 Welco i gael i'r 16 ymdau 2014 mewn Cymru Yn Ysgol Aelodau Cymraethol yn gyffredinol. Felly, rydyn ni'n dechrau i'r Par Hydro James Dornann ac David Torrance i gyrwch ddysgrifeld, ac rydyn ni'n dechrau i'r Par Hyg sauce. Prifysgol, wedi bod y ddechrau i'r gwaith o ychwaneg arall o'r swyddi, ac roeddiu'rdu nerdydd i'r Item 1 on the agenda can be agreed to take items 5, 6 and 7 in private. Item 2 on our agenda continuing our evidence sessions on the section 23 report on accident and emergency performance update, I would like to welcome Paul Gray, who is the director general health and social care and also the chief executive of NHS Scotland, John Conaghan, director of health, workforce and performance, John Matheson, who is the director of finance, e-health and pharmaceuticals, Professor Jason Leitch, who is the clinical director of the quality unit, and Dr Aileen Keill, who is the acting chief medical officer of the Scottish Government. Welcome. Mr Gray, I do not know if you or any of your colleagues wish to make an open statement. A brief statement, convening, if that is acceptable. I appreciate the opportunity to appear before the committee today. I wanted to say in opening that we take this issue of A and E performance very seriously, and that is why I have asked a number of senior colleagues to come with me to bring to bear their expertise in different aspects of this issue. The helpful evidence taken by this committee from the auditor general and NHS Scotland senior leaders and clinicians last week emphasised the complexity of the system within which unscheduled care operates. This complexity is not unique to Scotland, unscheduled care performance was affected during winter 2012-13 in other parts of the UK and in similar health systems across the world. Our approach in Scotland to tackling the issues related to unscheduled care is set in our overall vision that by 2020 more people will be living longer, healthier lives in home or a homely setting. We want to do all that we can to ensure that when people attend accident and emergency they get the right care from the right person within the standards that we set. That already happens in many cases, but we want it to happen consistently. Sometimes it will be better for people to get the care that they need elsewhere in a minor injuries unit, for example, or via and out of our primary care service through telephone advice. Again, that is happening in some cases, but there is best practice that we can spread further, which will provide improved outcomes for patients and reduce costs. I thought it would be helpful to comment briefly on the phrase A&E waits. What we are measuring is progress against a target that by September of this year 95 per cent of patients would be seen as appropriate, either treated or discharged within four hours of arrival at A&E. We are not measuring whether patients wait for four hours. We are measuring whether they are out of accident or emergency, with all clinically appropriate actions taken within four hours. As I have made clear in earlier correspondence, I welcome the recommendations within Audit Scotland's report, published in May of this year, and we are progressing those through our Unscheduled Care Action Plan. This plan is supported by local Unscheduled Care Action Plans, and each board prepares annually. I will mention briefly some of the key actions taken in the first year of the action plan. We have established the flow programme to improve the way that patients move through the system and cut out unnecessary delays. We have recruited an additional 18 emergency department consultants. We have put in additional bed capacity. We have issued signposting guidance to help patients be directed to the most appropriate treatment point. We have got a number of new initiatives preventing frail elderly patients going into hospital unnecessarily in 4th valley in Ayrshire and Arran. Discharge hubs in Fife, Lothian and Ayrshire and Arran. We have invested in theatres and grampian in beds in NHS Lothian and in staffing in NHS Lanarkshire. Over the period November 2013 to March 2014, Scotland recorded 93.1 per cent performance for patients being discharged or admitted within four hours compared with 91.4 per cent over the same period in the previous year. I think the figure of 94 per cent has been quoted in relation to June in published data, but we are not at the standard that we have set. I quite accept that and I want to ensure that patients who do attend A&E are able to leave A&E safely within that standard. That is the commitment that we have made and, despite the complexities, it is the one that we are continuing to strive for. We have also reduced significantly the number of people waiting over eight on 12 hours to be discharged or admitted again. We want to eliminate that as far as possible. We do not believe that people should have to wait as long as that to be admitted or discharged, certainly in very few cases, but fewer than 1 per cent of all patients remained longer than eight hours in accident and emergency. We do owe it to patients to go further where we can. In closing, I want to assure the committee that we are well aware that the context in which we are seeking to deliver these commitments is challenging. I am not here to provide a set of emollient statements about how it is all absolutely fine in our places where it is not. We have an ageing population, increases in patients presenting with more than one condition, often referred to as multimorbidity and recruitment pressures. They are not unique to Scotland, but nevertheless we are committed to doing all that we can for the people served by NHS Scotland to provide timely treatment so that they experience safe person-centred and effective care and enjoy good health outcomes. I am happy to answer the committee's questions, convener. If we do not have data immediately to hand, we will under it to provide it as quickly as possible. I know that you have had a lot of detailed information and we would want to make sure that any responses that we gave in that context were accurate. If we do not have it today, we will provide it as soon as we can. Thank you for allowing me to make a statement. Thank you very much for that. You recognise in your opening statement, Mr Gray, that you are not yet meeting the 98 per cent standard or target, but you talked about the milestones. Have you reached the 95 per cent performance milestone in September? As I will appreciate, convener, that data will not be published until the end of December. No, it is two months after the period ends. Two months after the period ends, so if it is September, then it will be November. Until we have that ratified data, I cannot confirm that. Are you confident that you will reach at least 95 per cent? On the basis of advice from boards, a number of them will. I cannot say that they all will until we have the data. I would not want to make a firm statement about that. Dr Martin McEchnie, who is the new chair of the College of Emergency Medicine in Scotland, has acknowledged that the additional £50 million that the Scottish Government invested had helped to, in his words or the words of the journalist, curb a crisis, but he then went on to say that there are still unresolved serious issues. Do you accept that? I accept that, for example, as the committee heard last week in Grampian, there is an issue with staffing and emergency medicine. I have acknowledged that not everywhere is perfect. I have no difficulty, convener, in accepting that in some pockets there are and have been and will continue to be difficulties. There was information in the public domain recently about a day when Heir Mayer's accident emergency dipped below 70 per cent in relation to the target on a kind of very high attendance unexpectedly on that day out with all the norms. We are not in a situation where every day will be absolutely perfect. You mentioned Lanarkshire. Last week we heard evidence from a number of boards, including NHS Lanarkshire. It was interesting. One of the things that I suspect the committee will want to look at more closely is how we share good practice, how problems are certainly identified and how we share good practice. We heard from NHS Tayside about efforts that they were making to ensure that patients or people weren't unnecessarily attending A&E when they could be treated elsewhere. We also heard from NHS Lanarkshire that they were quite confident that they could sustain the present accident emergency configuration. Since then I have seen correspondence that suggests that, for example, the GP out of our service in Lanarkshire was having problems. I don't know if it is at five units that there are in Lanarkshire and a couple of them had to be closed. Where the GP out of our service is unable to cope, we heard a certain concern that the public would make its own decision. Mary Scanlon identified a number of areas in the country where it would appear that the public were just attending A&E because they felt that that was probably the easiest and quickest way to receive a service. In areas such as Lanarkshire, if the GP out of our service is unable to cope because of a lack of staff, does that not place a huge burden on an already overstretched accident emergency service? If a particular aspect of the service in any board stops working for a period of time, then clearly that demand goes elsewhere. I think that Ms Scanlon made some important points about the choices that individuals make based on their perception of where they are most likely to get a service. One of the things about the national health service is that we never, nor should we refuse to provide a service. If someone cannot get a service through the GP out of ours then they will have a choice of phoning NHS 24, they will have a choice of attending A&E or in extreme cases phoning an ambulance. Those choices will remain available and clearly that pressure will displace from the service that is not available on to the ones that are. That is a fact of the way that the NHS operates in Scotland. Mary Scanlon. Thank you for that. The report that we are looking at today is about Audit Scotland A&E. We could not ask Audit Scotland what was happening with the ambulance service NHS 24 and why two out of three people presenting an accident and emergency were self-referring. I do feel that that is a question that we can ask you. Overall, the increase in patients in the past four years, overall, is 50,000. If you drill down slightly at Ninewells hospital, it is down by 46,000. If you look at Aberdeen, it is nearly 63,000. Edinburgh is up by 112, and Glasgow is up by 85,000. Is it not a case that... What are you doing to find out why there is this huge increase in self-referral? My point is that we no longer have an accident and emergency service. We have a 24-7 open door to the NHS, which quite rightly patients are now saying, this is where I choose to go, and maybe it is because they are getting there, perhaps they are not getting elsewhere. If this continues at this rate, we no longer have an accident and emergency service, and it would seem that GPs are doing less and less, and patients are voting with their feet to go to A&E. What are you doing about NHS 24 GP referral and the two thirds, 66 per cent of patients at A&E that are self-referring? Is that really an accident and emergency service anymore? A number of comments, and I will bring colleagues in on this as to some of the wider work that we are doing. First of all, I am very reluctant to criticise a patient for making a choice that might not actually be the best one for them. But what I am seeking to do, and colleagues are too, and perhaps I could bring colleagues in on the NHS 24 campaign that will be running in terms of helping people to understand over the winter what the most appropriate routes to treatment might be. What we are seeking to do is to work to educate the public on what would be best for them. In some cases, going to A&E is not best, but it is the only option that they believe to have available to them. I have been speaking to both NHS 24 and the Ambulance Service about what more we can do to help the public to understand where they are most likely to get the best outcome. They may very well get a good outcome from going to accident emergency, but they may have a quicker outcome by going through another route. They may very well feel that they ought to go to accident emergency for the want of quick advice that might have given them sufficient reassurance to wait until the following day until they could have gone to a GP. Those things are all possible. One of the things that the data pointed up to me, and I was discussing this with colleagues yesterday, was that we are not yet very good at collecting information from patients about why they made the choice they did. We know that they made the choice, but we are not always sure why. I took the time to go round with the Ambulance Service and to be in the NHS 24 control centre. Particularly in relation to the Ambulance Service, it was clear to me that some patients were calling for an ambulance because they were afraid. They had legitimate reasons to be afraid, but if we had a different source of assurance and advice to these patients, it might well have been that their anxiety levels would have gone down and we would have been able to provide a service to them in a different way. The same, I think, happens in A&E, but for the want of data, I am not going to make an absolute judgment about why it is people turning up to A&E and why they do not. You are right, however, to say that some presentations to A&E could be dealt with elsewhere. That is why we are doing, for example, a minor injuries unit, which allow someone with a minor injury to have a different source of advice and treatment if necessary. I do not know, Eileen, whether you want to say something. At Ninewell hospital, 50 per cent of patients at A&E self-refer in Aberdeen at 74, there are others such as hair mires that are over 80, etc. Why is it that 50 per cent of patients at Ninewell see a beacon of good practice and we welcome that? Why is it that 75, and I just picked out Aberdeen because they were here last week. We have 25 per cent more presentations at accident emergency in Aberdeen that self-refer than we do at Ninewells. Why is that? I am not saying that we do not have the data. What we do not have is the underlying information that tells us why the patient made that choice. It may be that in Aberdeen they made the choice because there are facilities available in Aberdeen that are available in Dundee, for example. We have not asked the patients so we do not know. My point is that I am drawing from the data the fact that we need to have a better understanding not just of the facilities available but of why patients make the choices they do. That is what I am keen to pursue as we go forward. Dr Keill might be able to add. I think that that is right. We do not understand why people are making these choices. We need to get a better understanding. There is a graph in the Audit Scotland report that I am struggling to find, but it talks about board usage of A and E and minor injuries units. It is very interesting because it is clear— Five. Thank you very much, Ms Gellan. I do not know that. It is a bit full. We were talking yesterday about why there is a enormous variation between boards in use of minor injuries units that are there on the board territory. Clearly, patients are choosing more to go to A and E. We need to gather a bit more intelligence around this and begin to better understand why those choices are being made. If you do not understand it, we are not going to get much further there. I was hoping that we would have got a more holistic picture from the health service today. It would be wrong to ask God at Scotland about the ambulance service and others when they only looked at A and E, but underlying this report is what is happening at GPs, NHS 24 and the Ambulance Service. That is why I am keen to understand that. Until we understand that, we do not know why hundreds of two out of three patients self-refer and they are doing that for a reason. We have to respect that reason. I would like to bring Professor Leitch in on that. To be clear, I am accepting the point that we need better to understand why patients do what they do. It has not been our approach so far to collect much data on that, and I believe that we ought to, because that is the way we will be able to modify what we are doing. If it is all right, I will bring Professor Leitch in. A couple of things, Ms Scanlon. You referred to Exhibit 3 and Exhibit 5, so let me deal with Exhibit 3 first of all. That is the difference in attendances between 0809 and 1213. It is two data points. It is a before-after data points. We need to see the trend rather than these. There are some interesting things about this data. Glasgow Royal Infirmary, which would appear to have the second-highest increase, that is because Stalpill hospital closed its A&E during that time, and Glasgow Royal Infirmary absorbed all of the Stalpill accident emergency patients. The Victorian Infirmary, where I did most of my training and most of my surgery, has the second lowest, so it says that it reduced its attendances by 61,000, but that is because it opened a minor injury unit and took all the people who they used to count as A&E attendances into minor injury units. That does not give you the overall trend. The overall trend for the whole country is 150,000 people a month, and it is roughly stable. That does not deal with where we are going and the holistic care point, which I completely agree with, that we should give the most appropriate care to the people in the right place at the right time. The data in Exhibit 5 is, I think, what would be the best description, weak perhaps. I do not think that we code this particularly well in the national health service. Just to take your two hospitals that you used as examples, Ninewells and Aberdeen Royal Infirmary, as 50 per cent self-referral and 75 per cent self-referral, it also says that Ninewells hospitals got 27 per cent of people coming in 999 ambulances, and Aberdeen Royal Infirmary having 7.2 per cent coming in 999 ambulances. That cannot be true. They are being coded differently. Those are two major district general hospitals, one with a third of its patients coming in ambulances and one with 7 per cent of its patients coming in ambulances. That data is not coded well by the health service. I am only deaf, convener, but that did come up with Audit Scotland last week, and it is very difficult for us to do the job when we do not have accurate, comparable data. I can only work on what is in front of me, but Audit Scotland did say that the data was not comparable. I will leave that to the convener. Professor Leitch, you say that the data is weak. That is not the fault of Audit Scotland. It can only compile what is presented to them. If the data is weak, then that is the fault of the NHS. That is the fault of the health department. That is not Audit Scotland's responsibility. The question is, why have you collectively not sorted out the presentation of weak data in order to allow Audit Scotland on behalf of the public to do an effective job? Those data, convener, are not routinely collected data for publication subject to the standards and strictures that we would apply. However, just in the interests of transparency, I discussed Exhibit 5 with colleagues here yesterday and said that I was clear that when I see chief executives this afternoon, given that we have some of those data, and given that it tells us that there are differential approaches to collecting it, we are going to have to improve that. I am not hiding behind the data. It was given to Audit Scotland. There is no criticism intended or implied of Audit Scotland in this presentation. However, we did what we could with what we had available. If we are asked for new information that we do not routinely collect for publication, then it is generally going to be of a lower standard. I understand that, but this is not anything new. This is something that is done on a semi-regular basis. The report that we have got was a performance update. It was not the initial report, so this is something that you have known about for some considerable time. Why is it only taken to a discussion yesterday for you to raise this this afternoon to say that there is a serious problem with statistics? There is not a serious problem with published statistics. The data is not weak. The data is weak. That is not serious. If there was a serious problem with routinely published statistics, that would be a very significant issue. If we are asked for something on an ad hoc basis, we do our best to provide it. That is what we did. I am not saying that you are saying this, convener. If the committee would prefer that if we are asked for data, we will stick only to data that is routinely published and subject to the quality controls that it has, we will do it. I do not think that that would be a service to the committee. I am simply telling you that I am taking it up with chief executives this afternoon because we have a meeting with them. That issue was clear to us some months ago. We have been working at it. I have got to the point where I want to speak to chief executives about it. It would not be appropriate for the committee to tell you which set of data to collect and which not to collect. That is not our responsibility. Our responsibility is to analyse and comment on reports produced by Audit Scotland on behalf of the Auditor General. Audit Scotland asks you for information. There is a discussion clearly that you need to have with Audit Scotland, but I am surprised that you are saying that in this report, which is a performance update, we have a set of statistics that you say are not routinely collected and which would appear to me to be part and parcel of an on-going observation on the performance of accident and emergency. That is something that we can explore later with the Auditor General about whether or not this set of statistics is unusual and therefore subject to the weaknesses that you have described or whether it has been going on for some time in which case it does seem surprising that it is only now that the problem is being addressed. Can I ask you one other thing before I bring? I have one more question to ask. It is a slightly different issue on ambulance service and accident and emergency. My only question is just my final question. I only had two questions. The second one was a point raised by the medical director from Aberdeen, and it was about the enrack figures and previously her birth nut. I do not have the figures in front of me, but I do remember. Per capita, nine wells get 1,945-ish and Aberdeen gets 1,500. For every single person in NHS Grampian, they are funded at £500 less than a patient in Tayside. Are they being punished for being the oil capital? Is the enrack formula, and I remember our birth nut 1 and our birth nut 2 and all that, appropriate? Are we really funding Grampian appropriately enough to provide the service that we can easily criticise them for doing? I will bring John Matheson in on the point, Ms Scanlon. To be absolutely clear, since you have asked the direct question, no NHS Grampian is not being punished for anything. It's less per person funding. Mr Matheson will explain the formula. Ms Scanlon, the formula starts with its basis, the population of the individual health board areas. It's then adjusted for the age and sex... ...head of population. It's based on population. It's then adjusted for age and sex. It's adjusted for morbidity and life circumstances. Then there's an excess cost index brought in to recognise remoteness and rurality. It's a dynamic formula. It's continually under review, just a reviewed date of remoteness and rurality. So what the results are telling you is that the population of NHS Grampian overall requires less demand on the healthcare service than the other parts of the country. We do recognise, as part of the movement towards gender parity, that not all boards are at parity. Grampian is one of the boards that is below parity at this point in time. We have an agreed day way forward over the next two years to bring NHS Grampian and the other boards below parity to within the 1 per cent of parity by the start of 2016-17. The difference that you've highlighted, Ms Scanlon, is a difference that is driven by the formula, which is a formula that was agreed across the NHS and is under a continuous review to make sure that it is appropriate and up-to-date. That is a complex and complicated issue. I think that it's one for separate discussion at another time. It's no doubt something that we can come back to for Audit Scotland to produce a report on that. Can I just ask you a question that comes to mind, both what Mary Scanlon said in your mention, Mr Gathe? It's about the connection between the different services. You've got a target of four hours which you're aspiring to and which you admit will be challenging. I've got an inquiry from a constituent about the ambulance service and no doubt others will have had similar inquiries. The woman had to wait seven hours for the ambulance to arrive. Now, when she gets the accident emergency, the clock starts at that point for the four hours, but potentially it's 11 hours from her reporting an issue to her being through the system. Is that acceptable? Without knowing the detail of the individual case, convener? Sorry, I wouldn't expect you to do that. I'm just talking about the concept of a four-hour target, but the reality is that it's potentially 11 hours. As I say, I wouldn't like to draw too many conclusions from an individual case where the wait for the ambulance does sound long. One of the important things in terms of the way we're trying to help the public better to understand what we do is that, particularly in a serious case, if an ambulance arrives with qualified clinicians, the definitive care to the patient starts at the point when the ambulance arrives, not at the point that the person gets to A&E. There is still something of a mental model in the minds of the public, and I would accept responsibility for that. The job of the ambulance is to pick you up and take you to A&E as fast as possible. In fact, the definitive care is delivered at the roadside in the home of the patient, and that is the life-saving care that is often delivered. The point at which the qualified ambulance practitioners, paramedics, decide to take the patient to hospital is informed by their assessment of the clinical condition. It is right that we have a target for the ambulance service to arrive based on the category of the call, and then we have a target in relation to performance at A&E. Of the cases that I was privileged to be part of in my short time going on with the ambulance service, in fact, only one case was taken to A&E out of five. The care was delivered to the person in their home, or as I say, by the roadside, and there was no requirement to go to A&E, so I do not think that we could join the two together. Colin Beattie and then Ken Macintosh. I do have to comment on the data collection, because the committee has again and again come up against deficiencies across the board on data collection. The report that we have in front of us is almost entirely data-driven, and the conclusions that we take from it are entirely dependent on the quality of the information that is provided. It is a concern that there are inconsistencies across the service that make it difficult to do comparisons or to draw the conclusions that maybe we would need to. Obviously, that is something that I am sure you are going to address. I hope so. As I have already said in response to the convener, for published data there are standards, and those have to be upheld and maintained. We seek to be transparent, so if we hold some information, we will give it with the caveat that it may be partial, it may be incomplete, but we are not in the business of withholding what we know, even if what it tells us is that we need to get better. The previous episode said that the Scottish Government was encouraging NHS boards to make use of the emergency departments and emergency medical workload tool. How widely used is that, and what conclusions have been drawn from the use of it? I will ask Dr Keill to help me out with that one, because that is a level of detail that I am not personally familiar with. The short answer is that I do not know how widely it is used. We are certainly promoting it as a means of measuring workload, which of course is not just related to the volume of patients coming through the door, but the case makes and the severity of the conditions that those patients are suffering from. John Connor, can you say a bit more about how widely it is being implemented? The tool is still under development. We have reached the later stages of development. We have piloted it now in a number of boards, and the plan is, in 2015, as early as we can, that we start to roll out on a national basis. It is a different kind of workload tool than we have used in the past. Most of the workload tools that we have developed, and Scotland leads the way in this, I must say, from a UK perspective, have been devoted more to nursing staff. This one, in Accident Emergency, takes all the staff that work in their doctors, EHPs and nurses. That is why it is taking a little longer than we would otherwise like in terms of development phase. We have done a lot of work on that. It is breaking, as I say, UK grounds, but 2015 is a plan for us to roll out. I do not have the roll-out schedule to hand at this stage, but I can supply more information on that, if needed. It has already been highlighted that A&E has a substantial number of people's self-referring. However, accurate figures are certainly a substantial number. The comments have already been made that, for a lot of those patients, there could have been alternative solutions for them. Clearly, a lot of those patients are going to be signposted away to other services, such as primary care and so on. How confident are we that there is sufficient capacity in other areas such as primary care to deal with the patients that you are signposting on? I will pick that up, if I could. One of the things that we have established in the last couple of years is a requirement for each board to produce a local unscheduled care action plan. That local unscheduled care action plan, where we are now in our second year, should take account of the demand and capacity in each of the parts of the system, which supports unscheduled care. The answer is that it is very much for local boards to return, but we have set up a national mechanism that says that we must do this. Those local unscheduled care action plans are published on each board's website. When you say that it is up to the local boards, is there some sort of consistency of approach there, or are there guidelines that they will have to follow? We issue guidance on an annual basis. We continuously refresh that guidance with our partners, for instance the College of Emergency Medicine, to make sure that it is accurate and up to date. We issue national guidance on that. We call that the national unscheduled care action plan. I think that most of us were very worried by this report when we first saw it. It shows that Scotland's performance against the A&E target has deteriorated over the past four years, and we have spent some time trying to work out some of the main reasons why that might be the case to make sure that it is being addressed. We had a very good discussion last week, with a number of colleagues from the NHS, in which we touched upon staffing, delayed discharge, sustainability issues and others. There is one particular issue that I would like to start with, for me, which emerged. It started with a comment from Professor Ferguson, who is an emergency consultant at NHS Grampian. He said, We still operate the way we have always operated. We know that people are more likely to die if they go into hospital at weekend. There is good evidence to suggest that. I followed that up, because I have asked the health secretary, Alan Neill, about this, and he says that there is no evidence to suggest this. Dr Daikouzen, who is the medical director, said, I agree with Ken Macintosh that because those studies, those are international studies that show this, that there is an issue at weekends, I agree with Ken Macintosh that because those studies show such a relationship, we should assume that the effects are the same in our country and our organisations. That is why we do those studies to learn what to focus on. Professor Ferguson later suggested, when he was questioned again by the convener on this, that there is international evidence that backs up that that happens. I would surmise from that that we have the same problem in Scotland, otherwise why we should need the safety programme. Can I ask Mr Gray first, perhaps? What do you make of that? Do we have a problem with excess mortality at weekends in the A&E departments or in hospitals generally? The evidence that we have does not tend to support that. You have quoted colleagues saying that they assume that, I would like to ask Professor Leitch to give us some insight into what the data is and what it is telling us and what some of those international reports said. Mr Macintosh, you are asking a fair question and we did anticipate it, so we have done some work to prepare an answer. Mr Macintosh and I have discussed this previously and there was an FOI. There is some Scottish evidence. There are international studies that suggest increased mortality at the weekend compared to weekdays. They do not tend to explain why and they do not adjust for everything that you can adjust for because it is very difficult because it could simply be that patients are sicker, they are more complex, there is more trauma, there is more alcohol use Friday and Saturday, etc. There are two pieces of Scottish evidence. One is the handle study that was quoted last week and it's weekend admissions is an independent predictor of mortality and analysis of Scottish hospital admissions. It doesn't adjust for admitting diagnosis so it doesn't make any decision about why you came in and it doesn't adjust for the severity of your diagnosis so it doesn't tell us whether your stroke was very bad or your stroke was very mild. It goes on to say in the conclusions that it may be that emergency departments see a different, more unwell population of patients at the weekend since in one study which used a biochemical measure of severity adjustment for this variable rendered the weekend effect insignificant. That could mean that the effect that we observe is actually due to admissions over the weekend comprising a more unwell population of patients who would suffer a higher rate of mortality regardless of factors that may apply exclusively to the weekend. Having had in your previous questions both in the Parliament and to Mr Neil we asked ISD to look at Scottish data in particular. You've had that, FYI. It looked at all deaths from 1 January to 31 December 2012 by specialty. Of course, there is variation. By day, there is variation by specialty. There is constant variation. You don't get the same mortality rates all the time. However, ISD says that the assumption that mortality is higher for patients admitted at the weekend cannot be backed up by statistical evidence. The data only took the type of admission into account. To understand this issue fully, there are a number of factors including case mix age and underlying health issues. I'm not dismissive of the weekend mortality literature, but I'm passionate about mortality in the whole week. I'm passionate about expected mortality and what we're doing about that in Scotland's hospitals. You won't be surprised for me to use the example of the Scottish patient safety programme and that's why it exists. It exists on Mondays and on Saturdays and Sundays. It is about sepsis. It is about venous thromboembolism. It's about early warning scoring. Your witnesses last week used it as an example of trying to fix the whole system all the time. Globally, it's the best recognised safety programme in the world. It is about reducing mortality every day. I'm not rejecting completely the weekend mortality thing, but I'm more focused on reducing unexpected mortality throughout the whole system. I thank you for that. I also thank you for following up on the issue. Clearly, if we don't agree that there is not a shared acceptance of the problem or identification of the problem, it's very difficult to address if we don't think that it exists, as it were. Picking up on those points, the figures that you published through the FOI were very welcome. I was contacted by one Professor Paul Aylin, who is the Professor of Epidemiology and Public Health. He is co-director of the Doctor Foster unit at Imperial College. Doctor Foster has been quite influential in changing health patterns in England, which I imagine is why it matters to him. His views on the information that you published through the FOI were cited by Mr Neil, which claims to support the fact that there is no excess mortality at weekend in Scotland, is inconclusive. The analysis, as it stands, breaks down the data into individual specialities by day of the week. As such, the numbers are just too small to show and affect either way. The key thing here is that the BMJ paper, your quote from Dr Handel's paper, you cited one of the comments on it. The conclusion was that there was a significant increased probability of death associated with a weekend emergency admission compared with admission on a weekday. It did say that further research should be undertaken, but it showed other factors. For example, this was a study over 11 years, and it showed a decline in mortality over that. It was actually quite positive, but it wasn't unrhymetically negative about what was happening in Scotland far from it. It did show that. There have been other studies. Professor Aileen himself, along with others, published a weekend mortality for emergency admissions, a large multi-centre study, showing very similar differences between weekend and weekday admissions. There have been international studies showing that. The point here is that, in England, the NHS is taking policy action to address weekend mortality and re-admission rates. It is recognising it as an issue, and it has changed the policy. I am not saying that we should. It could be that the patient's safety programme. I am not going that far. I am just trying to work out whether or not we can conclude, as Mr Neil seems to suggest, that we have no problem at all. The figures that you suggested that you published in this FOI suggest that between 2009 and 2012 there has been a marked improvement. In this study, in the BMJ study and others, there was still quite a difference. There was a 40 per cent increase in excess deaths a weekend. Quite a marked significant increase in deaths a weekend. If the figures now show that there is no difference, can you point to the policy initiatives that have made the difference? Can you show or demonstrate what it is that is working? I think that that is as important to us as whether it has happened. We should be welcoming it and celebrating it. We should also work out what has caused that beneficial effect. I suggest that the figures that you have published do not prove anything. They do not demonstrate that there is a problem one way or another. Indeed. I am not suggesting that the Handle Study is not telling the truth. The Handle Study shows an odds ratio of 1.41 compared to weekends to weekdays. It does not, by its own admission, adjust for severity of diagnosis. One of the conclusions that you could draw is that the patients at weekend are expected to die, for lack of a better description, because they are sicker than the ones during the week. We could isolate out Tuesdays, if we wanted, and spend all our time looking at the data on Tuesdays because we are worried about Tuesdays. I am worried about mortality and the safety of our healthcare system every day, which is why the Scottish patient safety programme and its interventions apply every single day. That does not mean that we are not tackling 7-day working and 7-day services, but those are not about mortality, but about flow and care and getting people out and delayed discharge reduction. Inside that 7-day working, of course, is safe, effective and person-centred care at the same time. We have those policy initiatives that the English are having. I know of nothing in England specifically around the safety of care at weekends compared to weekdays. I know that they are up looking at the Scottish patient safety programme and they are going to launch 15 of them in their regions, if they can, around NHS England. There is nothing in England that I have seen that says that they are doing something special at weekends to reduce mortality compared to during the weekend. I would advise against specific interventions that would deal with safety on a weekend day that we would not use on a Tuesday. I do not know anywhere where that is true. That does not mean that we do not want to increase the use of diagnostics at the weekend to improve the flow, to increase the use of pharmacy at the weekend and all of those other elements around our 7-day working service. Although the thousands of people who worked this Saturday and Sunday already believed that the NHS is a 7-day service, let us not pretend that we are not already working in a 24-7 environment inside the NHS. I do not want to spend too much on that issue, so I agree that this BMJ paper does not... We should not draw the wrong conclusions from it. Just as you were suggesting earlier from evidence in the Audit Scotland report, evidence reveals problems. You do not necessarily want to draw the wrong conclusions from them. The point that I am trying to work out is, first of all, do we accept or do we not accept that there is a difference in mortality at weekends compared to weekdays? Professor Ferwickson, who gave evidence last week, believes that there is. He has consulted working in Grampian, and he believes that there is. The handle study suggests that that is true as well. The handle study in the middle of it, particularly in function to policies, has been the report by Dr Fosser. It is a different report on an increased hospital mortality in the UK weekends, which has been linked to a reduced cover by senior doctors at weekends. That is a separate report. Fosser does not have Scottish data. That is exactly it. Fosser only has English data. There are different reports from which you might draw different conclusions. Indeed. At this stage, I am not even suggesting that we do draw these conclusions. I am just trying to work out whether or not we accept or believe that there is a problem of increased mortality weekends. The answer from Helen Neill suggested that there is no problem. He said that there is no problem at weekends. He accused me of scaremongering by saying that I was not scaremongering the slightest. I was actually coming from a constituent case. I was trying to work out whether the constituent's case was an individual case or typical of what would happen at weekends. I was slightly worried, I have to say. I was struck by what struck me as complacency on his behalf. If he thinks that there is no problem based on a survey that is not pure reviewed, that is statistically inconclusive according to Professor Eilin, that would really worry me if this is the one study that actually proves to Helen Neill that there is no problem at weekends. Can I ask you, for example, would it be possible to provide Professor Eilin, Dr Foster or any other medicine, including Dr Handel and all the ones at the BMJ with exactly the same evidence? They studied evidence from 2000 and over 11 years up to 2009. Would you be able to provide the same evidence breaking down, for example, not just weekend-to-week day admissions, but elective admissions and something that can be comparable with a BMJ paper so that they can actually meet the committee? So Hanlon has the Scottish data and he has as much of the Scottish data as is available by all the countries. The difficulty is nobody measures severity of diagnosis. So nobody knows how sick the patients are when they arrive. Therefore, it is almost impossible. Hanlon is a very good researcher. If he had had severity of diagnosis data, he would have adjusted for it. He hasn't not done it because he forgot. He's not done it because that data is unavailable in all of our countries, because we don't have a neat measure of how sick you are when you come to A&E. So much of the assumption, having done safety across the whole nation, remember, safety programme every day, early warning scoring every day, is that that safety system is in place on a Saturday and a Sunday as it is on a Monday. It's not perfect, sepsis care is not perfect, infection care is not perfect, but my focus in leading the safety programme and the hundreds of people who are doing that is in making that better every day. So that will need attention on a Saturday, but it will also need attention on a Tuesday. I'm not being critical of the safety programme. Anybody is far from it. It's just trying to work out if the safety programme by itself is going to address the weekend issue. If you don't have, if the issue at weekends is a lack of cover, because, and it's not a problem, this is not a political issue, this is a reflection of society in five-day week, it's not a reflection of a political Government of the day, but it has to be addressed by the Government of the day. So the patient safety programme addresses patient safety, it does not address weekend work, it does not address the issue of weekend working and whether there's an issue with it. Correct, so the work around seven-day services addresses the staffing, the diagnostics, all of the other elements. I am confident that patient safety is not affected on a weekend any more than it is in a weekday. However, the seven-day working process is about making the system better, about making the service better, not just about making the service safer. So we've got a seven-day programme, despite the fact that you don't think necessarily a problem with seven-day services. The seven-day programme is not about making it safer. The seven-day programme is about improving the flow through the system, making delayed discharges better. So we have traditionally, in my job, more difficult to discharge on a Saturday than it was to discharge on a Thursday or a Friday, where the family are perfectly happy to have the patient home on a Saturday, and that was more difficult because diagnostics weren't available, pharmacy wasn't available, so we're fixing that element of seven-day working. Scheduled surgery, very, very unusual to do scheduled surgery on a Saturday, now becoming more usual to do day surgery on a Saturday. That's what the seven-day working process is about. Just finding this, do you accept that there have been a number of studies, and this is the key thing, a number of studies in the UK and internationally and in Scotland, all suggesting an issue out weekends? Do you accept that that is the case and do you believe it applies in Scotland or not? I believe that there are a number of studies which suggest that mortality is higher at the weekend than during the week. I think that that may well be true in Scotland. What I don't accept is that that's a patient-safety problem. I think that that's a severity of illness problem. The evidence such as it is is deficient because we don't have the case mix, the severity of illness scores of those patients that are coming in at weekend. Like Jason, I think probably there are sicker cohort of patients, but the seven-day working, as he's already said, is about trying to speed up the patient journey through hospitals because we know that the longer you stay in hospital, the more likely you are to get a healthcare-acquired infection, for example. Patients don't want to be in there unnecessarily, so the idea about sustainable seven-day services is to improve access to routine diagnostics at weekends, get patients discharged at weekends, rather than waiting until the next week to get those investigations. I think that until we have studies that look at the case mix of patients coming in at the weekend compared to those coming in Monday to Friday, we will not know the answer to your question, Mr Macintosh, as to whether there is a problem there. The data indicates that more patients are probably dying at weekend but it doesn't tell us why. Professor Leitch said much the same thing, and some of it might be down to sicker patients coming in, as you suggest. The novel of it is, can you say with certainty that there is no increase in mortality rates at the weekend compared to the week? It's quite the opposite. There is an increase in mortality rates at the weekends than the weekdays. Cabinet Secretary say with certainty that there's not that problem. He's referencing the fact that it's not a patient safety issue. There may be higher mortality rates on a Tuesday than a Thursday. There is variation according to case mix. There is no systematic safety problem at weekends compared to weekdays causing excess mortality. The answer that he gave referred only to patient safety. It didn't refer to the rates. We can go and check that. That's fine. I like the studies around that. What he actually said was that the programme is probably a major contributing factor to why the mortality rate at weekends is no higher than it is during the week. You've just said, Professor Leitch, that the mortality rate at weekends is higher than it is during the week. According to the best study we have, which is the handle study, they found higher mortality rates at the week. More people die on a Saturday and Sunday. My premise is that that's not to do with safety, that's to do with case mix. That wasn't what we were trying to get. You're saying that there is a higher mortality rate at the weekend. The Cabinet Secretary said that there's not. That's something that we need to explore further. We'll move on now. Bruce Crawford. Thank you, convener. First of all, I appreciate the candid responses that we're receiving this morning. Thoughtful responses. I was very grateful to Paul Gray for laying out the areas from his correspondence. As the key actions and improvements have taken place. I'd like to move on from issues of data or statistics or the stuff that Ken McIntosh was dealing with to get to the core of what we're trying to do, I believe, as a committee. That's look at a positive way forward in regard to flow particularly through hospitals, but before we do that, Mr McIntosh, in his opening statement, made a rather sweeping statement to say that in recent years performance in A&E had deteriorated. From the figures that you've provided to Mr Gray on your correspondence, it would seem to me that from 2012 to 2013, certainly, the figures that we have available here, the weights over four hours are reduced by 19.2% and weights over 12 hours are reduced by 66.4%. Can you confirm that I've got these figures right and just give us a general comment on what you believe to be the overall performance in A&E? Over the winter period between November to March 2014, there was a 66% reduction in patients remaining in A&E more than 12 hours. Fewer than 1% of all patients remained longer than 8 hours in A&E. That's the information I have to hand. The performance in A&E was 91.4% in the previous year and is now, as I think I said, up to 94% indications from a number of boards. This is their data, not the published data, is that a number of them are meeting and continue to meet the 95% target. As I said in response to the convener, I'm not certain that all will, but the trajectory is in the right direction. We're treating, I think, one and a half million patients a year. For many of those patients, the vast majority are getting the treatment within the time that we would. It's a 95% target, because for some people it will not be clinically appropriate to have them out of A&E within four hours. We're discussing here 1 to 2% of patients who are not being seen and discharged or admitted within the time set. Any staff, consultants, trainees, nurses, other professionals, administrators are working very hard under high pressure, and I don't think that it's the intention of this committee. In any way to undermine that, and indeed at my previous session, the convener was quick to assure everyone that it was not the committee's intention to undermine the work being done by NHS staff, so I appreciate the point and would want to make it again. Can I just add some information for that as well? I think it's quite interesting if we also look at where Scotland has been in relation to the other home countries, and indeed further abroad. Certainly Scotland's performance for some considerable time has been better than Northern Ireland and Wales, and it's pretty comparable with England, almost the same. If I take a look at, let's say, median weights, Scotland's position in median weights is the best in the UK, roughly about 10% better than England and considerably better than Northern Ireland and Wales over recent years. One last thing that might be of interest to the committee is a study that has just been published by the Canadian Government, which looked internationally at best practice around waking terms and particularly at accident and emergency. It was published in June 2014, which highlighted Scotland with the lines Imagine a land where, and compared Scotland's performance with the Canadian performance, it shows Scotland in relatively positive light and is a good beat. Quite rightly, Mary Scanlon, in earlier evidence was looking at the issues of how individuals present themselves, and that's obviously something we need to understand better than you've accepted that. What I would like to try to get on to now is where the best practice is taking place in Scotland from what we saw last week. One of the areas seems to be Tayside. The question for me is, if Tayside are managing to get to the performance level they are, there's obviously a job for the individual boards themselves to do, but there's a particular job for the centre of the organisation, i.e. Government, to make sure that others can achieve the same high performance rates. Can you talk me through how we're going to use the Tayside experience and other good practice to try to get other boards to the same level of outcomes to help the people of Scotland? I'll give you. I'll ask John Conacher and Jason Leitch to give more detail, Mr Crawford. As a for example, Andrew Russell, the medical director of NHS Tayside, has been in NHS Grampian assisting them with developing their processes and protocols, including an accident and emergency. That's precisely because we believe that there were good lessons that Grampian could learn. I'm giving that as a specific example so that we don't just give you a series of generalised propositions, but, Mr Conacher and Professor Leitch, will be able to give more detail. I'd like to say a few words, particularly about NHS Tayside, and address a couple of things around flow. Perhaps Professor Leitch will add to the update on flow. As a practical example of some of the good practice that we've seen in Tayside, I would pick signposting. That's about making sure that it addresses some of the points in the Scotland that's raised about self-referrals. Tayside has had operating for some time a relatively good signposting system. We took a look at that and issued signposting guidance earlier this year to boards. We agreed that with... So that, for the public record, signposting becomes more visible, and what it actually means, tell us what signposting is as well. Signposting is directing the patient to the most appropriate point of treatment, whether or not that should be an out-of-hours referral back to GP on the treatment inside accident emergency. Signposting is clearly important. It gets the patient to the right and most appropriate treatment. We took the Tayside experience and we, as I say, issued that Tayside experience in the form of some guidance to NHS boards earlier this year. We are in the process of reviewing how that has gone down, and it's quite likely that in the near future that guidance will be refreshed by the first six months or nine months of experience of how that rolls out across Scotland. You mentioned a very important word earlier and the word was flow. Now, I don't want to give you the impression that we've simply just invented a flow programme for Scotland, and I'll explain what I mean by flow in a minute. Fairly recently, flow, in fact, has been an issue which has been addressed for a considerable number of years. So committee members may remember previous reports of some of that Scotland that looked at the level of day-case surgery that we were doing. That's one element of promoting better flow, because the more we can move out of an inpatient setting into a day-case setting that promotes better flow through the hospital resource and inpatient beds. So, in the course of our consideration of the national unschedule care action plan last year, we established what we call a national flow programme. We are piloting new techniques and four boards at the present time. We have imported the best international experience that we can from the Institute of Healthcare Optimisation to give us the best international advice on how we should set that up. We're at a fairly advanced stage, particularly in Fort Valley, in assessing how we can promote better flow. There are three main components to that in the flow programme. First of all, how we can have better utilization of operating theatres. Secondly, how we can smooth the elective programme. I think that Professor Leitch referred to the fact that when we take a look at electives, which is non-emergency in patient care, there are differences between a Monday Tuesday and, let's say, a Friday, Saturday, Sunday. So, smoothing that out will give a much better chance for boards to be able to cope with unexpected peaks in demand for unscheduled care. So, smoothing electives is important. A third element of that is managing some of the natural variation that comes in in terms of unscheduled care. I'll give you an example of the kind of thing that we want to look at and promote, which is time of day discharge. When we profile how hospitals discharge patients, far too many are discharged much later in the day, if we were able to shift that curve back to having much better discharge rates much earlier in the day, then it would help ease some of the congestion that we sometimes see in some of our hospitals. So, are there a couple of practical examples? I'd like to pass now to Professor Leitch on other aspects of flow. Very briefly. The sharing of best practice across systems of our size is a big challenge. It's a global challenge of how you move what is going well in Lanarkshire, for instance the hospital at home service, probably the best in the country, besides signposting system, probably the best in the country, how you share that around everybody. We have a number of ways of doing that. We do it in improvement programmes, using improvement signs, the safety programme, the early years collaborative, the person centre care programme. So we have learning systems where we create the opportunity for the practitioners in particular to share that. John has a piece of his organisation called Quest where they take efficiency and productivity and they apply that same method and they'll bring people together, they'll share data, they'll share best practice and they'll send people on visits. So Bill Morrison, the A&E consultant from Tayside, is regularly in other A&E departments sharing what they've done in Tayside around that signposting. Lanarkshire is a small example. Lanarkshire have started to use public advertising now. Their nurse director is on the back of a number of buses telling people where is the most appropriate, not actually, she's on a poster. On the back of the buses telling people where is the most appropriate person to engage with particularly over the winter period. I would commend John's mention of the flow programme. Professor Litvak, who is probably the global expert on hospital flow, has principally worked in the US and we've engaged his organisation to work first of all with Fort Valley and we had a day with him John and I just at the end of two weeks ago. They're beginning to do the data crunching of our flow through the Fort Valley hospital and then we start to do the work. What could be a fairly radical redesign of particularly how you do scheduled care and engaging the surgeons around how they might change their weeks and then we spread to another three boards and I'm confident having seen what they've done elsewhere that it will make a significant difference. Plecities, great mind boggling actually in terms of the scale of what you're having to deal with. Can I just bore down in one particular thing that you talked about, Professor Litvak? That's the Lanarkshire Home Service because one of the questions I wanted to ask was integrating social care with hospitals and making sure that this works better. I'm assuming that's what the Lanarkshire Home Service is doing so could you tell us a bit more about how that's operating because obviously if we're in a position to improve the delayed discharge issue and if the Lanarkshire Home Service is helping to provide that then it helps to flow and stops the backlog into hospitals so if I'm right is that what that's designed to do? It's called the Asset Team I think that most of us have been to visit it in fact it's a shining light of how to do it, it is not the only one in Scotland and I don't want to give you that impression Ayrshire and Arran have a very good system but the Lanarkshire One called the Asset Team is fundamentally moving hospital care into houses I had a friend who's a carer for his elderly wife who is very frail has multiple morbidities and in my old world of hospital work she would have been in hospital and she would have been in hospital for a long time she's never in hospital she has cared for at home they can do intravenous fluids they can do antibiotics they have doctors and nurses who can go out they do virtual ward rounds each morning in a location where they effectively discuss each of the patients and then nurses will go out to those people I'm astonished at how well they can look after sick people in their own homes in fact it's a big, big change I'm going to perhaps make a mistake and give you a statistic that I can't quite remember and maybe we should put brackets around it because I'll get you the real one I think the Asset Team's most recent data says they've reduced over 75 admissions from 70 per cent to 11 per cent it's a fairly radical approach to the way we deliver care and lots of people have been to visit and lots of people are using it in their now, contexts are different Inverness is different from Motherwall so moving it to Inverness or to the Western Isles will need adjustment you can't just take it but people are increasingly using it I know that Lothian have been very interested in trying to invest in it and you're right, it requires the integration of health and social care the people who visit the houses are not all national health service employees they're social workers they're care workers and the badges that they wear become less relevant to the family Last question, convener That's helpful in understanding that but that's stopping older people getting into hospital in the first place in many ways in the way it's doing it Currently we've got older people who are and I'm not going to use that term that's been used in the past it's just causing a delayed discharge so can you just give us a general feel about how the integrated social care work that's being going on in the legislation how you think that will help improve things as we move forward over the next few years because obviously we can help there it's going to help A&E because there'll be more beds available to get them in there a bit quicker if I've got that right I suppose the point is that when an elderly person with multiple morbidities goes into hospital they are probably of a category which then is more likely to become a delayed discharge so if that lady went in and the difficulties associated with her getting out would be more profound than in an ordinary case and therefore if we can prevent older people from going in in the first place you're actually reducing the likelihood of them becoming a delayed discharge on the other end in terms of integration of health and social care what we're doing is bringing together the provision by local authorities the third sector and the health service to ensure that the fact that for example people are waiting for care packages that holds them up what can we do to ensure that the process for getting a care package is slicker is there anything the NHS can contribute to that care package so it's not just a well this is the NHS's job and this is the local authorities job and never the twain shall meet to bring that conversation together so that the people who are developing the care package understand better from a health service point of view what it is the individual actually needs so that we avoid in all cases if you like a mechanistic assumption you've got X give a very simple example one of the hindrances we saw to someone leaving hospital was because they had to be able to go up three steps they lived in a bungalow but there was a standardised approach that said until someone could go up three steps they couldn't go out of hospital if you asked my mother to go up three steps she would probably never get out of hospital but so there's something there about ensuring that the conversations happen to take away any misunderstanding however well meant between the various aspects of the care provision there's also I know this is a discussion about accident and emergency but there is a 75% correlation between delayed discharge and increased pressure on accident and emergency and there is also in Scotland in many pockets a straightforward lack of care home places now one of the discussions therefore that has to happen between the NHS and the local authorities and I say it has to happen it is happening is what can we do to provide more step down facilities how can we ensure that there is a sufficiency of care home places you'll be aware Glasgow City Council wasn't able to let a contract for care homes because of the economic conditions and the differential in what Glasgow City Council thought they were prepared to pay and what the market wanted so there are a number of issues around this which to a degree the integrated joint boards and the chief officers of these boards will be working with the health service and authorities to seek to address but there are also some market conditions so I don't want to leave that point out of what I say I'm recalling I'm sure the convener will as well from time has been a council leader sometimes when councils withdraw themselves from the market in those circumstances it then leaves the private sector with a market to deal with in its own way and sometimes you need a bit of regulation in there but convener I've taken a bit of time to think about what we can do to improve things I referred earlier on to Dr Martin McEchnie he said that there was no problem recruiting young doctors to the first years of emergency medicine training in Scotland but they were not completing the course to become senior doctors or consultants Last week we heard from Mr Tachor from Tayside that he had a concern that medical students were being asked to specialise very early and I think he said that sometimes it was even before they had completed their courses and that that was prejudicial to moving in not just the accident emergency but to the way that they were doing training is that something that you're looking at? We're certainly keen to ensure that such flexibilities as can be made available are made available to see the point to which you refer convener and Dr Caleb will be able to say a bit more about that The current trainee doctor recruitment system is something called modernising medical careers which came in about 2006-07 and the aim of that was to better match the number of trainees to the number of expected consultant jobs at the end of their training and what happened was that doctors were recruited to what was called run-through training so they were set on a career specialty course very early on in their career after they'd done their house jobs The main aim of that was to try and better match the numbers of doctors that we were training to the number of available consultant or GP posts and the length of time it took to train a specialist In actual fact, the average length of specialty training is still somewhere between eight and nine years so it's not that much shorter We're now moving some of you may be aware of the greenaway review which was published a few months ago which is looking at the shape of medical postgraduate training recognising the new world that we're all inhabiting A lot of what we're talking about today is set in the context of an ageing population more people having more than one health condition multi morbidities and a question Have we got the medical workforce that's best able to deal with that new population of patients? The conclusion probably is that we don't at the moment know a bit from where we've gone in terms of subspecialisation to producing more generalist doctors who are better able to cope with the whole patient and deal with more of their multi morbidities So we're in a kind of transition period because we're beginning to explore how we might implement greenaway across the UK and this would offer benefits not just to the NHS but in terms of providing a more flexible medical workforce but I think also benefits to the trainee doctors in that they would be recruited to broad based training schemes with groups of conditions like women and children's health The training will bridge primary and secondary care and there'll be more opportunities for them to opt out of one particular course of training if they think that that's not going to suit them So more flexibility for the NHS in terms of the workforce that we're producing more flexibility for the doctor they're not locked into a specialist route So we're at a stage where we have a UK steering group which so happens is chaired by somebody from Scottish Government A number of stakeholder events have been held across the UK so we're going to gather the views from those and then make a decision about how greenaway should be implemented in Scotland Now that's not going to happen overnight but the aim is a better more flexible, more generalist trained medical workforce I think that the message earlier from Bruce Crawford there was to recognise that performance within A&E has significantly improved over the years rather than deteriorated I mean, I'm less concerned I would say whether we or whether we don't hit this 95 figure because only a number of years ago it was 84 and that was hailed as a fantastic performance so statistics can tell you different things and we can use them in different ways and so on As a member of this audit committee I'm more concerned to hear from you that there are systems and processes in play to continually improve and to address the issues that arise from time to time and I'm encouraged about a lot of the things that I've heard during this meeting and previous previous meetings Particularly from the Tayside representatives that came the other week and again Bruce Crawford raised their issue they talked about signposting and trying to deal with patients as they arrive and sending them to the appropriate care route for them and I would sincerely hope that those kinds of lessons are being learned and shared throughout the rest of the board so I mean, are you able to say with any kind of confidence that will we get to this 95 and do we have to? Because I think that Mr Gray you said that some patients might not be appropriate for them to be pulled out of the system within four hours but you mentioned that in your presentation and I was quite struck by that so as health professionals we're politicians and we'll react to the 95 figure when you release it or whether you don't but could we hear from you just what your view as health professionals about that kind of aspect are we going in the right direction are we improving the service and will we reach the 95 and do you think we really have to achieve that? First of all I should say that health professionals with me today are Dr Keil and Professor Leitch I have other professionals from other disciplines too so I will ask them to comment my view and this is my view Mr Coffey is that when we say that we're going to do something we should make a determined effort to do so a target is set to be challenging it's not set just to be simple I mean I could just say well I think we should do 90% and then we'd be doing it all the time and that doesn't seem to me to be realistic I think in terms of public confidence when we say we should do something when we say we're going to do something we should I spoke to the lead A&E consultant in Borders General Hospital about whether he thought that was 95% the right number we could argue whether 94 or 96 is the right number but certainly in his view 95% gave a sufficency of what I would call impetus to the system to ensure that people were not left in A&E beyond the point at which it was clinically appropriate for them to be there he was equally clear that there are in a number of complex and difficult cases no benefits whatsoever and some disadvantages to taking patients out of A&E if that's the best place for them to receive care so having 100% target would be plain wrong because it would disadvantage patients it would mean that they got less good outcomes as I say one could argue up and down on a few percentage points but for my part we have committed as a national health service to working towards this target I think that it's important for public confidence that we do so but I do think that we should never at any point allow a target to cut across a safe clinical judgement but perhaps Dr Keil and Professor Leitch would want to add to that I agree with your question we need to constantly be asking is it worth driving that extra percentage but as Mr Gray has said it's clear from emergency medicine consultants that they think that the 4-hour target is a good one with that 5% flexibility for those that need to be in A&E for longer within my professional life going back many decades I can remember patients languishing in A&E for well over 12 hours they were there the next day so the amount of improvement that has been achieved by NHS Scotland staff is quite incredible if you look back in just a few years so I think the performance is great it's clear that the consultants the medical profession want the target to remain they don't like all of the targets that we've got but they like this one so I think we need to stick with it I agree we should strive for the 95% but I also take the premise of your question that 94%, 93%, 96% is that really making a huge amount of difference I think the use of a target to make simplistic judgments of the quality of services is not the right thing to do I think it's one element and one lever that we have in order to improve the quality of the service that we deliver to the population so I think we should keep it but I think underneath that the fact that we treat and discharge or admit half of the patients within two hours probably says something about the quality of the service we're delivering equally as the 95% tells us so I think it's part of a package of things around quality improvement methods around scrutiny around the delivery of that quality service that we should make judgment for and just to emphasise Mr Gray's point that at no time should the target be used in any way to undermine patient safety and I'm confident that that doesn't happen You'll never hear any of that or at committee taking a view like that but I feel weird to meet targets I'm pretty sure but there was a good example raised during the discussion with my previous colleagues and it was this issue about people being discharged at weekends then a queue building up in admissions in Mondays and Tuesdays and it seemed quite an obvious area to win and to help push the target up if that's what we all collectively want to achieve Is that widespread across the NHS where people are discharged more slowly at the weekend and then we get a lot of people arriving in Mondays and Tuesdays because they've waited all weekend to present so what can we do about something like that and how can we smooth that across all the boards and be up even further I think you make a very good point there I think I addressed that in part when I was talking earlier about the flow project because one of the things that sat at the heart of the flow project is how we can better balance out the other half of the work which is the elective work which is the planned work that comes in and which has got certainly from our experience a waiting towards that work being done and started at the beginning of the week Mondays and Tuesdays are very popular operating days for surgeons Thursdays and Fridays are perhaps less popular so one of the things which is at the heart of the seven day project is considering how we can utilise the entire resource of the NHS over the seven days as I said earlier smoothing out those peaks and troughs So you're right that discharging at weekends and discharging earlier in the day is a help to that flow It sounds simple just discharge the patient These patients are often frair elderly they often need adjustments at home they often don't come with ready made carers that just happen to be in their family and they require extensive drugs on discharge and the bag of drugs is only one element of that discharge process very clear instruction they require education about what's going to happen to those drugs now It's not always as simplistic as a process as perhaps we're led to believe that just push them out at 3 o'clock on a Saturday and all will be well So the seven day project is about making that better in conjunction with social care colleagues in conjunction with those who do put in the little doors in your shower so you can be at home with the door in your shower and you can build healthy people having surgery who we need to get out on a Saturday and a Sunday My last point is just to pick up on that debate about morbidity at weekends it was absolutely fascinating the exchange between Ken Macintosh and yourself Professor Leitchman, if you look at any statistics a bit in him, you can pick a story can't you? You could pick when are people more likely to be killed in a car accident and there's probably a time that it's more likely and there's probably a day that it's more likely but the question, as I understood it from you is that a question of some kind of neglect in the system or lack of resource or lack of management or something that doesn't happen at that particular day or is it just a characteristic of the population and general behaviour as it presents itself and I took it from your explanation that it's probably the latter because we're uncertain about the reality and the facts of that I mean, human beings people are people we don't always act in a uniform and consistent way and our behaviours will be variable so until and unless you can have some kind of data some kind of analysis, some kind of research that can pinpoint any particular causes then we're no further forward but in my criticising my own position I'm not remotely complacent about safety in Scotland's hospitals and I don't think anybody could ever accuse me so if anybody has been focused on the safety of our hospital care then I would suggest it's me in our leadership of the safety programme so I do care about the data and I do care about making it better and if I see things in the data or in narrative or in story that suggests something different I will be the first to try and implement change that would be perfect you haven't seen that yet correct Colin Keane Can I just go back a question or two to Dr Keane was the information that we're giving about the difficulties and people going through training and all the rest of it is there some information of tracking of where the destinations and who the training actually end up you know you hear all sorts of stories about people going through training who have set their mind on having a future in research for instance and stuff like that and how can you actually encourage the popular subjects to be followed through after training as against what you're really looking for to see it locally Well NHS education for Scotland under beginning to try and do that kind of tracking it hasn't been commonly done but it's now becoming more feasible I think in terms of A and E if we stick to people training in emergency medicine it's clear from the trainee fill rates the number of people being filled that this is a specialty that is in difficulty and I think that's multifactorial people in that specialty work extremely hard consultants and trainees and it could be that younger doctors are not so keen in the sort of lifestyle choices that have to be made to follow through an emergency medicine career they're working under enormous pressure at the front door of the hospital and you can't do that for a career that's going to last 30, 40 years I think we have to increasingly recognise as people go through their career as consultants that's what I'm talking about now that we have to acknowledge they can't be doing the sharpen front door stuff as they did when they were in their 20s, early 30s but it's difficult to adjust a system to accommodate that to take that into account so I think that young doctors in entering training are looking at issues such as lifestyle choice we know for example that some of them are choosing to emigrate to Australia or New Zealand not in vast numbers but we know that there are significant numbers and that again is about lifestyle it's not all about the climate it's about the way work patterns are in those countries so we're paying attention to all of that and we know in terms of retaining people to work in Scotland if you train in Scotland and you have a good training experience and whatever specialty it is then you're more likely to want to train to stay in the country so I think that role models in terms of the medical workforce are incredibly important to junior doctors if you end up working with a consultant who's enthusiastic about how their career has panned out is enthusiastic about the work they're doing then you're much more likely to be enthusiastic to stick with it if you unfortunately end up with some who are a bit more burned out or cynical then you're going to pick up on that and maybe not stick with the training so I think it's incredibly important and part of the CMO's role to make sure that the medical leadership is there to demonstrate to trainees that what they're doing is worthwhile it's a rewarding career and they should stick with it It's not unusual to Scotland it would be everywhere Indeed in emergency medicine the whole of the UK it's difficult to fill speciality Okay, thank you Okay, thank you very much and thank you to all our witnesses for their contribution it's clearly a very challenging area and there's no doubt in the commitment of our witnesses to see improvement so thank you very much I'm going to have a suspended meeting and we'll get our next set of witnesses in Thank you Reconvening meeting Item 3 on the agenda 6 and 22 report the 2013-14 audit of the Scottish Government consolidated accounts and I will invite evidence from the Auditor General on the audit of the Scottish Government consolidated accounts common agricultural policies Mark Taylor, the Assistant Director and Gemma Dimond, the Senior Manager of Audit Scotland if I can invite the Auditor General to make a contribution Thank you, convener I'm bringing you reports of the committee today on an issue arising from the audit of the Scottish Government consolidated accounts The report is about the common agricultural policy futures programme the CAP futures programme The futures programme is a five-year business change process which is currently directed to cost £137.3 million to deliver CAP reform in Scotland There are two main elements to the programme firstly to redesign working practices to focus on the customer and generate efficiencies and secondly to develop a new IT system to deliver the new CAP and improved ways of working This is a very significant programme for the Government Each year the Government distributes approximately £700 million through the CAP to Scottish farmers and to rural businesses and any failure to meet the new EC regulations could lead to significant costs for the Scottish Government The purpose of my report is to highlight the significant risk the programme is carrying The Government recognises this risk in the governance statement included in its 2013-14 accounts and my report is based on a high level review of progress in the first 18 months of the programme We are undertaking more detailed work and will report on this as the programme reaches its critical milestones over the months ahead Overall my report highlights that the programme has so far proved significantly more complex and more challenging than the Government anticipated The programme team has recognised this They have recognised a significant risk to the programme which arrives from the potential late delivery of milestones and also from increasing costs The business case for the programme was approved in December 2012 At that stage detailed information on the EC requirements wasn't known The programme has experienced continuing difficulty since then and total forecast costs have increased from £88 million to £137 million as the team has had more detail on the EC requirements and the IT needed to deliver this It's important to note that the programme is working to fix regulatory timescales and within the next three months the team will have to make critical decisions about whether the new IT system will be ready to manage the payments application process or whether they need to implement contingency plans In a bid to meet these timescales the programme team has had to scale back some of the original scope of the business case This includes changing the plans for the IT components and map registered land and also removing some of the wider business change elements that were originally included Management acknowledged these difficulties and are taking action The last independent assurance review in May 2014 concluded that significant changes to the programme were required immediately if successful delivery was to be achieved and as a result the programme board established a corrective action plan There's evidence of progress against that action plan but it's too early to see if these actions will increase the confidence in successful delivery of the programmes I've concluded that the future programme will carry significant risk right up until implementation and beyond The purpose of my report is to bring this to the Parliament's attention together with the on-going risks of achieving successful delivery of the programme and overall value for money As always, convener, my colleagues and I are happy to answer questions from the committee Thank you I was actually very surprised at how interesting Scottish Government's consolidated accounts into the common agricultural policy was I actually thought it was just a paper but the more I read the more concerned I became So I just have very brief questions if I may convener The first one is from paragraph 5 It states that Scottish Government has estimated that it could incur costs of up to 50 million a year and failed to deliver cap reform 50 million is a lot of money Is that Well, it's obviously a possibility and where would it come from My second question relates to paragraph 8 to 10 You've already said that the original business case was 88 million and it's now 137 million I would like to ask who the IT partner is and the next question goes on to exhibit 2 on page 7 and that is really will the farmers be paid the risks arising from this December 2015 reputational risk as customers previously been paid in December and it may affect this timetable and for June 2016 ECN deadline for making payments a regulatory risk with financial penalties arising from non-compliance So it's the 50 million that the Government is incurring which seems to me some sort of fine for not achieving deadlines Secondly, the huge increase from 88 to 137 million for the IT system Thirdly, the uncertainty to farmers will they be paid I have no doubt but will they be paid when they expect to be paid and they need that money to purchase grain for the following year and will there be future fines for the Government June 2016 this financial penalties So those are my three questions Thank you Mr Scanlon First of all, I'm delighted that you're finding the consolidated accounts interesting we think they're fascinating and it's part of our mission to convince all of you that that's the case I'll start on the value for money questions, the costs and bring colleagues in and we'll then perhaps move on to the IT system and the impact on farmers and rural businesses First of all, we think the financial risks, the value for money risk fall into three categories The first is that the cost of the system is clearly already significantly higher than was originally envisaged from the original estimate of £88 million to the current estimate of £137 million and the possibility that that may increase further Linked to that, we know already that the scope of the system and the programme will be more limited than originally planned with some important elements being taken out of the current phase and if they are to be developed the need for that to be part of a future business plan and future costs associated with that The third cost, as you've suggested relates to the possibility and it is only a possibility at this stage that if the programme can't deliver the EC requirements there may be financial consequences or penalties for the Scottish Government directly and I'll ask Mark at that point to pick up the question of the £50 million if I may I'll pick that up before I bring Mark in because it's clearly key At the moment it's fair to say that the Government is absolutely focused on making sure that payments can be made to farmers this is a vital part of Scotland's economy for parts of Scotland it's a huge part of the economy overall and there's a lot of attention going into that there is still a risk there but I think it's the focus of efforts the other risk though is that those payments are made without all of the EC requirements in terms of controls being met and the possibility there may be fines coming from that but we can perhaps expand on that as the answer develops I'll pick up the £50 million question Yes, thank you Auditor General the question of the £50 million that's the Scottish Government's estimate as to what might be at stake from the system that the European Commission has essentially to police the way in which the Scottish Government makes sure it pays the right amounts to the right people at the right time and the European Commission and the long-standing members might have a memory of this issue coming before the committee previously but the European Commission has the power effectively to withhold funding where it feels that the control system the checks that are required to make sure that the right people are getting the right amount of money aren't as robust as it feels they should be and there are certain requirements that are laid down and specified for how those systems should work what the Government recognises is if it develops a system to deliver the new cap programme and some of those checks aren't built into the system those perhaps aren't operated as robustly as they might be and the European Commission ultimately comes along and identifies that the £50 million is their assessment of what might be at stake in those circumstances and that's one of the numbers that is factored into the business case for this the Government's clear that it needs to have improved systems to make sure that the system that it operates is as robust as it can be to mitigate, to prevent the risk of that £50 million being at stake later I think we think there's a lot of work still to do Government recognises that to get such robust systems in and that's why £50 million is stated in the report and very much features in the Scottish Government's own business case for the need for the system Thank you, it's actually more concerning at that, just leave it there but the fact that the system is more limited and that its investment will not provide all the functionality originally planned so we don't have the new system we wanted we've got a bit of an updated system that we've already got to try and make it work by the way, you haven't mentioned who the IT provider is Gemma, we'll pick up that part of the question The second one, I mentioned the £50 million and I also mentioned the risks to farmers and the risk to the Government for not making the deadline The £50 million is allocated for not being able to achieve deadlines at the moment Could there be an additional penalty you said that the EC could withhold funding if the systems are still not in place Could it be more than £50 million? I think the short answer to that one is that yes, it could be more than £50 million I think to be clear on the £50 million that has been budgeted for and allocated I think that this is an amount that in assessing the business case that if the systems weren't ultimately as robust as they would need to be then that might be the amount that would be payable and would need to be budgeted and allocated in the future That £50 million would come out of the agricultural budget so it would come from elsewhere within the budget So to be clear on that the Scottish Government would have to find the money from somewhere and manage it across its budget as a whole They'd have to find it from within the budget Or the budget as a whole The budget as a whole The Scottish Government has contracted with CGI as its IT delivery partner previously known as Logica Previously known as who? Logica I'll just leave it there Thank you, Bruce Crawford First of all, check that we're dealing with like for like figures the £88 million and £137 million Are those like for like figures? Not exactly but mainly because of reductions that have been made to the scope of the project When the business case was originally put together in 2012 the overall estimated cost at that stage was £88 million That's been revised upwards over the period since then and is now the current estimated cost is £137.3 million is forecast to buy a more limited IT system than the one that was planned at the start of the process I get that bit It was more to do with whether VAT was applicable to both figures We asked Gemma to talk you through that to make sure that we don't mislead you on it There are some factors about the treatment of VAT and contingency I want to make sure that we're dealing with like for like There are difficulties in comparing business case figures and the spend to date because of how some factors have been implied including inflation The original business case the cost was estimated at £88 million and that was without any VAT or inflation that was not included in the original business case The most recent business case which was in March 2014 estimated the cost at £111 million and that is directly comparable to £88 million If you then add VAT and inflation to the £111 million that converts £111 million to £127.8 million and we can then take so that's the full cost essentially in the revised business case and when you can compare that £127.8 million to the £137.3 million which is the current forecast for spend Let's take this back to the very beginning then £8 million If you apply VAT and inflation what would that figure give us? That wasn't calculated in the original business case because of the we couldn't compare the two we've essentially taken the steps to be able to take you from what was the £88 million to what is the current spend to date but we haven't converted that original cost in the business case of the Scottish Government didn't apply inflation factors at that time of VAT Can you give us those figures because really we need to be able to compare one with the other to get the real level of uplift is it possible to obtain that? We can give you our estimate of it and provide it separately Gemma's point is that it wasn't included in the original business case I understand that and it probably should have been but to enable this committee to be able to look at the real starting figure and the real potentially end figure would be useful for the £50 million fine which is obviously a concern if it was to become a reality would you consider it to be an advantage that the Government have removed some elements that were originally part of the functionality and are prepared to spend a bit more money to get to where they need to be even though the estimates are higher than they should have been in the beginning is that an advantage to avoid being in a situation to pay £50 million fine to pay £50 million fine We certainly welcome the fact that the Government recognises the significant risks that are associated with delivering this programme which is key to the rural economy farmers and rural businesses and the fact that as problems have become apparent a lot of effort has gone into forecasting what the impact of that might be in terms of the Government's budget and the effects on farmers and rural businesses and looking at what the options are for responding to that so there are two elements to that response one is contingency plans for dealing with applications from farmers when they come in if the system is not able to do it at that stage and the second is looking at how the system itself can be reduced in scale to make it more possible to deliver what's required that planning is a good thing having said that I think we would all rather not be in the position where it's needed given the importance of this investment for such a major programme with a big impact on large parts of the economy I'm very grateful to the report because it does highlight the risks quite clearly but I think Scotland's farmers as Mary's identified how important they are will realise the complexity of CAP and the scale of challenge to get this right and what do I mean by that? In May June we became aware I'm not sure of the exact date of the way of what the agricultural policy regime would look like and it takes into account a myriad of aspects and I just wrote down a few last night that I know of modulation between pillar 1 and 2 convergence uplift payments measures to deal with slipper farmers regionalisation specific provisions for islands specific provisions for new entrants measures around greening and ecological focus voluntary couple support for the beef sector and voluntary couple support for the sheep sector a hugely complicated system that's being asked to design and cope with all of these elements is that at some of the reasons why in the circumstances the Government have had a challenge on their hands to make sure they have an IT system that's fit for purpose given how late in the day they knew about what the actual elements would be no doubt that the complexity of the new cap scheme and the late point at which some of the details became available to governments across Europe has made this more complex one of the reasons why I thought it was right to report to this committee at this stage is because some of the underlying factors in the delivery of the programme are consistent with what we've reported in the past about large IT developments in the public sector so we have seen continuing problems in the right capacity and capability of staff able to do this we've seen some problems with the programme management from the outset of the business case and the development and we've seen changing governance arrangements which have not made it easier to deliver something which was never going to be a straightforward project both of those things are true it is complex and we think there were shortcomings in the management of the project which are common to a number of other public sector IT developments so here's my last point in that wider European perspective I'm aware that the European Court of Auditors opinion, because I just did a bit of a Google search on it produced a report on the 8th of March and that Court of Auditors at that time said they expressed they had doubts about whether the measures proposed in the cap could be implemented effectively without imposing excessive administrative burden on managing agencies and farmers they also said as far as the cap reform was concerned the limited specification additional administration burdens introduced will have an effect on the costs of their forum which the commission estimates are likely to represent an increase of 15 per cent overall member states consider that the percentage increase in costs may be even bigger so this isn't just a Scottish problem according to the European Court of Auditors it's a European problem would you share that view? I've said that it's clear that this is a complex scheme to administer and some members here will be aware that we will be required to do more as auditors to verify the payments being made in Scotland so the administrative costs and complexity are higher, there's no question about that the question about whether that investment is justified for the benefits of the scheme is one that I'm not equipped to answer at the moment Marks our expert on European agriculture funding and liaises with auditors across the other UK Governments about progress that's being made and the challenges being seen and they might want to amplify what I've just said about that I think it's fair to say that the challenges that the Scottish Government are facing at the most basic level to put in a new system against the tight timetable, fix regularity fix deadlines and the complexity that you've outlined are shared across Europe, of course they are and different organisations are at different stages of responding to that I think historically within the UK there's been issues with other paying agencies across the UK other parts of the UK who have had difficulties in implementing their systems and those are well documented in the rest of the UK and I think that each of the component parts of the UK are facing those sort of problems at the moment I think that as the Auditor General said we are keen to highlight the risk of the particular project to the committee but also to against that context to highlight that in the way in which the programme has been managed we don't underestimate the challenge that's here there are some common themes coming about some of the difficulties that the Scottish Government themselves have recognised and to be clear we understand that they're aiming to address these but there's underlying issues as the Auditor General said about capability and capacity it's a very difficult plan to put together but I think there's been some frustration internally that within the Government that it's taken them the period it has to get more specific, more detailed plans in place and I think they recognise those issues and we think they're aiming to do something about it but there is that underlying risk there and that's what we're keen to share with the committee today Yeah, thanks convener it was obvious from the 2005 cap reform the huge difficulties that experienced in England in terms of bringing in the new system there and obviously that caused them huge problems I hope that we don't get to that level of difficulty here Okay, thank you Colin Beattie Thank you convener I'll just explore some of the cost issues and so on here The original business case was in December 2012 Comments made several times about the delays in clarification of the regulations Would it be reasonable to say that those clarifications were what drove the review in March 2014 of the business case and was that done reasonably timelessly? I think it was part of the reason why they revised the business case Essentially the programme team were further through the project and had a few more known information so they had more known and more information on costs and more detail They'd also been working with their IT delivery partner on what the scope of the IT would look like and what the actual requirements of the IT were and obviously that is linked to what the requirements the EC requirements were so it was essentially part of the reason why it was revised at that time The programme team keep the business case as a live document so there are minor revisions quite regularly but this was a major update that they did to the business case in March 2014 Almost the entire increase in the overall business case is caused by IT and one can be very cynical about IT costs because they all seem to work out a multiple of what you expect but would it be reasonable to say that the virtual doubling of the IT costs relates directly to quite simply the new regulations coming in and the realisation of the complexity of that and the additional costs coming from that I don't think it is fair to say that but again I will ask Gemma to amplify for you her experience of working on this closely I think again it is part of the issue I think that when the programme team started working with the IT delivery partner there was a long time spent looking at what the requirements would be for the IT the work that we have done so far is only a high level of view as your general mentioned we are going to continue to look at this and to look at what have been the most significant problems with the programme encountered to date but what we can say is that I think that it is part of the problem in looking at the EC requirements but that they also were looking internally at what else they wanted to achieve just about the IT it was also to deliver business change and changing the working practices so that involved working internally to be clear about actually what did that mean in practice and what would that look like but having said that the increase the cost of the business case is almost entirely IT related and not to the other part of the project would that be, well it is correct because that's what you say here I think that the point that we're trying to convey is that that doesn't only relate to the EC requirements so for example one of the things the Government wanted to achieve was having mobile technology that field officers could use to go out and verifying land parcels and the features of the businesses that were attracting grant that was intended to generate efficiencies in the Government's running costs as well as satisfying what the EC required so the EC requirements were part of it but so were the requirements for ways of working more generally in the Government's administration of this and both of those affected the IT costs and those upgrades were in the original business case and the original IT cost that's right and they're not in the £137 million forecast cost at this stage they're things which have come out of the scope to try and contain costs and increase the probability of delivering a successful system on time so again coming back the changes to the EC regulations must have been quite startling because you've got an IT budget that's doubled and you've taken a lot of key elements out of it in order to keep it moving forward so there must have been quite horrific changes there's a number of things going on in there the first is that the EC the scheme itself is different so the basis on which money is paid is a different scheme from the previous cap scheme the EC's requirements in terms of controls and checks and validation to ensure that money is properly paid are more rigorous than they have been in the past and the Government was hoping to get efficiencies in ways of working from investing in the new programme through things like mobile technology and allowing landowners to update the records of land parcels online themselves all three of those were things the EC requirements are only one part of that they are important but they're not all of the shift in the IT costs When did the IT partner come on board? The IT delivery partner was appointed in March 2013 so there weren't part of the original programme that was agreed in December 2012 did they participate in that? The business case that was approved in December 2012 had an options appraisal in it about how they would contract with an external contractor to deliver the IT system the option that was chosen within that business case was to appoint an IT delivery partner a subsequent to that approval they went through the tender process to appoint the external contractor in March 2013 So when the external contractor was in March 2013 they must have at that point accepted the costings, the budget that was available The original business case had a forecast cost of £8 million the tender documentation that went out for the IT delivery partner had a forecast wasn't a fixed contract that was signed because we would need to go through a scoping phase with the IT delivery partner as to what was going to be delivered the forecast cost for the delivery partner was £20 million at that stage Presumably we now have a contract in place that's got a figure around it The contract is still the same contract that was signed at that time it's not a fixed price contract It's not a fixed price contract The pricing is determined through discussion with a supplier So each component part is priced and that price is agreed by the Government and the IT supplier as part of the contract It's not just an open-ended contract The Scottish Government and the supplier are using quite an incremental approach to delivering the IT which means that they are not doing it in big stages but they're trying little bits of a time and costing it along with that process So it's quite a different way of approaching it than the Government has been used to in the past But you're comfortable the controls around it are adequate and robust Within the terms of the contract the controls are adequate and robust but as is the case with many large IT developments it's practically impossible to let a contract which is fixed price at the outset and costs increase as the work develops The scope becomes clearer and the programme management improves So there is a risk cost could increase further as we've said in our report The way it's being managed at this stage we have no cause to be concerned about but there are significant risk to cost as well as delivery as we've said in this report Okay, thank you Will the coffee then come back to us? That sounds very much to me like a kind of requirement specification issue again rather than a specific IT issue It's not about failing computers or software It's akin to being asked to build a house before you get the drawings and then as you get the drawings you discover you're being asked to build a set of lats That's quite a common issue throughout the whole history of IT projects that I was working in over a course of my professional career and it's what happens when your customer in this case the European Commission is not clear about what they require at the outset So it's hardly a surprise that that will change during the course of that and as you begin to develop what the specifications and requirements are clearly the cost is going to go up but that's not down to the IT partner or the Scottish Government it's down to the requirements set out I presume by the Commission Looking over the course when the system is up and running and working, will that last us for a period of time? Is there a life span attached to that? Is it for as long as the cap reforms are in place until Europe changes them again? I mean how long will the system stand as in good stead once it has settled down? If I can just take your first point for Mr Coffey, I think it is true that some of the increasing cost is due to the way in which the ECE requirements have emerged over time It's also true, as I say in my report there are some weaknesses in the way in which the programme has been managed and governed that have contributed to those costs so both are true and I don't want to suggest it's one or the other. In terms of the lifetime of the programme the new cap scheme is a five-year scheme it is quite possible that parts of the system that's being developed can be used for future iterations and for example one of the ways in which the Government is currently looking to contain costs and improve the likelihood of successful delivery of elements of the old land mapping system in the new system so some of this programme as a whole should be possible to reuse for future iterations of cap assuming it continues in something like the current form some of it may need to change and I don't think we're in a position to say that at this stage Do you want to add to that, Mark? Just really to reaffirm that last point we are clear that there's more audit work to be done here and to understand the progress of the project governance arrangements and controls that are in place when we intend to do that work in relation to how long is it for the business case set out a period which Gemma will be able to help us for in a second and that's what the spend is based on, is getting benefit over that period of time Gemma, you're able to... The futures programme is a five-year programme so it started in 2012-13 and was really to deliver both the business change and the IT system to help deliver that business change and to deliver EC requirements over that five-year period currently 18 months into that five-year programme Potentially managing over the five years if it's £700 million a year I think you mentioned the Auditor General you're talking about £3.5 billion programme and of course to this system why we want to get it right on the budget as we can possibly do but it's managing that kind of size of budget On current figures the amount of money going into Scotland's rural economy to farmers and small rural businesses will be about £3.5 billion over the period The cost of this is the cost of being able to deliver that but also to deliver efficiencies and better customer service and to avoid the risk of regulatory penalties if it goes wrong so it's an important investment direct financial cost but there's wider costs and benefits associated with it Last question Cymru, is everybody now totally clear at this point what the requirements are I mean software engineers will tell you tell us what you want and then we'll build it for you Is everyone clear now about what the requirements are and are they basically getting on with the job? I think everybody is now clear what the EC requirements are and there has been a very focused piece of work by government on what should be delivered to maximise the chances of successful delivery over the next 18 months that's not to say there may not be more changes in the way in which it's done we all know this is the case Gemma Mark, I'm not sure if you want to add to that general answer Mark As you would understand Mr Coffey a long-term project which has a number of releases a number of different parts to it and the initial focus is on those early releases the initial focus is on getting an application system that allows farmers and other rural businesses to apply for the grant and I think those requirements are now well understood and works progressing on that the next challenge is then to get the back end processing in place which allows those data to be processed I think there's a fair amount of understanding but the detail of that is still to be worked through and I don't think that is linked entirely to the European regulations there's a bit of work still to be done around that the last more general point I'd make if I could is that one of the issues we've come across is the challenges that the Government have and having the right commercial and contract management skills we've talked about how the Government works with an IT provider and one of the things they've recognised is they've not been doing that as well as they might have been in terms of getting that clarity and getting that relationship right with the IT provider again as we go on to do more detailed work that'll be one of our main areas of focus to really understand how that's working Thank you I have to say I read the report it's depressing enough to read about the money that this scheme is now costing and no payments have yet been made but it's the depressing familiarity of it all can I just check the report that we looked at on this committee about managing IT that was actually produced in 2012 before this contract was awarded and signed am I right do you think that anybody in charge if I don't know if you've actually asked them has anybody in charge of this project actually read your report? I'm going to ask Gemma to come in in a moment but it's important to set the context that we're reporting this project to you now because of the risks associated with it and because it arises from the Government's 2013-14 accounts we are also in the process of doing a significant piece of work which is revisiting that 2012 report to look at the way the recommendations have been picked up and conveniently Gemma is leading that piece of work as well the business case for this project does make reference to our reports and some of the recommendations in that I think that the themes that were raised in that initial report certainly ones around capacity and capability are not easy ones to be fixed that quickly our report published in the August of 2012 the business case came was approved in the December and some of these the weaknesses that we had reported in that report were certainly ones that would not be able to be fixed that quickly but that would need a continuing focus to make an improvement I noticed that you suggest that there's increasingly little contingency what contingency plans does the Government have are they going to if this programme is not in place and doesn't work go back to manual payments what's going to happen the Government are looking at a range of contingency options and I would say that they are actively looking at contingency options at the moment putting a lot of work into that to minimise that risk to the payments they are looking at a range of options so that includes manual processing it includes using existing systems for a little bit longer it includes accelerating new build and maybe holding back others so prioritising what needs to be done and it's also looking at standalone existing IT applications that they might be able to use there's an app for this is there can I just check you're talking about they haven't filled in some of the posts is that still the case there's been a constant difficulty for the team in filling the posts they have now filled most of the certainly senior level posts they had vacant which was around programme management and contract management they have now filled those posts but it has been difficult for the team and it really relates back to the theme that we raised in our 2012 report on managing IT contracts on that capacity and capability across the wider Scottish Government for managing IT projects The programme's only been running for over a year how many programme directors has it had? The programme has had one consistent senior responsible officer over that period and the IT director or the chief technology officer has that changed? That has changed, the chief technology officer has quite a new post that has come in Can I just check as well who's the minister in charge of this programme? Cabinet secretary The rural affairs is overall responsible Has he reported on this either to Parliament or to the rural affairs committee Are we the first committee to be aware of this or are any of the subject committees or is Parliament aware of the fact that there's a crisis going on in this programme? I don't think I can answer for any reporting that may have happened to other committees of this Parliament I thought that it was an appropriate time to report to this committee given your specific responsibilities for overseeing the use of public money and the value for money that's achieved for that Are you aware of any process of accountability of this programme so far? Has it been debated or discussed on the committee at all? I'm not aware of any but that doesn't mean that it hasn't happened For the other general to reflect on the committee business in this Parliament Thank you very much Thank you It was just a very small point on that from memory when we were taking evidence on the managing IC contracts I seem to remember being given an assurance that what had happened the huge increase in cost but I seem to remember being given an assurance that IT contracts over a certain amount would actually be managed by a team within the Government that it wouldn't just be left to public sector organisations small and large or professional I can't remember who that is and I hope that my memory is right but I do remember being given an assurance that we wouldn't see the likes of RAWs and the other problems we had Procurator Fiscal's Office etc and that a team within the Government would oversee all those contracts So two years later A, am I right in my memory and B, what happened to that team in respect to this contract? I'm going to caveat my remarks by saying that we are looking at the wider follow-up of those recommendations at the moment and we're not at the position to report them yet Having said that the Information Systems Investment Board was a new part of the governance arrangements envisaged for large IT contracts and the business case for the programme was approved by that board in December 2012 We hope that that has improved some aspects of governance, it's clear to us that some problems with governance remain This committee will be hearing from me over the next few months with problems with other large IT investments and it seems to me there's something really systematic here which we and the Government need to get to grips with not only because there are often significant and anticipated costs associated with them and benefits not being achieved but because the wider question of the way in which public services respond to the continuing financial pressures we know are going to be in the system for the foreseeable future must depend on making better and more creative use of ITs and collectively we're not very good at that so I don't want to pre-empt the question about how well those recommendations have been responded to other than to say there clearly is still a systemic problem that hasn't been resolved Do you want to add to that, Gemma, based on the work that you're doing so far or would you rather hold your piece until we're ready to report? I think I'd probably rather hold it off I think we've seen elements of what the Government said they were going to do after our 2012 report to come in place, for example, the Information Systems Investment Board being made a significant part of the governance process for IT projects within the Scottish Government but as we follow up in the round our recommendations we can see what improvements that has brought to the process I do find it quite disappointing that we were assured that this crack team from Government would ensure that the errors of the past wouldn't likely happen in future and we have a report here today of a programme which will carry and I quote your paper will carry significant risk right up until implementation and beyond and I did take that assurance that this new Government team overseeing contracts would be quite rigid and I put my trust in this so on the record I'm disappointed to see this and obviously more has to be done Cair Bruce Crawford I'll lead out till we move to item 6 given how much we have earned in time Cair, well, can I thank the Honour and her colleagues for their contribution and move on to the next item on the agenda which is item 4, major capital projects Members have had circulated the report on the major capital projects Any comments or questions? Mary? Just to retain my consistency over the three years I've been on this committee the two that I would like to mention the new prison for Highland £40 million was allocated in 2009 and we've got £62 million allocated in 2014 and no current project status in preparation so five years later an increase of £43 million and we're still in preparation and my second one convener which I've raised I think on all of these occasions is about the dualling of the A9 and the two projects were the A9 concreted already and I'm very pleased to see that that's on-going but the other most significant part of the dualling that was previously mentioned was Lunkarty to Burnham and that's disappeared so I would like an update on what's happened to the previous commitment of Lunkarty to Burnham and register my just to acknowledge that I'm very pleased that the concreted already which is about three four miles is going ahead but Lunkarty to Burnham was about 10 to 12 miles from memory and I think that is the most congested part of the road so We can clarify that with the Scottish Government but there could be a number of issues one might be that the amount doesn't meet the minimum requirement for reporting it's not yet reached the outline business case but we can clarify that I can just say the Lunkarty to Burnham is three times the length of concreted already and that's why I mentioned it because it will be on average two to three times the cost We can clarify that with the Scottish Government Ken Macintosh We just to clarify a couple of issues this is the new format adopted I think although it's my understanding right that we're going to have a session next time six months time with the Government officers or with either the ministers or with the officials responsible as well It's not date June, March 2015 Right It was just to find out clearly the document itself is useful I'm still slightly concerned about how much it flags up change and delays and slippage and so on I mean we can see some examples here for example just to clarify there was one Inverness college Inverness college is there sorry bank pages 31 32 because the way this is about the Government is supposed to flag up in the annex the ones in which there is change so for example Inverness campus is that a Scottish enterprise or a Highland Islands enterprise building that appears to have slipped from May 2013 to November 2014 Inverness campus isn't the same as Inverness college which is a separate entry Yes, Highlands Enterprise has an input there so it is separate When there are clearly a number of dates that have slipped and so on which do emerge towards the back I'm not 100% convinced though of the way it's laid out that everything is immediately transparent One for example that I would have question about is the New Southern General, the South Classical Hospitals project Either page 26 on page 26 and it's also on another page it's also on page 5 page 26 so again it goes back to my worry about what we're saying about these this document seems to give you at least some indication of what's happened over the last six months so that's useful what it doesn't do is really give you a starting point and an end point The Southern General Hospital excuse me but this is obviously etched in my mind because it was of quite political significance to me when it was first drawn up and a contract and a decision was made to house the new hospital at the southern it was estimated that at around about 260 260 million roughly this is off the top of my head within about and it was the decision was taken on grounds of cost because it was seen as to be something in the region of 10 or 11 million pounds cheaper than another location within about a year or so the cost rose to 300 million the estimate rose to about 360 million in 2007 what happened was that this was going to be procured by there's something going down the line of producing a public sector comparative figure for an NPD programme and that's where they came up with this figure of 840 million 841 million because from 268 to 360 to 841 which is a comparator figure which I assumed was including the cost of NPD and then it goes back to being a capital traditional capital procurement and yet the cost stays at 841 and I have to be honest with you I've never quite understood how we made those jumps I mean it's three times the original and these costs were all in the public domain hugely debated debated intensely in Parliament and in the local area where I live I mean this is the sort of thing I'd like further information on about how did we get to this point you know I'm not sure whether it's a question for the Government or the Auditor General but it's the sort of issue that I'd like further information on this particular document doesn't really satisfy you know it sort of offers an assurance that I don't find I don't find assuring I was wondering how for example how would I be able to pursue my concern about this particular project just as one example I think there's a number of different things there may well be particular issues that you want to follow through as an ordinary member of the Scottish Parliament as far as the committee's concerned or Audit Scotland or the Auditor General I think to answer the specific points you raise I think that would be for the Scottish Government you've asked a specific question about how the costs went from an original figure then included an amount for NPD calculations and then reverted back to capital and the figure stayed the same I think the only way we can get that clarified is to write to the accountable officer to ask for clarification on that so we can certainly do that I think the wider issues which you may want to pursue yourself can then be raised when we have an oral report in March 2015 and we will have a chance to come back to some of that then so I think there are issues that you might want to pursue we will ask the specific questions on that of the accountable officer OK Advice to us what we've been asked to do here is look at how this is laid out and whether or not we are capable of interpreting this to show enough differences to flag up for other people effectively and the Government has been on a journey I became a member of it trying to produce improvement after improvement on how this was laid out I frankly don't know where else it can go now in terms of producing that improvement in more detail without becoming more burden than we already required because the information from that what I can see on the new South Glasgow hospital tells you when construction was started tells you when it went to market now it tells you that a full business case is available and that could be sought out by any member of this committee to look at to see what the variances were so in general terms I'm happy with the direction that this is going in terms of a layout and I could crawl through this and look at every single project that's appropriate to my area in my constituency but that's not my job to do this here I think what we can also do is whether the document is an improvement in reporting terms and whether it helps us to identify issues because well except what Bruce Crawford says it's not necessarily a job to go through everything with a fine tooth comb at the same time where there are obvious areas of concern that it is appropriate for the audit committee to identify and address that so I think we can also seek comments before the moment The other material which goes with this is the programme that's delivered by the Scottish Futures Trust or the Hub projects they're produced online again the difficulty with those information is that what it doesn't draw attention to is slippage date increase cost and that's the fundamental problem whether or not these are desirable or otherwise it's just whether or not they're being managed properly and I've still got a problem with these the difficulty with information coming to this committee it implies in some way that we are either approving or auditing it or giving it some sort of official premature which I just don't think we are in this case and I just want to raise my concerns that the lack of information the lack of scrutiny that we are able to apply I know the lack of scrutiny that Auditor General is able to apply to these projects just to round off we're talking about billions billions of pounds of public money I think it's just what we put on record that what we are not doing in these considerations such as today is giving any imprimatur whether or not we think that the figures are acceptable that the progress is acceptable it's a report which is trying to lay out in a more helpful way progress that's been made there are a number of parliamentary routes available to members of other committees to also pursue some of this information but where we identify a problem then we can legitimately ask questions of the opportunity to do that in the next oral update in March but it would be wrong to suggest that every time we get this report it's up to us to go through each individual item and if nothing is said then somehow it suggests approval or otherwise from this committee that's not the purpose of this I would suggest that with the clarification that we're going to see from the noble officer that we note the report otherwise, okay? Agreed? Right, thank you for that next item on the agenda is moving into private session