that and I welcome your focus on the fact that sometimes it's the negative areas that we dwell on because what we see across Scotland by and large is really high quality care so I would like to give that assurance to the committee but going back to the particular issue that you're raising in terms of how we undertake our inspection we've moved away as Paul mentioned earlier we've moved away from a position of quite a traditional approach to regulation where we focus on inputs to one over the last couple of years that we're actually looking at much more around collaboration to support improvement so scrutiny in itself is a diagnostic that actually helps us use our intelligence to really delve in and find out what's working well and what needs to improve we have a range of mechanisms that enable us to form a picture of what's happening within a care service for example we have notifications that come into us so care service providers must tell us about particular incidents that happen within a care home or our care setting we also get a lot of information through our complaints process and rather uniquely we are an organisation that has a statute responsibility to investigate complaints so complaints can be made to us by an individual or indeed anonymously and I know that some of you around the table today have also been in touch with me to raise concerns and make complaints so we take all of that intelligence we also look at what we've got in terms of our own intelligence from our scrutiny activities and we use that to actually as a diagnostic to help us hone in on where some of the concerns are lying so one of the things that particularly helps us in terms of the intelligence that we receive so the care inspectorate may be in a service once every 12 months for example in a care home there are many health professionals and social care professionals in and out families are in and out a care service as well so we really welcome some of the intelligence that we get from for example district nurses and I think in the case of Pentland Hills we did receive information from nursing profession to enable us to be much more detailed in our scrutiny activities and therefore find out truly what's going on within a service and what the quality of care going back to the point that you made around the time taken to actually close the service what we must always remember when someone moves into residential care for example it becomes someone's own home and therefore none of us in this room would like to have to move every time a care setting was closed but equally so what's critically important is that we have enforcement powers and we use those and we use those wisely so where there is a risk to life health or safety of any resident then of course we're going to use those powers but at every opportunity and unlike the organisation down south that is our sister organisation we support improvement to every single turn if that's possible and it doesn't impact on the health safety and wellbeing of vulnerable people in relation to the particular example one of the things that we do is we can issue requirements we can issue improvement notices and we try to work with service providers and have on-going dialogue throughout our whole scrutiny process there are no surprises here no provider should be surprised by the outcome of a scrutiny activity whether that's an inspection or a complaints investigation because we will be sharing with them and asking questions about our findings and our observations of practice all the way through that process we can apply to the sheriff and this is sometimes where delays set in that in terms of the evidence base and the high tests are required to close the service we have to apply to a sheriff to enable us to do that the other thing that i'd like to share with the committee this morning is not only do we have a responsibility in terms of providing public assurance and that's done through our scrutiny activities we have a responsibility to support improvement but under the regulators code we've also got a responsibility in terms of sustaining economic growth and indeed community empowerment so all of these fit together and we need to think of that in terms of how we best support vulnerable people in Scotland first and foremost to remain in their own homes and receive high quality care there have been other cases where a very few where an inspection has been carried out and they've been given a good report or a satisfactory report only for pretty soon afterwards some horrendous practices exposed in that establishment how does that happen it's a really important question actually welcome it the care and spectra can be in services 24 hours a day seven days a week 365 days a year when we go in and undertake scrutiny we're evidencing what our findings are based on the intelligence process that i've just explained however things can escalate very quickly within a care setting so for example where we see a change of manager where we see agency staff coming in all of these can compound what is actually a very good service can then change very quickly overnight and issues escalate if you've got a member of staff who is not sure about how to actually best support an individual if you've got agency staff coming in who don't know the needs and choices and wishes of an individual then that can escalate very quickly and that's sometimes not always but sometimes where we see some of the issues convener that you're describing this morning okay thank you Richard thank you convener um can i turn to similar vein asked in the last panel the number of complaints you're getting uh i believe 2000 complaints the majority of which were upheld upheld um are you concerned about the number of complaints you're getting and that and i have to also again put on the record that i believe that every complaint is important and every you know the number of care homes year or care services you're looking at 13678 number of care homes you look after 1430 what is the majority of the complaints you're getting is it care services or is it care homes or is it a mixture of both majority of complaints that we receive are actually about care homes and generally care homes for older people you're quite right that in the past year we received 4086 complaints and we investigated around half of those in terms of the complaints that we see we've seen a 46 rise since 2011 when the care inspector was established what i would say is treat that figure with caution because we've undertaken significant public awareness raising about the complaints process and encourage people to access that at every opportunity we would encourage people to try to resolve their complaint with the service provider but we also recognise that sometimes that's not possible and that's one of the reasons why people can come to us to make a complaint they can make that complaint in person or indeed they can make that complaint anonymously in terms of the complaints about care homes what we tend to see is around 25 percent of the complaints about care homes for older people focusing on specific healthcare and that tends to be around nutrition medication infection prevention control that type of thing and we also see some complaints around staffing which is around 16 percent of the complaints we receive and indeed communication plays a big part around 10.7 percent of the complaints that we receive in relation to care homes we tend to uphold about 75 percent of the complaints that we receive thank you convener that's all Alison you spoke earlier about enforcement powers and said that you can apply to a sheriff i just wondered if that's a timely process when you have to do that and also how often are you using enforcement powers we have served just over 30 enforcement notices on 21 services over the course of the last year what we tend to do is we focus on improvement first and foremost and the reason for that is that wherever we can support a provider to improve a service that means that people stay in their own home and what we're looking for is the quality of care and their experience and outcomes to improve so we always try to support improvement first and foremost firstly because of the benefits it brings to people residing in a service but actually there are economic benefits in terms of and perhaps convener with your permission i might digress slightly and just to illustrate my point day in day out our inspectors work with care services across scotland one to undertake inspection but also to support improvement we had an example and this is one of many many examples as i say day in day out we had an example of a care home in the northeast of scotland in quite a deprived area where around 20 residents very vulnerable high dependency needs were looking at actually having to move out of the care service because the care service had bumped along for a short period of time we were not happy in terms of their ability to improve we had two choices we could apply to a sheriff in terms of closure of the service or we could bring in and work with the local authority the local health liaison coordinator we also have quite uniquely as well a health and improvement well-being team in the care inspectorate with a range of professional knowledge around for example pharmacy tissue viability rehabilitation dementia and so on we brought in a team to work with the service over a period of time a short period of time the service made significant improvements the net result of that was that they have sustained those improvements i may add 20 people remained in their own home but actually people living in quite a deprived community in scotland retained their jobs and suppliers continued to supply the care service so that's not just a one-off example our staff in the care inspectorate do that day in day out when i suppose that you're in a very good position to to study if you like any pressures rising in the the care service because of you know the move to make sure that people aren't in hospital aren't in acute services do you see that that growth in numbers is increasing pressure on the services and is that increased pressure impacting on quality at all having the benefit of being a scrutiny body that looks at both the national picture in terms of strategic scrutiny and indeed regulated care service scrutiny means that we can draw some of the conclusions that i think you're referring to we work very closely with healthcare improvement scotland in relation to adults and older people and indeed education scotland in relation to children's services to look at a strategic level in terms of some of the outcomes the strategic commissioning that's happening across either the integrated joint board or indeed the community planning partnership that enables us to look at what we're actually seeing in terms of some of those pressures but equally so how are those pressures if they are translating into a much more local level and therefore impacting on the experiences and outcomes of individuals so it's a really precious and invaluable golden thread in terms of having that robust scrutiny and assurance regime both at a national and at a local level can i ask another question convener um it seems that there are more complaints about care homes than than there are you know for those who are being looked after at home why do you think that is is that a cultural problem is it about education is it about engagement with yourself and making sure that improvement happens it's a mix of all of those things and um one of the things that tends to happen is that when you make that really really difficult choice to place yours at your loved one within a residential care setting you're going in you're visiting you're looking at what's happening you're hearing what's happening to your loved one then you're much more familiar in terms of is this right is this the quality of care i want for my loved one and therefore accessing the complaints process perhaps more quickly than what happens out with that one final question please um personal assistants aren't covered by the regulatory regime is that why is that the case and is it at all problematic um i'm not able to answer why personal assistants are not covered um it's certainly not covered by the legislation does it pose risks then yes of course it does um but and this is really crucial for the committee to hear there is still a responsibility in terms of strategic commissioning or the commissioning of local authorities in particular in terms of the use of personal assistance we would expect every local authority to undertake the necessary checks and balances before they actually arranged for for example direct payment in relation to personal assistance so um i know that people are concerned about risk and rightly so but it's crucially important that we remember that actually there are checks and balances there in relation to local authority and perhaps if i may just digress slightly because this is critically important we recognise some of those risks and whilst we don't have a statutory responsibility to look at personal assistance what we do have is a statutory responsibility to look at adult support and protection adult support and protection has not traditionally had the same focus in terms across scotland as child protection and one of the things we will be doing next year along with the thematic review of sds and it's by no means a coincidence that we're doing this is we will be looking at adult support and protection and again i'd welcome the opportunity to come back to this committee in due course with the evidence that we find in relation to a national overview of adult support and protection thank you thank you yes can i just ask about a number of things relating to your relationship with healthcare improvement scotland in the previous session with the Ombudsman we heard about a uniform complaint system across health and social care which in the age of integration i think we can all see the sense of and i think in the papers it's clear that yourselves and healthcare improvement scotland work together and that there are new joint statutory arrangements about commissioning etc you'd accept though i think that they're very different bodies yourself and healthcare improvement scotland one's a non-territorial health board and yourselves are independent non-departmental and my general question is do you have any observations about the continuing operation of these two distinct regulatory bodies within the world of integration i do actually thank you and i've been asked this question a number of times of late what i would say to that is it's really important that we consider the totality of both organisations roles and responsibilities you're absolutely right that we have very different and very broad remits and from the care inspectorate's perspective in addition to that very small and shared interface with healthcare improvement scotland around strategic commissioning and indeed improvement we also have responsibility as paul mentioned in his opening statement for social work services nine and a half thousand children's services we have lead agency responsibility for joint inspection of services for children child protection adult protection multi agency public protection arrangements community justice significant case reviews serious incident reviews and deaths of looked after children so i hope that what that sets out for you is that in terms of our range of statutory responsibilities including a statutory responsibility to support improvement across the whole of the social care sector it's quite significant one of the pieces of work that we have done with healthcare improvement scotland recently and i'm certainly very happy convener with your agreement to send this in for your information is we've mapped out the differing roles responsibilities of both bodies and where we have a small interface and how we actually add public value and that's the critical question is whether our relationship is with healthcare improvement scotland or whether it's with education scotland the key question is how do these organisations come together to add public value and therefore ensure that the quality of care learning justice is actually what we would want to see across scotland so i hope that answers your question right maybe just add to that because i work on the board of his as well and denies quests it's on our board as well and you have to remember i mean we we are largely we employ a lot of inspectors and we carry out thousands of inspections with his they have things like sign the medical devices body the medicines consortium the health council there's a very wide variety of activities that aren't registration and inspection and as Karen says the interface is important but it is actually quite small there's a they employ a handful of inspectors in comparison to us just on about providing a committee with more information one of the things the ombudsman provided us was with was an analysis of complaints about the sectors it was very obvious he was talking about health but you have sub sectors if you like sub sections what you look at could you provide us with that and what those complaints are about so is it workforce issues is it communications or whatever we've very recently just produced our five year reports on our findings around complaint silence sure that that comes to you convener hey alex thank you convener i just a couple more questions firstly and i should declare an interest here and that before i came to this place i worked for eight years for social care provider ablara childcare trust exemplary work that they do there but i'd like to ask about context because i think knowing the social care environment particularly some of the higher sort of tariff needs end of the spectrum in terms of care home provision social care can be quite a visceral place environment and quite a frenetic one as well and i just wonder you know where where context comes in for example you know if there's a pattern of injuries coming out of a care home due to passive restraint because of the very severe behavioural needs of the of the people within that how does the balance work and and is there sufficient expertise within your inspectors do you understand the nature of the care that they're inspecting yes and what i would say is that just a couple of years ago we changed the way that we actually undertook our inspection activities and we will be changing our methodology in coming months as well our inspectors now focus on their area of specialism so previously they had generic caseloads now they have specialism so only those with an adult background would be inspecting adult services only those with a children's background would be inspecting children's services and that really plays the professional knowledge and skill that our inspectors bring. In relation to issues around restraint it's actually quite an interesting one we're a member of the national preventative mechanism which is the UK wide body where we see issues around restraint we will regularly work with organisations such as the mental welfare commission where we believe that our intelligence tells us there may well be some issues around restraint so we reach out and get specialist expertise and i think i mentioned that earlier in relation to your point about the health and safety executive similarly if there are issues about restraint that we are concerned about we will reach out for specialist expertise but by and large i am absolutely confident that the inspectors working with the care inspectorate have the knowledge and expertise to conduct and fulfil our statutory responsibilities effectively. That's very good to hear and the second one speaks to your point that you made about your role in terms of the death of looked after children. Again part of my work with Abel Iwer was influencing the passage of the children and young people bill and the big battle that we've faced with legislators with all stakeholders really was an understanding that our responsibilities to looked after children does not end with the removal of their supervision order but actually they become care experience young people and we still have a duty of care to them and the fact that before that bill passed there was no knowledge about life outcomes really for care leavers there was no sort of mechanism for when a care leaver died prematurely although they are demonstrably far more likely to die prematurely than somebody who's not been in care that finally we got a provision within the bill that ministers Scottish ministers will be informed on the death of care leaver. What role will your organisation play in a helping to deliver on that responsibility but secondly to disseminate learning and investigative work around that? Okay thank you so we have a statutory responsibility when we are notified of the death of a looked after child we have a responsibility to actually look into what's actually happened and what are the learning from the situation. Every death of a looked after child is a tragic situation. What we want to see on the back of that is taking the learning from our review of a death of a looked after child and see the partners involved to primarily local authorities but other partners as well take some of that learning and think about how could we make this better for looked after young people in the future. We take all of that in terms of the learning from our review we put it into practice in terms of improvement. We also have a link inspector who undertakes a role working very closely with at the moment local authorities but very soon to be across the integrated joint boards. We would expect our link inspectors to be having conversations with those local authorities if there has been a death of a looked after child and actually supporting them around some of the improvements that they need to make and that's actually the real added public value of having an organisation that can undertake both the scrutiny element but also support improvement quite unique to what's happening down south. Okay and if I may just tease out one of the points in your answer there Karen thank you for that. In terms of the looked after children population as is in Scotland on any given day we have 15,000 children in care the majority of those children are actually looked after at home I'm not really familiar because Ablaard didn't deliver services for looked after children at home what are the sort of powers and responsibilities that you have to have some sort of oversight of those children because I would imagine given that their life outcomes are demonstrably worse than any other looked after cohort that there's probably a higher ratio of deaths in that cohort as well and so as such can you speak to your responsibilities to looked after children at home? I'm very happy to follow up with a subsequent conversation with yourself if that would be useful. One of the things that we do in terms of our joint inspection of services for children we have a responsibility as part of that process to look at outcomes in particular for looked after children whether they're looked after at home or away from home so we utilise our responsibilities and discharge them through that process we actually report and again I'd be happy to share this with the convener we have an update report of our first two years of joint inspections and some of the findings some of the critical issues we find around looked after children in particular but actually in terms of child protection those children who are on the child protection register is the local authorities responsibilities in terms of undertaking appropriate assessment chronologies is a big issue the ability to respond to immediate concerns and need so as well as being able to identify where those hotspots are and what needs to improve in terms of delivering better outcomes for children and young people in Scotland we've also got a responsibility to help support improvement in relation to our link inspector role working more closely with local authorities to ensure that they are actually learning and sharing that learning the other thing that I would add for committee members information is we have a hub so you can go online to the care inspectorate website we have a hub that's got a range of good practice that we see during our scrutiny activities that we actually promulgate on our website so I would actively encourage you if you've got a particular area of interest then to go on to our website and access some of the good practice that we see across the country thank you panel for your answers so far I'd just like to expand a little bit on what Alex Cole-Hamilton was talking about there about learning from experience that you've had and from the reports that you've done we heard the ombudsman earlier on referring to the Francis report which one of the major criticisms there was there was no corporate memory in the NHS in England at that point in time and I'd be keen to hear about how you disseminate some of the learning that you have from inspections that you do at good and bad experience particularly to you were talking about nursing home sector where there are a high level of complaints often they work in small businesses isolated perhaps not as plugged in to bigger support networks as perhaps the NHS is and so if you can maybe expand a little bit on how you make sure that you disseminate the your findings into those areas thank you every single inspection that we undertake results in a public report and that's available on our website so we would also expect providers to be able to share our reports with people who experience care or their families or carers so we produce around this past year 7400 inspection reports at regulated care service level they're all available on our website in terms of some of the learning as I said earlier scrutiny is not a compliance based process it's not where we were probably five years ago it's a process about working with a provider to actually identify what's working well where there is good practice and highlighting that good practice but equally so working with a provider to support improvement so our inspectors although scrutiny happens across a short period of time we would expect to see that on-going dialogue no surprises about our findings and support for improvement at the end of the scrutiny intervention so in terms of overall we I think at the last count did around 12 to 14 000 scrutiny and improvement interventions of those about 7400 were actual inspections so you can see from those figures that there's quite a significant focus on supporting improvement the other thing that I would say is that where we see things working really well and really good examples of practice once we've undertaken two inspections we will highlight good practice out in the media but similarly where we're seeing poor practice not only will we take immediate action in terms of trying to support improvement or indeed moving forward with enforcement we also put that information out in the press as well so two episodes of good two episodes of really poor and it goes out into the public domain equally so over the course of the last 18 months or so we've developed a really powerful and strong relationship with Scottish Care which given the majority of care home providers in Scotland are from the private sector we work very closely with Scottish Care in terms of supporting improvement and are doing some close pieces of work ensuring that care home providers across the country can actually deliver high quality care. We also put up an engagement with service providers through quality conversations so some of the running issues are teased out to those and it allows us to take soundings from the various sectors as well as give them some of our thinking and keep them in the loop. Also we've had some quite successful conferences as well maybe do you want to maybe tell us a little bit about the conference conference we have? Yes absolutely and we were very grateful to the chief nursing officer who provided part funding for us to undertake a conference that actually supported the development of a continence resource particular but not exclusively for people with dementia so the conference attracted over 350 delegates and we actually had a waiting list as well so there's a whole range of different things that we can do in terms of sharing information promoting our findings having quality conversations with providers and we tend to do that by sector type to actually find out what are the issues how can we work more collaboratively with you because ultimately we've all got the same end goal in mind we all want people in Scotland to experience high quality safe and compassionate care and taking a compliance a stick based approach doesn't enable that to happen so working much more collaboratively sharing information highlighting good practice is undoubtedly the way to go. I think earlier you said that 75% of complaints were upheld is that correct in relation to care homes have they gone through that particular organisation's complaints procedure before they come to you? I don't have that information to hand but I can certainly check and come back to you convener because I think the committee reading the committee in the earlier session is quite surprised that 56% of complaints were upheld within Jim Martin's remit in the years at 75% and does that cause you a lot? 55% care homes. Is it 65% or is it across? No it says 59% university cross-care services so. Both of them are quite big figures. Do they cause you concern and alarm? They do and what I would say to that is first and foremost wherever we see a complaint we investigate a complaint we don't just leave it at publishing our investigative results we actually work with the care provider in terms of supporting improvements so it doesn't just stop with undertaking a complaints investigation what we want to see is the follow-through in terms of how do you support improvement within a care setting because ultimately that leads to better outcomes and experiences for individuals so that tends to be our focus now rather than purely stopping and drawing a line once the complaint investigation is undertaken. I hope that that gives some assurance although the statistics may sound alarming in terms of 75% of all those complaints about care homes for older people being upheld we do follow through in the back of that and ensure that we work with providers to support them to improve regardless of what area they may need to improve in whether that's in health and bringing in our health and improvement wellbeing team or in other areas. Have you done any analysis of the source or trends within that so for example we hear the care home providers say that they are really under pressure financially is that an issue? We're not seeing that in terms of some of the complaints that we're investigating what we have done is we have analysed the source of where the complaints are coming from and they tend to come from family members or indeed staff who work in the social care sector and some time ago about a year ago we actually put out a public awareness campaign and requested that social and healthcare professionals actually have a responsibility where they are entering into a care setting and they are not seeing good quality care actually it's their professional responsibility to highlight those both to the care service provider but actually they can come to the care inspectorate to investigate complaints about the quality of care and care services the briefing that I said I would send in convener in terms of the five-year overview gives a whole range of distilled information about our complaints both in terms of where they came from the types of complaints we receive where they're upheld across all different types of care settings and so on so I'm sure that information particularly helpful to you and again I'm very happy to have a further conversation either in the context of Parliament or indeed with you individually if that's useful. Two things in relation to the workforce I think it's a good thing that they are approaching yourselves but is that an indication of a problem within the organisation the owners of the organisation and that staff maybe don't feel confident in approaching them about a particular issue? Not always so you know there are pockets of that there's no doubt about it but it could be for example a nurse who is accessing a care home that's concerned about the quality of care that raises it with the care home manager but actually also comes to the care inspectorate as well so it's not an either or and there's a mixed you know no not at all we would always encourage people to try and resolve complaints at the earliest opportunity and with the care service provider if at all possible but sometimes it's not possible to do that and we recognise that so that's one of the reasons why we take complaints whether or not they've been through the actual care service providers process and indeed anonymously. One final thing from me we have heard and we've took evidence from social care staff about a whole range of workforce issues in relation to their employment and we've heard that you raised yourself issues about agency staff and obviously the implication of that is about continuity of care. One of the first things that the social care staff raised with us was about their concern about continuity of care but on top of that we've got a whole range of other workforce issues around low pay, the lack of value that they see as society placing on their work and insecure contracts, all of that. Do you believe that those issues are contributing to people's feelings that the social care system is not as good as it could be? I think the first thing to say. Do you think that we treat our social care staff fairly and value them enough? Okay, thank you. The first thing to say and to set in context, we see over 85 per cent of care services in Scotland with evaluations, that's professional evaluations of good, very good or excellent so that's quite significant in terms of the quality of care that's happening. As you said convener, the things that tend to cause us the most concern is the really negative things that we find out about. Overall the majority of care services in Scotland we actually evaluate the quality of staffing so we look at practice, we look at qualifications, we look at training and we're finding that the majority of care services across Scotland are actually getting good, very good or excellent evaluations. That said, we know there is an issue in terms of the use of agency staff, we know there is an issue in terms of temporary contracts, those in themselves are not specific issues for the care inspectorate but where they impact on the quality of care they are. What we are actually seeing and we've got a real opportunity at the moment in terms of integrated health and social care is to look at integration and action and what I mean by that is we've got a real opportunity for example in the private care home sector to work more closely with NHS in terms of nursing staff. We have got an opportunity in terms of looking at recruitment and retention so we've recently worked with the Scottish Social Services Council which is the professional regulator as you know for the social care workforce to produce safer recruitment guidance and that means that not only are we looking at the recruitment process, we're looking at the values and qualities that staff members bring in to social care in terms of being able to deliver, not just the clinical side of care but actually the value side of care, being able to be compassionate, nurturing and much more in line with the new national care standards that are out for consultation at the moment. But around those workforce issues, around pay and conditions, do you think that we treat staff fairly in that regard? I think that without a doubt the progress made in terms of implementation of the living wage is great. What we are looking at and it's too early for us to tell given and you'll bear in mind that we do a respective look over the last 12 months in terms of the quality of care, we're not seeing implications of the living wage at this moment in time but rest assured we are looking to see if we're seeing implications from the living wage in terms of the quality of care. So we are pleased to see the living wage being implemented, we want to see is there any impact in terms of the sustainability and therefore the quality of care as a result of that. I'm not sure if that was a yes or a no to my question. Can I follow a point leading on from the question that you just outlined there, convener? It's with regards to visit times and I think that's what's raised with me again and again by constituents is this a 10-15 minute visit times, which many people who are being cared for at home receive just not being enough time and some really concerning issues around that with hearing aids being lost and people being left without their hearing aids fitted properly. Do you actually think that that period of time is enough and if it's not in your eyes what do you think the Government and local authorities should be doing to broaden that to improve care in Scotland? I think it's very difficult to say is it enough or isn't it enough because when one thinks about 10-15 minutes is that adequate time then without actually knowing the context of what someone's actually looking at. So for example if it's primarily a visit to ensure someone's taken medication then perhaps that is enough time. If it's about the quality of care and looking at personal care or various things in terms of an individual's needs, rights and choices then it will depend. So it's not easy for me to answer that without having a context but I know that it is a particular issue. What I would say is that where we are seeing hearing aids being lost, people not being treated particularly well, where we see the quality of care in terms of some of the care at home and housing support services then of course we will take immediate action or indeed we would actively encourage you to encourage people in your constituency to lodge a complaint with the Care Inspectorate. Thanks very much, convener. In your written submission you note the fact that you report publicly on emerging themes and trends in relation to quality of care. Can I ask whether you are concerned about or aware of problems and care services resulting from extra pressures on increasingly limited resources and does that impact on the number of enforcement actions that you have taken or learning experiences that you have recommended? Five years ago, when the Care Inspectorate was established, the quality of care was probably around 80 per cent and we are actually seeing an improvement in terms of the quality of care overall in Scotland. That comes at a time where we recognise some of the challenges that are happening in the social care sector but with those challenges also comes opportunities in terms of innovation. One of the things that we are currently looking at, for example, is some of the pressing funding constraints that are happening across Scotland means that service providers are looking at different models of care. One of the things that we are supporting at the moment is working with a large national care provider around the Burt's Ork model and different ways of designing, delivering and commissioning care. We recognise that there are financial challenges. We recognise that both at a strategic level in terms of our responsibility in strategic commissioning and, as I mentioned earlier, the golden thread that runs through between strategic commissioning and what we are seeing in terms of outcomes and experiences of care at a regulated care service puts us in a really robust position as a scrutiny and improvement body. To summarise, yes, there are some challenges about funding. Yes, there are opportunities in terms of improvement in innovation. We are watching the impact of the living wage very carefully and we are also supporting care service providers to think differently about the models of care that they are designing and developing. The care that we are all familiar with today will be significantly different, I have no doubt, in the next three to five years in terms of the way that it is designed, delivered and commissioned, and the care inspectorate is absolutely front and central to empowering and enabling that to happen. I take on what you say, but it does not really answer the specific question of whether or not, when you look at, as you say in your written submission, emerging themes, whether or not the pressure on resources is an emerging theme and whether or not that impacts on, for example, the number of enforcement actions that you take or the number of learning experiences that you recommend? Apologies, I should have answered your point about enforcement action. No, we are not seeing a year on year increase in relation to the enforcement actions that we undertake. That is primarily because over the last couple of years the care inspectorate has moved away from that traditional compliance-based approach to one that is about supporting improvements. Every opportunity we will try to work with a provider to improve. In terms of some of those financial challenges and constraints that you mentioned, because of that work in terms of supporting improvement, we are not actually seeing that in terms of impacting on the quality of care, but we are not naive and rest assured that when we see that impacting on the quality of care, then we will be coming out and in terms of some of those thematic statements that we make, we will be coming out and making those statements. Finally, the issue around new care standards has been kicking around forever, seemingly. What is the delay in the new standards coming forward? On the back of that, the committee has a priority of looking at health inequalities and reducing health inequalities. How will the new standards impact on health inequality? In relation to the work, the care inspectorate was asked around the end of 2014 to work with Healthcare Improvement Scotland to develop the new set of national care standards. We initially developed a set of principles that were consulted on very broadly across the whole of Scotland. I think that we had over 1,700 consultation responses, which was absolutely fantastic. The principles were agreed and signed off by the cabinet secretary. We have then commenced a period of wide consultation and involvement of a whole range of both organisations and, more importantly, individuals experiencing care in terms of what the new national care standard should look like. They are out for consultation. The consultation closes on 22 January. On the point about how will the new standards address health and social inequalities, the new national care standards are perhaps, in my opinion, the most radical and progressive set of standards that we have seen not just in Scotland, not just in the UK but across the whole of Europe. The reason that I say that is that we have moved to a position of, rather than having 23 standards, that perhaps start off with saying that you should receive, they are written from the perspective of an individual, I experience. That is a significant difference. We no longer have 23 standards and I think that it was 2,402 indicators. We now have four general standards and three for specific groups of people and around 177 statements in total. It makes it much more simple, much easier to understand in terms of the quality of care that I, as an individual, should receive and therefore makes it much more simple to expand on where we are not seeing high-quality care or, indeed, where, through our strategic and our regulated care scrutiny work, we are seeing inequalities and being able to report on those publicly. How will those standards impact on inequality? In terms of the standards themselves, they will impact on inequality quite simply because we will be able to aggregate what we are seeing in terms of individual experiences across Scotland, be able to aggregate those up using our intelligence, and, if I might give a very practical example of that, we will be able to evidence the quality of care an individual receives regardless of care setting. We will be able to correlate that in terms of the integrated joint board or working with partners in the integrated joint board right down to postcode level, so, in future, we should have a much more matured and sophisticated range of intelligence that tells us, for example, in what postcode area people are presenting most to their GPs. That will give us really robust information. Equaso, we will be able to use that from a children's perspective in terms of looking after children, children on the child protection register, that type of thing, so I am absolutely confident that they will go a long way to addressing health and social inequalities across Scotland. Okay, thank you very much. Can I now suspend briefly for the change of panel and thank you for your attendance? The eighth item on the agenda is consideration of a legislative consent memorandum from the Scottish Government on health, service, medical supplies cost bill. I welcome to the committee Shona Robison, Cabinet Secretary for Health and Sport, Rosemary Parr, chief pharmaceutical officer and Martin Moffatt from the US policy adviser in pharmacy and medicines division of the Scottish Government. Welcome to the committee. Cabinet secretary, I would like to make an opening statement. Thanks for the invitation to speak to the committee today. I am grateful to the committee for taking the time to consider this important legislative consent motion regarding the information powers proposed in the health service medical supplies cost bill, especially given that the challenging timescales surrounding the passage of the bill. We all have a shared responsibility to deliver value for money within our public services and to look at every opportunity to better control costs and healthcare is no exception. Medicines are by far the most common form of healthcare intervention used by clinicians. In 2015-16, the NHS in Scotland spent a total of £1.67 billion on medicines and appliances, approximately 13.6 per cent of the total healthcare budget. In primary care alone, the gross cost of drugs and appliances is dispensed increased by over 14 per cent between 2006-07 and 2015-16. With advances in science and our ageing population, those costs can only continue to grow. The measures in this bill will enable the four UK Administrations to secure better value for money for the NHS from its spend on medicines and other health service medical supplies. The information powers, which are the focus of the legislative consent motion, are a key plank of the bill and will be instrumental in achieving its aim to better control the costs of health service medical supplies and in particular medicines. They will augment the existing quarterly drug pricing inquiry survey in Scotland, which we conduct through the provisions made in the NHS Pharmaceutical Services Scotland regulations and will help to provide greater transparency and insight for the Scottish Government and NHS Scotland on the costs of health service products. They will help to evaluate whether the supply chain or specific products deliver value for money and control costs and assess whether adequate supplies of health service products are available for the health service. In particular, the information powers will open up access to information on sales and purchases of health service medicines and other medical supplies from other parts of the supply chain, particularly manufacturers and wholesalers. Through the development of memorandum of understanding arrangements, the powers will allow the UK Government and devolved Administrations to work together to access and share data on more products and from more parts of the supply chain. As well as collaboration on health service costs, this approach offers a more streamlined framework for application of the information powers and reduces duplication of effort across the four UK countries. Data requirements on UK suppliers of health service products will be set out in regulations. The process of developing these regulations, including consultation with stakeholders and the impact assessment, will ensure that data requests put the minimal burden on industry, while ensuring that the Government has the information that needs to make decisions on health service medicines and other medical supplies. Subject to the passage of the bill through the UK Parliament, it is anticipated that the consultation on regulations will take place over spring and summer of this year for commencement in autumn of this year. I am happy to take any questions from the committee. Richard Cymru I was quite astounded, basically, if I can pick parts here. There are two systems, the statutory scheme and the voluntary pharmaceutical price regulation scheme, PPRS, which shows that a number of single source unbranded generic medicine manufacturers have recently been able to significantly increase prices, often by over 1,000 per cent. Is that the case? In some cases, yes, it has been. One of the important elements of this is to look at how costs can be controlled. That is the whole purpose of this LCM. Martin, do you want to say a little bit about the PPRS and the statutory schemes and the relationship? Do you want to add a little bit more detail? In terms of the PPRS, which is a voluntary scheme, and compared with the statutory scheme, what the bill aims to do is to create a level playing field between the two and prevent switching, so that we can have a far greater insight and control over how costs of drugs are investigated and examined and how we can help to control the costs of drugs. The drugs that we are talking about are specifically in relation to unbranded medicines that would not naturally fall under either the voluntary scheme or the regulated scheme, because those focus on branded medicines. As soon as something comes off patent or the licence is sold on and is marketed as a generic drug, then it falls outside the scope of either the statutory or the regulatory schemes. What the bill aims to do is to close that gap. I am right in saying that the UK Government has this as a reserved matter. The Scottish Government does not set the prices. The UK Government has set the price to bear with me. When this came out, the original clause only applied to England, which is contained within this paper, and also, basically, falling agreement between the Department of Health and the Scottish Government. We finally got this resolved, but basically we had a situation where they also had it in clause 9. I just love this. Clause 9 of the information regulation states that all English producers must keep the falling information, all English health services, medicines and produce it when requested by the Secretary of State, names of buyers and sellers. We are being asked to resolve this by next week, but, prior to this, it was only at England that it was in this, and then they suddenly realised that they had to add other people in so that they have now amended it to include us. Is that correct? Yes. The bill is largely predicated on the reserved matters around price regulation, but, after discussion across the four countries concerned, it was agreed that the best way and the most practical way of looking at this was to involve all the four countries across the UK about how we can better monitor cost of drugs and control the cost of drugs. One of the things that we wanted to make sure was that, because of the nature of the way industry is, particularly manufacturers and wholesalers, they are UK in character. It was thought that, rather than taking a separate approach, we would work together in order to have a more aligned approach to managing costs. Last question, convener. Was it previously the case, ever, that manufacturers, drug manufacturers, were charging a price there in England, a price in Wales, a price in Northern Ireland, and a price in Scotland—different prices? Or have we not found that? Obviously, some of that information is quite hard to ascertain, but I think that there is evidence that we are talking more now about when medicines are brought through various systems, so SMC, NICE, etc. I think that it is fair to say that the offer that is put forward by pharmaceutical companies is quite often different to different health services. That is not just the case in UK, but it will be the case in other countries as well. I suppose that it is more marked when it is across the four devolved nations. Rosemary, you are on a slightly different issue. Generally, when we are talking about the costs of medicines, I think that that is right. Our health services are treated separately, but we have a close relationship with the UK. As Martyn has already said, I think that the issue around wholesalers is very important, and that supply chain is mostly UK-based. It is up for us now to go back to this particular piece of legislation to say to get the best that the Scottish Government and the NHS can do for the price of drugs and to stop some of the areas where it was not a level terrain ground. Last question. This LCM will stop that practice. On the issue of the generic unbranded medicines and making sure that action can be taken around some of the issues that you cited, the 1,000 per cent increase. What you were then moving on to was more of an issue about when drugs are brought through the approval systems and the price that the companies offer. That can be different to different health systems. I think that what is important is that our health system and our approval process through the Scottish Medicines Consortium tries to achieve the best price and the fairest price. I think that there is a responsibility on the pharmaceutical industry to offer the best price. Some of the changes that the Montgomery review has brought forward will help the Scottish Medicines Consortium to be able to have more options around, for example, putting a product out into the market for a period of time to test the clinical evidence around that and involving National Services Scotland in helping to be more robust around the price negotiation at an earlier stage. What we want is for patients in Scotland to get access to medicines as quickly as possible, and we want the health service to get the best price and deal around those medicines. I think that the SMC changes that have been the recommendations that I have approved will help to do that. Thank you. Why are medicines regulated under two systems—two codes, voluntary and non-voluntary? The PPRS is something that has been a UK Government issue for a long time, and it only really comes to the control around branded medicines. That is a particular type of drug that is not the same as generic medicines, which is what we are trying to get the level playing field for here. It is a payment mechanism that comes to the department of health, based on their aspects of sales. The bill means it back to me without no doubt that the purpose of both schemes will now have that level playing field to allow us to look at both. Historically, it has been done on a UK-level and looking at different aspects of both generic and branded medicines. It is also fair to say that the PPRS has not worked as well as had been anticipated, which is why Jeremy Hunt has been in and around the negotiations with his health officials to try and secure a better deal. There is work still going on around that to try to get a better deal for 17.18, while other longer-term changes are made. Obviously, we have a very close interest in that, because the PPRS receipts are very important for the new medicines fund. My experience being in here for the past six years has been that I have been, and I am sure that other members have been, lobbied heavily by drugs companies and regularly. I am sure that you people have yourself. I have a real problem with the way in which the drugs companies do that. The conversation usually goes along these lines, but they will come in and say, we have this new drug. It is usually to deal with life-limiting conditions or very serious conditions that people have got. They say that we want this on to the NHS system, and it is going to provide such a difference for patients. We really want your help or anybody else's help to get that through that system. The question that I always ask is how much is it? They are taking a lot of breath through their teeth and they are shrug their shoulders and say, we could have a good discount for the NHS, and then they say, how much is it? Then we get to it, and it is 50,000 or it is 60,000 or it is 70,000. They never, ever, ever have lobbied me for anything that costs a fiver, a tenor or 20 quid. I think that there is a real problem with the way in which the drugs industry behaves in regards to dealing with Government and dealing with the Parliament and the way in which they try and promote the products. I think that they are, in many senses, playing God there because they have the power to help people, but they engage in that game. Will that help us get away from that and see what the real cost of medicine is? It is almost at all helping part because it will bring back into line the companies and the very minor, I suppose, number of companies that might be flipping between the different systems, so that will stop them doing that. That is really where there has been a product, one particular drug that has come off patent, and then we have seen a huge price increase that is maybe back to 1,000 per cent, so that will absolutely be able to stop that. I think that that is a real benefit. However, the bigger picture around medicines and supply and costs is a very difficult and complex area. As the cabinet secretary has said, we have systems in Scotland that are looking at clinical and cost-effectiveness. That is really important for when we are looking at the whole population across Scotland and what is good in medicines terms as that comes through. We have also got national procurement. Once those medicines are approved, we will try to get the best and the most fair price there. However, it will always be that discussion around that. We are working on the pharmaceutical industry as a global market, and they look to the UK to be very important as part of that global market and price as part of that as well. I would not like to say that it would be the end of our difficulties or asking for a fair price. I think that we will need to continue to do that. I think that the SMC Montgomery recommendations will help as well. What we are looking for here is a fair price. We recognise that there is a lot of research and development costs that go into the development of these drugs. Obviously, a lot of that is borne by the pharmaceutical industry. We recognise that. However, I think that what we have seen through the SMC is that quite often, when they come back a second time or a third time with a submission, there is a different price attached to that. What we want to be able to get to system with involvement of NSS and others to try and get the best and fairest price early so that we can get the drugs into the hands of patients at an earlier stage rather than having this process of rejection and resubmission with a better price. If there could be a better price at resubmission, why could not there have been a better price first time around? Hopefully, the Montgomery recommendations, which are separate from what we are talking about today, but nevertheless are going to be important in helping to get the drugs into the hands of patients more quickly, but at the fairest price. That is what we are talking about. Does that shed any light on how much that tube appointment or the packet of pills costs to produce? I think that most of the information that we will always have is about what it costs the NHS. I think that it is very difficult in that kind of global market to work out where the development costs and the marketing costs are so difficult. Thank you, convener. I should declare an interest in that I am a pharmacist registered with the General Pharmaceutical Council. Like many of my colleagues, I am pleased to see the loophole being closed because, as I have highlighted in the Audit Scotland report for the NHS, it is galling to see the price of old drugs being hiked up because there is a small market and few alternatives. I really welcome that. I do not want to be the defender of the pharmaceutical industry, but I note from their submission to us that they have some concerns about the data requirements. Can you expand a little about whether you think that it is achievable what the bill is asking them to do in terms of extracting the information for individual generic drugs and extracting UK information out of the global information? I do not think that it is on and on. A lot of the systems are already in place. I note the concerns that have been raised, but we do not believe that those are companies that are already required to keep information on sales and income for tax purposes for six years. Therefore, the requirement to keep and record similar information under the information powers will not create a huge additional burden at all. I know that the UK Government is going to have a developing impact assessment for the regulations, which will hopefully take account of any concerns that are raised by industry, but I do not know anything about that. Just to add to what the cabinet secretary said, it is not really intentioned to look at every product. It will be where there is a specific instance that may require further investigation around value for money for that product or for that product across the supply chain. It would be wholly unreasonable to collect that level of information on a routine basis, so what we would be looking for—for example, the best example that we can cite for that are the high-priced unbranded medicines, and gathering that information will help to open up some further intelligence about whether or not the prices that are being charged are justified or whether they need to be amended in some way. However, the cabinet secretary says that there is going to be consultation in all of this, and industry will have an opportunity to respond to that consultation and to look at any areas of practicality that may be a cause for concern and to try to address those through the consultation process. Thank you. I wonder if I could ask a further question about the submission that we got from the Royal College of General Practitioners. I think that one of the dispensing doctors in that group submitted some concerns around the particular issue about pregabalin, which I suspect will not be tackled by this bill. As I understand it, the pregabalin issue was that the licence for the generic drug did not cover all of the indications that the licence for the proprietary drug did cover. Is that loophole likely to be closed by the bill, or are we going to need further legislation to tackle that type of loophole? We need further legislation, but we would have to be quite clear up front that there is an issue around pregabalin that is being subject to judicial review and appeal process. I think that, in terms of getting into the detail of that at this stage, we probably should not. However, I believe that once all of this has gone through a proper judicial review process, there will be opportunity to re-look at the prices that are being associated with drugs such as pregabalin and to try and make sure that those costs are better controlled. Any other questions? No? Thank you very much for your attendance this morning, and we now move into private session.