 Yr ysgolwyd angen, a ddigidolwch i gael ddiogelu 27 ym mhwyaf yng Nghymru yn 2018. Felly, ddigidolwch i gael ddiogelu yn gweithio chi'n ddigidol iawn i gael eu bod yn cyfathorol. Felly, ddigidolwch i gael yr hynny fel David Torrance, ac bob Dorris yn gennym i gael David. The first item on our agenda is an evidence session with NHS Dumfries and Galloway as part of our programme of one-off evidence sessions with each of the territorial boards. The focus of these sessions is on performance against local delivery plans. I welcome to the committee Philip Jones, the chairman, GFAS chief executive, Julie White, chief operating officer and chief officer of the integration joint board and Dr Kenneth Donaldson, medical director. Can I start by asking about issues of financial sustainability? There is a statement in Parliament this afternoon on last week's report by Audit Scotland. I am sure that all health boards will have been reading that avidly over the last few days. Clearly, each board has its own challenges to face and its own issues to address. Can I ask you to start us off what progress the board is making to ensure that savings are achieved on a recurring and sustainable basis? First, I thank the committee for its advice. I am sure that it is pleased to answer all of your questions and will take it either in turn or collectively. I thought that the Audit Scotland report was very fair in its assessment of the challenges and from a Dumfriesen and Galloway perspective. We have been a board that has always broken even. It has been tough over the last five or six years in particular, but we have always achieved our revenue and capital targets. This year is far and away the toughest it has ever been. We still believe that we will achieve a break-even position at your end, but, as you have seen from some of our submissions, we are using quite a significant amount of non-recurrent windfall savings to achieve that break-even position. The challenge for us, exactly, as I set out in the Audit Scotland report, is to try and create that three- to five-year vision of what a sustainable health and social care system looks like with the resources that we have to play with. Again, from a parochial point of view in Dumfriesen and Galloway, the biggest single cost improvement that we can make is to address our recruitment challenges. We are paying quite a considerable premium at the moment for local staff, local medical staff in particular, but also some nurse agency costs have been creeping up. If we can address those recruitment challenges and hopefully we can hear from Ken and others of some of the work that we are doing to do that today, that makes a significant financial contribution to us in the region of £5 million to £7 million of potential savings. We are in a difficult position, as you will have heard from colleagues across Scotland. We believe that we will break-even this year, but the prize is for us to set out to you a sustainable model. At the moment, we do not have that over the next three to five years. Thank you very much. One of the things that is striking about the Audit Scotland report is across the country how far boards have been uncertain of where they were going to find savings for a given financial year and the way in which that has increased from the beginning of the financial year two years ago to the beginning of the last financial year to the beginning of this financial year. Is that the case for yourselves? When you talk about finding £6 million or £7 million of savings, does that include a significant number of savings that you have not yet been able to identify? We do have unidentified savings at the moment that we are going to need to pull back by year end just to break-even. We are looking in the region and the figure changes on a week-by-week basis, as you can imagine, in an organisation of £350 million, £360 million. At the moment, we are looking at an unidentified savings gap for this year of around £3 million. That is within the range that we think is achievable for us to pull back. What is much more concerning to me is that if I look at our underlying financial position and strip out all those non-recurrent savings, then I am probably looking at closer to a gap of £9 million to £11 million as my challenge for next year, that is a big target after five or six years of difficult cost savings. It might be useful to hear from Julie White, as board chief operating officer and chief officer of the IGB, just some of the on-going plans and potential plans for next year at this point. In terms of our long-term plans, we have introduced something called our business transformation programme in the health and social care partnership. That is a programme that is a three to five-year programme for reducing expenditure on health and social care services and producing the required level of savings. It is about addressing the challenges that are highlighted in the Audit Scotland report on transforming the way in which we deliver health and social care services. There are a number of specific projects contained within our business transformation programme that are looking at the redesign of health and social care services within our localities. They are also looking at the future shape of how we deliver social care services with much more of a focus on prevention. We are looking at a range of, within the health and social care partnership, a range of specific savings in relation to our social work budgets. We also have given each of our services, each of our directorates, an efficiency target, so a 2 per cent efficiency target that we expect each of our service areas to deliver within the next year. Plans are being developed in partnership with our clinical and professional teams to deliver those targets. As Geoff said, we have significant challenges in terms of our recruitment and recruitment challenges are not just within health within Dumfries and Galloway. Those recruitment challenges exist right across health and social care. We find that our provider partners within the local authority in terms of our care at home providers and our care home providers are also struggling to recruit staff. That remains a significant challenge right across the whole health and social care partnership. From my perspective, as board chief exec, if we faced with a sort of one to one and a half per cent cost reduction target, I can be fairly relaxed with that. Our systems tend to innovate at about that rate and will generate their own cost efficiencies of around about that one per cent one and a half. The difficulty over the last two or three years is that that target's been two and a half plus and that's the point at which we've certainly locally had to rely on some non-recurrent advantages. We're doing a lot of property rationalisation, for example, at the moment, and being able to take advantage of our move to the new hospital to divest ourselves of some very expensive older facilities. Those sort of things can only be done once and that's our concern at the moment, is that viability. If the future is around 2 per cent to 2 and a half per cent cost reduction, that is historically more than health systems have generated in savings. Thank you very much. Sandra White. Thank you very much. Good morning, everyone. Having read through the report, one of the areas that I'm quite interested in is the rising drugs costs, and you mentioned that in your paper as well. Basically, that's still a challenge. I know that you have some efficiency savings there from 9 per cent expenditure compared to 13 per cent expenditure in the 2016-17 report. What steps are the board taking to help to reduce that? I'll bring Ken Dawson in to answer specifically on some areas of realistic medicine that we're addressing. To make a general point on drugs, I think that over the last five or six years, the increase in acute drug costs in particular has been a real problem for us. Scottish Government has been aware of that and has been very helpful in establishing the new drugs fund, which has enabled us to deal with some of that up to now. However, if that pace of increase in acute drugs, particularly very high-cost end-of-life drugs for example, continues and we don't see industry adapting its pricing model for the sort of financial pressures we are, it is again quite difficult to see how we can generate continually enough money to be able to meet those drug inflation. That's been probably a change over the last five or six years, whereas previously we'd been worried about GP prescribing and the growth there. It's been acute prescribing over the last four or five or six years that has really been beyond our predictions, but I'll bring Ken Dawson in. Realistic medicine, as you know, is a national agenda. That's one aspect for looking at how we can reduce some of that drug spending, especially the really high-cost drugs, in that these drugs are available and often they are fantastic and can be life-enhancing. However, as Geoff mentioned, they can be used at the end of life and maybe they aren't adding quality. A key part of that is a kind of cultural change in the medical community as well as in the general public around what is the quality we're getting from this medication. Is it going to extend your life? Is it going to give you enough time that is of value? I think that the part of the realistic medicine agenda that are on shared decision making is something that really is striving to address and that we're having meaningful conversations with patients and their families, not just around drugs, but around all forms of treatment that are available. In Dumfries and Galloway, we have been working on realistic medicine for several years now. We have a team that is dedicated to that led by one of our associate medical directors. There are a number of areas of improvement looking at that shared decision making and getting quality feedback from patients about how they feel the consultations have gone, leading into smaller bits of work to change behaviours in the medical community and what public expectations are around that. There are a number of areas of work at the lower end of medications that are not quite so expensive but are not necessarily so ensuring that if we are using medications, we are using the ones that are most cost-effective and are, I think, the best value. Again, there's a bit around public engagement and public education around what it should be asking for and what we should be delivering. Thank you. It's obviously not just in Dumfries and Galloway, it's a national situation. You mentioned expectations. Excuse me. Is that one of the biggest problems, expectations, or could it be that, if we're looking at it nationally, and some particular drugs, the newspapers will create a story out of it and lead on to people's expectations? You had mentioned Mr Ace in regard to the rising costs. Should we be doing something about perhaps a profit that drug companies are making? Maybe you don't want to answer that question, but you did say that the last five years have risen. Therefore, it seems an unfair advantage that the drug companies have mixed with the media and the expectations of the general public as they are being told. How do we tackle that? That is a profoundly difficult question and clearly not just a Scottish question. That is affecting the whole of western medicine. Essentially, in what products the drug companies choose to produce at what price is very challenging to us. SMC, the Scottish Medicines Consortium that was established around about 2000-2001, was pretty groundbreaking in its time and did create a challenge back to industry about the value that we would put on to new products. We used quite sophisticated health economic evaluations looking at quality, the quality-adjusted life years and the price that we would pay for a new product. I think that that did create a different relationship with industry. I understand that we have relatively recently made exceptions to that process for end-of-life drugs for some cancer products. I fully understand why that is ethically morally seen as the right way to go. We must make sure that we do not lose that challenge back to industry that enables us to procure at a price that does not cause huge pressure elsewhere in the system. It is clearly very easy for us as health systems to spend money. It is enormously difficult at the moment to fund that increase by taking money elsewhere. Thank you very much for that. Do we have evidence from any other countries where the drugs that are being put forward just now are cheaper to buy? There are. It has been some while since I have sat on the Scottish Medicines Consortium, so I might be slightly out of date. There are different approaches across the world. New Zealand used to be cited as a country that had negligible relationship with industry and bought at spot price, so essentially constantly seeking the lowest market price. The difficulty with that is that New Zealand has no pharmaceutical industry, so it does not benefit in the same way from the search projects, from rapid access to drug trials that patients in Scotland do. There needs to be a partnership with industry. That is valuable to the citizens of Scotland, but it must not come at the price of us not being able to challenge back on product price and challenge back effectively. Do you think that Brexit will make it worse to get the drugs at a reasonable price or perhaps even a higher price or not get them at all? It is possible. From a health service point of view, there are two distinct Brexit issues. There is the short term disruption of a no deal in which we are very concerned about the availability of a number of products, longer term potentially because we are moving out of the European Medicines Agency. There may be some requirements to purchase from global markets. That will almost inevitably be more expensive. We can see examples of products that are a factor of three or four times more expensive than we are currently procuring. Brexit is without wishing to be flippant. It is hard to find an area that Brexit does not give us great cause for concern at the moment and drugs are certainly one of those. Two brief supplementaries, Bob Doris and then Dave Stewart. I am conscious that the pricing of medicines is a reserve issue done on a pan-UK basis, but reimbursement is devolved and SMC and there are special measures being developed on going and active this committee. We will be looking at it in relation to orphan and ultra orphan medicines for rare conditions and the like. There is a lot of emerging good working partnership in relation to outcomes-based reimbursement for orphan and ultra orphan medicines. Drug companies short horror make huge claims about the benefits of certain medicines and procedures, but you do not actually know in real time how that is going to deliver until you administer that medication. Scotland is great at retaining data and following patients through the kind number right through real opportunities there to actually make drugs affordable, because if they do, what drug companies say they will do, you get delivery and you can save money. It is Dumfries and Galloway health board actively involved in discussions with SMC and the Scottish Government to look at outcomes-based reimbursement, not just for orphan and ultra orphan conditions but more widely. Represented around the SMC table and the new drugs committee table, so we are in the midst of that. As you say, it is a fascinating area. There has been some concern for a considerable number of years about the fullness of clinical trial data that is presented publicly and which trials are published and which trials are not published. Clearly what you are suggesting based on outcomes gets around that completely and gives us genuine real patient data and that will be invaluable. I have taken a big interest over the past six months on the withdrawal from your atom, which is always notified in article 50 by the Prime Minister. The great concern that I have is that we import our radio isotopes from Europe, which provides about 60 to 80 per cent of the world's source. You will know, as medical experts, that the great worry is about a half life, so it cannot be stored very easily. Is this something that the board has looked at specifically? The board will be taking a paper to public board in either December or in its January performance committee on the risks of Brexit to NHS Dumfries and Galloway. We are sharing that paper with other mainland boards to try and make sure that we have a co-ordinated risk assessment that we have all got basically the same understanding of where the risks are. For us, as with all territorial boards, there is a real concern over a no deal scenario and our instruction to plan for potentially six to twelve weeks of disruption to our supply chains. That affects the uratum products, that also affects our basic clinical products and indeed how we feed and maintain patients in hospital, so we are profoundly concerned about the prospect of a no deal. I hesitated to comment on any prospective deal until I could see the information on it. Thank you, convener. Good morning, everybody. I need to declare first an interest as a former employee of NHS Dumfries and Galloway, and I know everybody across the table this morning. I am interested in hearing about the new DGRI, the planning, the process, the settling in. It has been almost a year now. There are challenges with running concurrent sites at Mountain Hall as well as the new build, but it is a really good news story that I think we should be sharing that we have a brand new hospital in Dumfries for Dumfries and Galloway, but there were financial challenges and pressures associated with the new hospital, so I would like to hear a wee bit about that. Just to start, the new hospital was eight to 10 years in the planning, the development and the delivery, and the planning partnership with Highwood Health was a really successful model for us in Dumfries and Galloway, and the way in which we engaged, particularly with our staffing groups, as we came to the later stages of the hospital having been complete, being prepared and made ready for us to take occupancy, we had the HR team that did a hugely significant piece of work in familiarisation trips with meetings and discussions with small groups, so people could understand where they were moving from and what they were moving to, because obviously you leave one hospital one day and over the weekend you then start the operation in a new one, and there was a hugely successful management of change process put in, so much so that our HR team actually won a national award from the healthcare professional body for HR team of the year for the work that they've done on that particular work, because the most important thing that we recognised was patient safety, and patient safety had to be guaranteed through the understanding of the staff who moved as to where they were going, what they were doing, because it was a wholly different configuration in the new hospital from the old one, so when people used to walk out of theatre and turn left, they wasn't left anymore, so simple things were made more practical and start ready by the background work. I'll let Geoff speak and Julie on some of the detailed aspects of the new hospital. I'll hand over to Julie, who was a project lead throughout the new build process and delivered at the time NHS Scotland's largest capital project to the day on time and to the pound on budget. We were immensely proud of what we achieved. It was far and away the biggest change project that we've ever undertaken. We've experienced building new facilities previously in Stranraer and our new mental health unit at Dumfries, but nothing on this scale of a complete move. To physically move over 170 patients over the weekend in December was the most terrified I've ever been in work and the most proud afterwards of everyone who'd achieved it. It was an absolute iconic moment for us. I'll hand over to Julie, who is the single individual most responsible for its success. In terms of the move to the new hospital, as Geoff said, it was the single largest change that any of us had been involved in in terms of the senior management team within NHS Dumfries and Galloway and, indeed, across the health and social care partnership. We had been planning for the move for some eight years, as Geoff said, submitting a business case to the Scottish Government in April 2013 and then successfully moving into the new hospital in December 2017. The timeframe from submission of an outlined business case to moving into the new hospital is one that's probably not been matched anywhere else in the country. I appreciate Geoff's kind comments, but that work was undertaken very much as a team. We had an incredibly strong team working on the development of the new hospital, and much of the success was absolutely down to our clinicians and our clinical teams, our service teams and their engagement with us in developing the plans for the new hospital. Within the new hospital itself, Emma is asking about some of the changes that have taken place. There have been a whole host of changes in relation to the way in which we deliver services within the acute hospital, so we've developed something called a combined critical care unit, which brings together what you've traditionally got in intensive care units, surgical high dependency and medical high dependency, and that involved real changes for staff in terms of the way in which they worked and how they worked together as a team, and that team really came together and did a lot of preparatory work before they moved to the new hospital. One of the single biggest changes we have in the new hospital is something called our new emergency care centre. In the emergency care centre houses our A&E department, our GP out-of-hours service and our combined assessment unit. Our combined assessment unit is the unit where our emergency admissions access is for rapid assessment and diagnosis of their condition with the expectation that we'll turn around as many of those patients as possible back into the community. We've found that in the first six to nine months of operation within the new hospital, our combined assessment unit has turned around 41 per cent of our GP admissions straight back home within about a 12-hour period, with the remaining individuals going on into our downstream wards. Again, that level of change with a combined assessment unit and emergency care centre required a huge amount of planning and a huge amount of investment of time of our clinical teams in looking at how we were going to work differently to better meet the needs of our population. This was about us having an assessment unit, not an admissions unit, so it's about people coming to the hospital for a rapid assessment and diagnosis and wherever possible, as then supporting them to go back home. We also, within the new hospital, we say that we are the most digitally enabled hospital in Scotland. It was one of the key factors in developing our new hospital. Our new hospital has Wi-Fi throughout the new hospital. The Wi-Fi also supports the telephone system and it supports our telemetry system, which supports our sickest patients within the hospital. We've also introduced electronic patient records, an electronic prescribing system and an electronic ordering system for diagnostic tests. We have also introduced a range of technology, a roaming desktop in our wards, which means that our clinicians within the single patient bedrooms can access the patient information within the patient bedroom within the roaming desktops. We're very proud of the technology that we have within the new hospital. One of the key features of the new hospital, which I'm sure the committee will be aware of, is that we moved to a hospital that was 100 per cent single rooms. That, in the very early days of our planning, required myself and members of the team to have quite significant engagement with our communities around the fact that we were moving to 100 per cent single rooms because there was some concern and some anxiety about the fact that some of our population was concerned about loneliness and isolation within the single rooms. I'm delighted to say that when we had our patient experience week earlier on in the year and we got some feedback from our patients in terms of the use of the single rooms, we had feedback that they really loved the environment, that they felt that it made seeing their family easier. We have an open visiting policy within the new hospital, so family members and friends can attend the hospital at any time, day or night. They felt that hospital wards were a camera as a result of the single rooms and they loved the fact that they had a TV in each of the patient bedrooms. We also did get some feedback though that it wasn't ideal for some of our older patients who maybe didn't have family members or friends close by. We've done a number of things within each of the wards. We've got a socialisation space where, when patients are ready, they can access that. We've also used volunteers within the hospital. We're really delighted with the number of volunteers that we have in Dumfries and Galloway. We've got over 200 volunteers and we've got ward-based volunteers who support people who are maybe isolated and don't have visitors. As I said, there's been lots of developments within the new hospital, lots of advantages, but we do have an on-going challenge around recruitment. Jeff mentioned it earlier. It is one of our really significant challenges. We'll move on to address recruitment in a moment. I wonder if you can perhaps simply say something around the financial pressures and the consequences of operating old and new hospitals side by side. Yes, we'd always intended to leave some ambulatory services at our old site, so we've left renal dialysis, some therapies and ophthalmology at that old site to make them out in a whole treatment centre. Those services do not need to be on an acute hospital site, so we wanted to create a more setting more suitable for ambulatory care for people to walk up and be treated in that. That's moved well. We budgeted for the double running costs of that. What we hadn't sufficiently appreciated was the scale of additional staffing required in our new hospital. We'd budgeted for an increase of around 80 staff and we recruited to almost all of those posts before moving, but we've since recognised that staffing is itself not optimum and we've moved to recruit further staff in addition to that this year. It's within the £3 million of unidentified savings that I've quoted earlier, so it's not putting any additional pressures. As I said, we would still anticipate a break-even position this year, but it has been noticeable. The sheer footprint of the hospital, the new ways of working around the front door and the single rooms issues are probably testing some of the traditional staffing models that we used to set our baseline staffing. I think that's an issue that our nurse director, Eddie Docherty, has raised nationally that we do need to look at tools for single room nursing to make sure that the advice for future developments is bang up to date. You've covered already the challenges of dual sites or double sites. How do the staff then engage if you're needing dialysis and intensive care, for instance, but you're running regular dialysis at Mountain Hall? We've got dialysis centres across the region, Stranraer, Carcubrie and so on. Do those staff manage to float? Do they agree to do that? Is that part of the challenges? Is looking at models of working that the staff are actually accepting? If I may, convener, I'll defer to our nephrologist alongside me. As a renal physician, I guess I should answer that one. There was a lot of planning around the move towards having the split site working. One way of looking at it, as you've mentioned, is that we've got a satellite unit in Stranraer, Carcubrie and, in some ways, the Mountain Hall centre is a satellite as well. Although it does act as a main base, we recognise there would be staffing issues around that because we need to have rotas for nursing staff to be in the acute hospital to deal with your ICU patients and patients on the renal ward, and we need medical staff as well. There will be increases in both numbers, particularly when we recruit an extra renal consultant of the staff numbers to make that rota workable. Like a lot of aspects of moving into a new hospital, there's been some teething around just how that works, but I'm pleased to say that the team are in a good place now. They've got to the point where it is a very different way of working than they used to. When you mentioned how the patient is requiring dialysis, if they're in the Mountain Hall centre, when that was the main hospital, getting an extra, getting another specialist was all very straightforward. Now that involves sometimes having to move to the new hospital, but we've worked processes around that, and I think that it's working really well now. In your submission, you refer to banking surplus with the Scottish Government £7 million, and then that being released this year and last year in order to meet those. How does that mechanism work? Is it a capital mechanism only, or does it apply to revenue funding as well? We'd been doing for a number of years, convener, is essentially brokering money with the Scottish Government in anticipation of needing it for the move. We had been building up our previous year's cost reduction plans to create that buffer, knowing that when we move into the hospital our cost base increases as we planned and budgeted, and I would like to probably put on record our appreciation to the Scottish Government in managing that cash flow with us. It's been very helpful. It would be very difficult to undertake a capital development of this scale without that flexibility between years, so that's worked well for us. It's essentially into your flexibility, so you have capital allocations for year A, which you don't fully draw down on the understanding that you'll be able to draw them down in year C. That's right, and we've been using revenue in the same way. We've been banking revenue with the Scottish Government that we have now drawn down to allow us to deal with the higher cost base associated with the new hospital. That's been a good example, I think, of Scottish Government working flexibly with the board. That's very helpful. Thank you very much. Moving on to address some of the staffing issues, David Stewart. Thank you, convener, and thank the panel for their contributions so far. Many of your contributions have involved recruitment and staffing, so I want to drill down into some of those issues. Having a quick glance earlier at the ISD Scotland consultant vacancy rates, if I've understood them correctly, your board has the highest consultant vacancy rates in mainland Scotland, and if you look at figures for over six months, you are the highest in Scotland, including the island boards. Clearly, it's understandable, I think, of members for some of these reasons, but could you talk a bit more about your initiatives that you've got to try to address that extremely high vacancy rates? If I can start, convener, and then again, I'd like to bring in Ken Dawlson, who's leading on this work. I think that the recruitment difficulties that we are now facing are of a scale that is our biggest single challenge. I think that money keeps me awake at night, but recruitment is the one that is having the most direct impact on our staffing teams and their ability to deliver the sort of quality care that they want. I think that this is the most urgent issue for the board to fix. I take personal responsibility for this. I think we were late seeing the scale of the difficulties. We were as a board. I arrived in Dumfries and Galloway in a previous role in 1999. We were a board that had no difficulties in recruiting. We had long lists of applicants for consultants, jobs, our GPs did not experience difficulties. I think that we were slow to realise that this was not a temporary blip in recruitment, but that this was a structural change that was going on. Clearly, you can see it across particularly rural Wales, Englanders and Scotland. We were slow to get off the blocks on that. I take responsibility for that, but I think that we've now got a raft of initiatives going forward. I'll bring Dr Donson in to discuss those, if that's okay. We're in a different place and have been for a few years now. It used to be that it's not simply about advertising, whether it's on show or in the BMJ or other journals. There's a different requirement for us to find permanent staff. I think that what I've certainly found over the last few years, and I'll explain some of the reasons why I've found this out, but it's clearly less people out there to be applying for jobs, but Dumfries and Galloway sits a little under the radar. A lot of people suddenly don't actually know where we are or, more importantly, what we have to offer professionally in the way of this lovely new hospital and what we can offer there, but also in the way of quality of life and the surrounding area and how lovely it is a place to live. However, some of the initiatives that we've engaged in trying to get staff, one is that we've employed it with a headhunting agency, who our initial tender was just for five posts, which I'm pleased to say they have filled for us, two consultants, two special doctors and a GP. Working with them, I and a few others went to Sweden on a recruitment drive, which was an interesting and a bit of a learning process, but there were many doctors in Sweden who were looking to come to the UK, so we had an opportunity to go out with that company and promote them for East and Galloway as the place to come. We have been involved in international recruitment as well, mainly through a more national approach, but that's been really successful for us, particularly in radiology, which has been an area that we've been really struggling with for some time, but we now have a number of filled posts, and that's been a real change for us. Over a year ago, myself and a team went down to London to the BMG careers fair, which is where I first realised that a lot of doctors, particularly in England, didn't really know where Dumfries and Galloway was or what it had to offer. That was a useful exercise, and we went down again just over two weeks ago. It was more in NHS Scotland on standard at this year. As part of that, we've been throwing out our prospectus, so we've developed this prospectus. I'm happy to pass that around, but that's just something that we can hand out at any careers fair or anything like that that we're at. We have been fairly active in using social media, particularly in Facebook, but other forms of Twitter, et cetera. I certainly see an awful lot on Facebook. I'm coming from an NHS Dumfries account, advertising roles in a quite pictorially attractive way, but other ways we have—one of our local GPs has a account called DG Connect, where it's based on recruitment, but it's more about promoting Dumfries and Galloway. If you look at this prospectus, you'll see that there's lots of pictures in the front of members of staff holding a card saying who they are. Thank you. He puts out a picture that sadly has used myself—maybe not the most pictorially best one to use—but it says medical director, but it says a little bit about me, why I'm in Dumfries and Galloway and what I like about it and what opportunities, etc. We've been trying to get our brand out there, as it were. The final bit is in the recognition that Jeff was saying that we, as a board, need to really sit up and take notices that we have agreed, as a management team, to recruit a team locally who will be about recruitment, a bit more about digital media marketing and how we brand Dumfries and Galloway and how we get out there and have a much different approach. Kind of what I'm describing, but maybe a more consolidated, co-ordinated fashion, and not just around medics, but around nursing, AHSs, etc., which we have problems in recruitment. In the longer term, there's things like ScotGem, which we're a part of, and that will hopefully bring us in particular to GPs, but people who wish to come to the region. Even more in the longer term, we're promoting healthcare professions in schools, so going out to schools and talking to you, so do you want to be a nurse, do you want to be a doctor, and explaining a little bit about what that can tell, what we have to offer. Ultimately, I'm keen that we bring fairly young school students into the hospital, into GP practice, and show them what there is there. It's not just about being a doctor or nurse, there's working laboratories, there's working in other areas of healthcare as well. I think that you touched on, and you'd be aware of the scheme with St Andrew's University in Dundee and UHI, from my passion, Highlands and Islands. That's the very point that they were making, that the way you retain staff is by having a lot of local staff, and the best way of doing that is by having some connection at school level as well. It's obviously obvious that universities that train medical students, such as Glasgow, Edinburgh and so on, are able to retain them. If you look at the league table, you find that that is in fact the case. If I go to one of your neighbours, I know that you can't speak for NHS Borders, they have a very low vacancy rate. Is there any compare and contrast that you could usefully inform the committee about, as far as that's concerned? I'm guessing a bit, and maybe being a bit unfair, but I guess that the right Borders does share a lot of similarities between Scali, but it's one slight difference, as it is generally just a little bit closer to Edinburgh and Lothian, and they do share an awful lot of services, whereas we sit a little more indistinct in our own. We have links with Glasgow, obviously, but there's something about geography there. I think that it just means that we're not really commutable from Glasgow unless you live out in sort of the Lockerby end, etc. Even that is still a bit of a journey, whereas I think a lot in the Borders isn't much easier to commute to Edinburgh. As I say, I'm guessing, I don't know if that's for a fact. I think it's important to realise that we're asking families to move quite often into Dumfries and Galloway, and that comes with the professional role for the spouse of the individual that we're recruiting. In a small economy such as Dumfries and Galloway, that's particularly challenging. We link up with the council to look at joint opportunities, so if they're recruiting a teacher with a partner who's a nurse, for example, we can make those links. However, if somebody has a profession outside the public sector, the private sector in Dumfries and Galloway is relatively small and its ability to absorb those sort of newcomers is commensurately limited. I think that that may be a slight difference between us and Borders with its Edinburgh hinterland, but, as Ken says, we're surmising. We speak frequently with colleagues at NHS Borders about what they are doing with recruitment and retention. We are confident that they have not hit on secrets that we haven't, but we are certainly keen to learn from whoever is currently being successful in this field. The knock-on effect of having a high consultancy rate that I mentioned earlier is that you're going to have high agency costs. Obviously, I noticed from the figures that the figures have shocked quite a lot up in the last 12 months, which I know must give you some more sleepless nights, Ms Dress. I can totally understand that. Most of the most agency costs are into medical locum. Traditionally, we've used very little nurse agency, which is slightly different from the pattern across Scotland. You'll see some hotspots. It's really only been the last 12 months and last winter in particular that we started to see gaps that we couldn't fill in nursing staff. I think that, at Ken's point, we must make sure that when we reinvigorate our approach to recruitment and become much, much broader based in terms of our use of social media, that we don't just focus on medics, that we get ahead of the next set of problems around nurses and AHPs, but at the moment you're absolutely right that our cost driver is around medics. You mentioned my sleepless nights, which I brought up myself. We can manage this cost more or less. That's not what worries me. It's the impact on our teams that are working with non-permanent staff members who are much less engaged in service redesign, are much less willing to take on or able to take on clinical leadership roles. The pressure that that puts on the residual teams, that's the bit that we, I think, are impacted on by locum staff more than the actual financial hit, great as it is. Many boards that have appeared before have said the solution to any problems they have on most of them are financial recruitment, involve two main things, which is, first of all, what you can do with regionalisation, and secondly, what you can do in partnership with national government. You've obviously done a lot of very interesting initiatives with recruitment fairs and the prospectus about the region, which seems very sensible. Is there any other initiatives, then, that the national government should be doing, which will help your particular issues? If I can take regionalisation first, the west of Scotland regional work is quite interesting from our perspective, and we have had some successes where we're looking very closely at aligning our vascular network that is currently a partnership between ourselves and Carlisle. We're looking very closely at realigning that with west of Scotland, which will give us certain advantages in terms of sustainability. We've got a very good partnership with Aeshawn Aran around urology services, particularly in the west of the region. Some of those regional initiatives are working for us. Again, I would probably need to caveat in realism just the distance and travel time between, say, Glasgow and Dumfries and Galloway. It makes joint appointments inherently inefficient. We will lose a fraction of capacity simply by the M74 travel time, but there are things that we can make progress on in specific areas. Nationally, I think that we would welcome continued focus on the attractiveness of living in rural Scotland, and rural Scotland not simply meaning the highlands and islands. I think that that would be very welcome. My final question was touched on Brexit, and I'm loath to raise that issue at my last question, but you mentioned that you're having a discussion with Brexit and that will be on your risk register. In terms of staffing, how significant are employees of the other 27 nations within Dumfries and Galloway? Looking beyond that for the two-two visas, how significant are employees from outwith the EU as far as your employment status is concerned? We are about, in conjunction with other mainland boards, to formally survey staff to achieve the precise numbers, and we'll work with those individuals on an individual basis. We're lucky we're a relatively small system. We know that EU staff are absolutely critical to our continued safe working. They have been a hugely important part of the success of Dumfries and Galloway, both in primary care, dentistry and in our acute service. They're an integral part of our service, and it is deeply uncomfortable to go out to survey those individuals and to talk to them about their needs. Jeff, you mentioned the distance and time travelled, and I know that that's an issue for people just even going within the health board from Stranraer to Dumfries. Digital infrastructure and the roads infrastructure is an issue—A75, 76 and 77. We're always bleating on about how we need to invest, so how does the digital infrastructure and the roads infrastructure affect attitudes towards recruitment? Is that a challenge where we really need the Government to pay attention and contribute significantly, maybe more, about digital and roads infrastructure? That would be welcome. You will see if you get a chance to look at our brochure, we've tried to create a map demonstrating travel times to Glasgow, Edinburgh and Newcastle, Manchester, to show that Dumfries and Galloway is not remote in the sense that people from England might think it is, but clearly anything that can be done to minimise travel times to airports, to minimise delays in accessing fast broadband increases our offer to individuals, particularly with individuals with young families. Things like digital connectivity are as important to them as the train commutes to Edinburgh, so it is part of that offer that we are trying to create for people to come and live with their families in Dumfries and Galloway and for that offer to be attractive. We need all of those advantages lined up, so help would be greatly appreciated. That would include railway as well as the roads. As a team who have suffered from a train cancellation this morning and a very stressful drive-up, that would be most appreciated. I would like to turn the discussion to child and adolescent mental health. You have your performance in Dumfries and Galloway is higher than the national average, for which you are to be commended. However, it is still worryingly difficult, I think, it is fair to say, and represents a declining picture. I just wonder if you could explain to the committee what the primary barriers are to having children seen within the 18 weeks prescribed. I will take this one. You are absolutely right. In terms of our performance in Dumfries and Galloway, I am disappointed to say that our performance has deteriorated. However, we are starting to see some shoots of improvement with our latest performance between April and June, sitting at 77.6 per cent in relation to the target. The challenges that we have had in Dumfries and Galloway have been two fold. They have been again come back to this recruitment issue, difficulty in recruiting to posts, and the same applies within our child and adolescent mental health service. As well as we have had some difficulties in backfilling posts of individuals who are having taken on roles elsewhere, national roles, and that might be challenged around why we are not keeping people locally, but we are really keen to learn from experience elsewhere, so it is getting the balance between how many of our staff members we keep locally and how many we encourage to learn from experience elsewhere. We are also seeing increases in terms of the demand for our child and adolescent mental health service, but we do triage our referrals three times weekly in order to make sure that those children and young people who have got the most urgent need are seeing it as quickly as possible. We have also introduced a number of improvement projects within our child and adolescent mental health service. We have introduced a primary mental health worker in general practice, so this is a mental health professional who works within general practice and receives direct referrals from the GPs of children and young people with mental health problems. We have seen that that has significantly reduced the demand on our tier 3 specialist mental health service, so that pilot has been running for a year. In the practice, which was one of our large practices where we received the direct referrals, we saw that very small numbers of those children and young people had to have onward referral to the specialist mental health service, and indeed all of those children and young people were seen within three weeks. That sets us a target for us within Dumfries and Galloway, and we have, with our new mental health strategy funding, identified the development of those primary mental health workers in general practice as a key priority for us, and we will be extending the number of those across Dumfries and Galloway to improve access to children and young people to mental health services and to reduce their waiting times, but also to provide that early assessment of children and young people where we saw, as I say, those children were seen within three weeks. We also have introduced a mental health worker for urgent referrals within Dumfries and Galloway, so that is somebody who undertakes urgent assessments of children and young people who present to us with mental health problems for example those who are admitted to hospital following an overdose, for example, and that mental health worker, our evidence today shows that we are able to provide those assessments for those children and young people with either the same day or the following working day, so those are some improvement projects that we need to roll out, and we are confident that we will see some improvement in our performance towards that 90 per cent target, but as I say, it is coupled with the challenge of the difficulty that we have in recruiting. We have talked about our medical recruitment, our nursing recruitment is equally challenging, particularly in the specialist areas such as child and adolescent mental health services. Thank you for that very comprehensive response, and you clearly seem to have a handle on what is going on. Can I ask about, specifically, tier 4 referrals, because one of the problems that we have noticed in wider parts of the country is those young people who are referred for inpatient support at tier 4 level, but are turned away effectively because there is insufficient staffing capacity to support them. What is the picture in Dumfrucing Gallery for tier 4? We do have challenges in terms of access to tier 4 services, as is common across Scotland, but we will make sure that the level of support that we can provide to those children and young people through the tier 3 service is delivered in as timely a manner as possible to avoid any further escalation of needs for those children and young people. I do not have data in front of me in terms of the numbers of people that we have had waiting for tier 4, but I can provide that to the committee following the discussion today, but it is very small numbers for Dumfrucing Gallery in terms of the numbers that we are waiting for tier 4. Thank you. Can I move on to the other area? I would like to move the discussion on unless any of my colleagues want to come in on cams. I am just looking at your complaints processes. One of the things that jumped out of the ISD figures for me was the fact that, in terms of your response rate, it is sitting around 55 per cent being seen or responded to within 20 working days, which is quite significantly below the rest of the field. I just wondered if you could explain why that is. Thanks, yes. This has been an issue of contention at our board for some months and possibly even longer than a year. We have been in the process of revamping our complaints process to deliver something that we think will provide a greater degree of satisfaction for complainants. I am very pleased with the way that that work is developing, but what it has done is created a process that is not moving quick enough to hit the target. We have made it clear and the chairman has made it clear to us as executive directors that we cannot simply sacrifice timeliness for this enhanced quality and our preference for meeting physically with complainants so that we have to square the circle of timeliness and quality. We are pushing on that very hard at the moment. You will see those figures improve quite dramatically over the coming months as we make that system slicker, but to go back to my first point, I am pleased that we turned the system upside down to look at what complainants were receiving from us and how satisfied they were with the complaints process and what we could do to make that better. That was a good piece of work. Where we have slipped up is that we have not really taken a lean approach as to how we can do that in a timely enough fashion, but we are under great pressure from our chairman and the other non-execs to turn that around and we will. Thank you for that. I think that one of the reasons behind my question is that when it is clear that rates of response to complaints or complaint systems in general are suboptimal, it gives cause for concern about other areas where complaints are important. I think that this committee concerns itself quite often with the issue of whistleblowing. We exist in a landscape where that is very contemporary at the moment, particularly around the travails of other health boards. Can you explain to us, first of all, whether you think given in the context of the slow response rate that you have for normal public complaints, whether internal complaints are dealt with appropriately and that your systems are robust? Yes, I can give that assurance to the committee. We have a relatively flat management structure in Dumfries and Galloway. I guess that is a symptom of being a relatively small system. It does allow us to quickly address concerns that are raised to understand the pressures that staff are under at various levels in the organisation and to respond accordingly. We have had two whistleblowing incidents in Dumfries and Galloway in my time as chief exec, both dealt with our established process. I would hope to see no more. I think that whistleblowing is a symptom of where your internal controls and checks and assurances are not working appropriately and a symptom of staff frustration with that. I would be deeply disappointed if staff felt that they could not raise concerns appropriately to myself, to Julie, to Ken or to their general management level. That is not the organisation that I have tried to create in my time as chief exec. We pride ourselves on being an open and transparent organisation. I think that the evidence of our walkarounds are individual discussions with managers and their teams. The performance that we have delivered in the light of great pressures over the past few years is a testament to how our staff are working and how they are working with us. Do you follow the SPSO guidelines in relation to complaint handling? Good morning. One of the key strategy objectives that I am insist on is progressing between or shifting resources from acute to community care. I wondered whether you could let us know what progress you are making in that area. In terms of shifting the balance of care and moving resources from one part of the system to the other, I think that it is important to highlight the committee. I am sure that you are all aware of our integration scheme within Dumfries and Galloway being quite unique in the sense that it includes all of acute services, all of community health and social care services, primary care services and mental health services. One of the primary drivers for that was to ensure that we had transparency in terms of the use of resources across the entire health and social care system. As the chief officer of the IJB and the health and social care partnership, I am absolutely clear that I have got that authority and control for the integrated budget across acute services, community health and social care services and mental health services, as well as a range of other services within Dumfries and Galloway. As a result of acute services being delegated to our IJB, I would suggest to the committee that our IJB is extremely aware of the significant demand pressures that are facing acute services across the whole of Scotland. We are aware of that increasing population of older people and the material demand that people living longer with multiple long-term conditions has on our acute service. We talked about the new hospital earlier. When we were modelling the new hospital, the bed modelling for the new hospital, we made some assumptions about the use of acute services within Dumfries and Galloway for us to live within that bed model. Those assumptions included us reducing the demand for acute hospital beds and reducing our length of stay within acute hospital settings. We have projections of an increase in population of older people up until 2035 and we expect that that will continue to provide pressures on our acute service. As an IJB, we have not been focused on taking money out of acute services but rather on spending larger proportions of our total delegated budget on community-based services compared to acute services. That has been our focus about what does that balance look like. Our forecast for this year in terms of the balance of that split is that, at the end of 2018-19, we will spend approximately 49.8 per cent of our budget on hospital services and 50.2 per cent of our budget on community-based services. That is a significant achievement in Dumfries and Galloway, given what you have heard earlier about the development of a brand new district general hospital and all the additional costs that come with that. We have also seen a considerable increase in expenditure on acute services because of the new hospital and the new nurses that Jeff alluded to, increasing domestic staff, etc. However, it is important to say that we look at the totality of that resource that is delegated to us because, on paper, there are some developments that may look like an investment in acute services in Dumfries and Galloway, so we have agreed to the recruitment of an additional palliative care consultant, an additional care of the elderly consultant and a new integrated respiratory team. All those may look on paper like it is an investment in acute services because that is where those budgets sit at the moment in terms of palliative care, care of the elderly, etc., but they are actually investments where, if we are able to recruit to the posts—again, we have difficulties in recruiting to both of those consultant posts that I have mentioned—but, if we do recruit to those posts, those posts are absolutely about providing services within the community. I would highlight to the committee that that split in terms of the expenditure at the moment and our focus being very much on increasing that proportion of our spend in community services compared to acute services. You mentioned earlier on that the prevention agenda is key to your long-term efficiency or projecting long-term efficiency. You might have some examples of where that resource is starting to shift towards that prevention agenda. Specifically in relation to the balance of care work, we have in the last year spent over £1 million on a rapid response service in our biggest locality in Dumfries and Galloway in Nithsdale. That service was introduced to work primarily with GPs around the avoidance of unnecessary admissions to hospital and to support discharge from hospital services. The feedback from our general practices has been very positive in relation to that, in terms of the impact that that rapid response team has had on providing GPs with an alternative to sending someone to an acute hospital. That has been very positive. We are also working very much at the very upstream end. We are working on our focus as a partnership very much on reablement. We have a reablement service, which is called our STAR service, which is focused on providing inputs and support to individuals to bring them to a level of independence that is the maximum level that can be achieved for that individual, given their long-term condition or disability. Last year, we had over 1,000 people in Dumfries and Galloway referred to a reablement service. Over 55 per cent of those individuals were discharged from a reablement service with no care and support. That reablement service gives them rehabilitation activities of daily living support, but it also importantly signposts individuals to other community based activities and support. That might be things like walking groups and craft activities to encourage people to maintain their level of independence at home, but we are really proud of the outcomes of that reablement service, because we are able to demonstrate that, as I say, almost 60 per cent of people who go through that service have been discharged with either no care or a reduction in their care packages. If I could, you did not retain a set-aside. Does that help you to shift resource into this? We do not have a set-aside budget because all our acute services are in the partnership, so the totality of our acute services are within the partnership. I think that it has really helped us in terms of that transparency, in terms of understanding where our expenditure is and what we are achieving in terms of that expenditure. I think that one of the challenges is about how we look at our performance in relation to that expenditure. Having all of our acute services in our partnership gives us the opportunity to have really open discussions around our IJB about our spending acute services and how we want to see that shifting. However, as I say, it is not about taking money out of acute services, it is about increasing the proportion of our spend in community services. In terms of the IJBs, is that a move towards regional planning that is very prevalent at the moment? I imagine that we have struggled a little bit with how the roles and responsibilities of the board work within that regional planning. Who is accountable and where does the decision-making line for service planning deliver in performance? I am very clear in Dumfries and Galloway that the responsibility for service planning around acute services sits with our IJB. The functions for acute services are delegated to our IJB, so the responsibility for that planning at that strategic level sits with the IJB. However, our IJB has also been actively involved in the discussions around regional planning because we recognise that the sustainability of a number of our acute services for the future requires us to be actively involved in regional planning. In terms of accountability and planning, we are very clear locally that we have delegated those functions to our IJB and that our IJB has that responsibility. However, we are active players and actively involved in the discussions around acute services because we are very, as I say, the sustainability of a number of our acute services requires us to work in partnership across the west of Scotland. I just want to be clear that you are suggesting that the IJB is the accountable body in terms of delivering those services? No, in terms of planning of those services. The IJB is a strategic commissioning body, so the IJB has got the responsibility for the strategic planning of those services. I am clear as a chief officer to that IJB that I am accountable to the IJB for the delivery of that strategic plan. However, in terms of the operational delivery of the services that are delegated as the chief officer, I am accountable to two chief executives, to Jeff, as the chief executive of the NHS, and to the local authority chief executive for the delivery of those services. I have got a dual accountability. Fascinating conversation. I was really struck by some of the performance outcomes for Dumfries and Galloway. There is a list here in relation to clinical care and governance of a number of outcomes that do not appear as if they are going to be met. I will mention just two of them. The rate of acute emergency admissions per 100,000 adult population looks in the last quarter of the report if that is unlikely to be met. The rate of acute emergency admissions in bed stays per 100,000 adult population. I am looking at that. I am also looking at, for example, in August there, any waiting times performance of 93.6. It is not 95 per cent, but a strong performance. I think that there has been a relatively strong performance generally in that area. In terms of outpatients waiting less than 12 weeks, it is 96 per cent, above a national average of 75 per cent and inpatient and day cases under the treatment time guarantee. It is certainly not there yet, but it is 84.5 per cent as opposed to 74.6 per cent. A mixed bag, I suppose, but targets can mislead as well as inform. So, there is a tension there between those two things that looks if they are not going to be achieved, and that is acute emergency admissions. Some of the good work that Julie White has been mentioning, because I look at it beneath the surface of some of that performance, and I am wondering in relation to preventive agenda, which was my substantive question. I just wanted to put some of that on the record about the mixed performance of the inpatient drug board and health board. If someone goes in for a cataracts surgery, that could be an acute intervention, a hip replacement, that is an acute intervention, but if you do that hip replacement early, rather than having a long wait, it is actually a community intervention because they are going to be enabled far quicker and be healthier and safer in their house similar to cataracts operation where you trace slips, trips, falls from someone waiting far too long for hip replacement or far too long for their cataracts operation, you increase the risk and you drive up emergency admissions. So, there is an example of an acute intervention that has a direct community benefit. Have you mapped anything in relation to early intervention on acute procedures in NHS that actually has a direct benefit to community enablement in keeping people, particularly an aging population, in the community longer? I do not think that the Scottish Government has particularly done that. I think that I am probably going to have to say no to the comprehensive question that you asked, because it is a great question. We have had discussions individually with clinicians and I can think of talking to ophthalmologists about our intervention point with cataracts, which is lower than some other boards in Scotland. The discussion being that in a rural community driving is critical to getting around because of the public transport difficulties that we have touched on. We positively recognise that we need to intervene earlier than other systems might be comfortable with, but that comprehensive map of early interventions we do not have. I think that shifting the balance point that was raised earlier is a fascinating one and a fundamental one for this committee. I was interested in your report that was published yesterday. From a Dumfries and Galloway point of view, in the lead-up to the new hospital, we did an awful lot of health intelligence planning about who would use acute services, given our demographics, as Julie said, up into the 2035s. We could not, with any certainty or any, no matter how optimistic we were, forecast that we would cut acute spending in that period. We think that we have taken an ambitious line of being able to redesign lengths of stay and admission rates, as you say, so that we can hold within that acute footprint. We are not planning for a significant and substantial shift of resources out of acute and into community because our health intelligence models say that our population will continue to demand hips, knees, etc. We will continue to require trauma services. When we model the relationship between age, particularly over 85s, and hospital bed use, we cannot see a smaller DGRI than the one that we have now. When people talk about shifting the balance of care, we really need to tease out how exactly are they going to take a system that works on around about three beds per thousand population, which is at the very low end of the European average. How exactly are they going to take out that large amount of resource to feed into community services? It is quite a profoundly important point for future planning of health services in Scotland. I have no preamble to the supplementary, but I promise you, convener. Julie White could make a case to say that I want more hip surgeries, knee operations and cataracts operations at a much earlier stage than clinicians might be able to grant them, and that is for community purposes. Perhaps some of that acute expenditure could actually be transferred over and presented as a bid from community to actually drive community outcomes. Would you seek to map that perhaps in your next annual report? We could map that, and I think that it is the beauty of our system that, as you say, essentially Julie controls the expenditure on all aspects of health and care. We have been dealt the hand that we are coterminous with the council, so we have been able to take this unique step of putting all of acute services in. I think that it does give us a unique advantage in that we are able to look holistically in that way, and we are not seeing a sort of sterile competition between community and acute services for resource. Those of us who are old enough remember from acute trusts and community and primary care trusts, and it is an utter waste of everybody's time to be fighting over resources when we should be collaborating with the patient at its centre. I think that we do have a unique service model because of our advantages, and I do think that we can begin to demonstrate some real gains from that compared to some of the more complex models that are necessary elsewhere because of overlapping borders, et cetera. So, for example, early acute intervention, which supports community enablement, because that could be presented as part of the community budget? Is that something that certainly we took a paper to our board in June written by our public health team looking at what were the biggest impact interventions that could be made from a public health perspective that would avoid a decline of individuals into frailty. Key amongst those and top amongst those will work on falls prevention, for example, and on physical activity for all ages in the population. I think that fits very much with your question about that point that you intervene and how successful you intervene to avoid further frailty. Thank you very much, and I'm glad that you've referenced our report yesterday in advance of the budget, because clearly you'll have gathered that the committee is very supportive of the shift in the balance of care, but very aware of some of the challenges in making that happen. Julie White talked about being accountable to the IJB for the creation of the strategic plan and being accountable to both the NHS board and the local authority for the delivery of that plan. How comfortably does that sit when you're presumably employed wholly by the NHS and not at all by the local authority, and how does that work in practical terms? In practical terms, I have, rather than having a one-to-one with Jeff for my performance reviews, I have a one-to-two with two chief executives. I have two chief executives whom I meet on a regular basis, who meet me to discuss areas of operational concern, my performance in relation to objectives, etc. At a practical level, it works well. As Jeff said, we have been dealt quite a fair hand in Dumfries and Galloway in the sense that we are a fairly small partnership, and we are co-terminus in relation to the boundaries with the local authority. I think that we have taken the opportunity to develop an integration scheme that is as robust as it can be with the inclusion of all of our acute services. At a personal level, I feel very comfortable about my accountability to both chief executives for the operational delivery of services. I am very clear, however, that I have an accountability to the IJB itself for that strategic plan and the delivery of that strategic plan and how that would normally work in practice. I have regular meetings with the IJB chair and we have really strong leadership from our IJB chair and vice chair in Dumfries and Galloway to push forward with our integration agenda. I have regular meetings with both of them, and I will present performance reports on a quarterly basis to give the IJB assurances about the delivery of that strategic plan. I believe that Dumfries and Galloway is one of the councils in rural Scotland that has talked about joining forces with the local health board in order to form a single entity. Is there a response to that proposition from NHS Dumfries and Galloway? I was not aware of that. Perhaps I am anticipating what is coming next. Several years ago, we discussed a scheme where perhaps councillors could act as non-executives on the health board to create a greater linkage. My personal view is that I think we are using the IJB vehicle as effectively as it can be used in Dumfries and Galloway. I think that the gains to patients' families that we are seeing are—we can demonstrate that things are improving and that we are generating improvement. I would be loath to look at a further structural change that will delay us getting on with what is really important. Good morning to the panel. I wanted to ask about drug and alcohol services in Dumfries and Galloway. Looking at your 2016-17 budget, you were asked to find a shortfall of £452,000 after the Scottish Government made a 20-point cut to alcohol partnerships. Your account suggests that you have found £234,000 of that shortfall. I wondered what impact that had on service provision in the area. If I can kick off then again, I will hand on to Julie. We were able to match the amount that we had spent previously, so, as you have noticed, our budget was higher than spent previously. We had a degree of unallocated expenditure. We were about to go into another grant round, so we did not see significant reductions in services that we were able to provide, but clearly drug and alcohol services are an area of particular focus for us. We have seen an increase in drug deaths, for example, in Dumfries and Galloway. This is an area that I know that the Alcohol and Drugs Committee is working very closely on. However, if I can bring Julie in on the detail. I think that just to echo what Geoff said, in terms of us being able to match, we were able to match the funding for what we were previously commissioning. We did not have to reduce the level of commissioning or stop services as a result of the full allocation. We were in the process of developing a new commissioning strategy within the alcohol and drugs partnership. Within Dumfries and Galloway, we have taken quite an innovative approach to our commissioning strategy this time. We have taken a co-production approach with service users, their families and carers, looking at what matters to service users in drug and alcohol services and their families and carers, identifying with us what our priorities need to be for commissioning. We are in the process of going out to tender for a number of our drug and alcohol services, but that co-production work has really helped us to be prepared for the additional £505,000 that we have received in Scottish Government funding recently. That has given us some indicators of what matters to people in Dumfries and Galloway and what services we should look to commission. It is particularly important that there are areas of family support, rather than providing support to the person who is affected by drug and alcohol misuse, but providing support to families, carers and young people who are affected by substance misuse. We have been working closely with partners in the third sector on how we can commission a family support service. Our alcohol and drugs partnership brought a report to our last IJB, which outlined our annual performance and our priorities for the £505,000 investment. As a partnership, we are passing all the resources that we are given to us around alcohol and drugs, to the alcohol and drugs partnership for them to work with our partner agencies, with our service users, their families and carers to identify priorities for use. Jeff mentioned the issue of drug deaths. As an alcohol and drug partnership, we noticed that, in 2017, we saw the highest number of drug deaths in Dumfries and Galloway that we have seen in recent years. We have a drug deaths group that meets regularly. We review every drug death to see what learning can be gleaned from that. There have not been any common themes that we have noticed from the increase in drug deaths, with the exception of seeing an increase in drug deaths among the older population of drug users. That is something for our £505,000 that we need to focus on in terms of what initiatives we need to undertake. I do not have the plan for that just now, because we are still working that through with the alcohol and drugs partnership. We are also aware of our need to improve our delivery around alcohol brief interventions. That is a key priority for the drug and alcohol partnership. We know that we need to increase our number of alcohol brief interventions in the acute setting and in the primary care setting. We are working with colleagues in both of those settings to look at how we can improve our alcohol brief interventions. What we think is that a number of those alcohol brief interventions are taking place, but we are not recording them appropriately on to the system. That is a summary of where we are at with alcohol and drugs at the moment. Thank you. It is useful to hear about the future plans that you have outlined. One thing that jumped out to me was that Dumfries and Galloway has the highest percentage of drug-related hospital admissions, which is a crisis point. I do not know if that is also somewhere for the new work that you have outlined to start cross-referencing. We are one of the things that we are looking at is around prescribing. Obviously, part of that is looking at the reason for the drug-related alcohol admissions, and we are looking at what support we can provide around prescribing. That is something that we can consider in terms of what further action we need to take to reduce the rate of hospital admissions that are influenced by drug and alcohol issues. You mentioned co-production, and earlier I talked about preventative agenda and signposting. I recently attended a transforming Wigtonshire event, and people were using the language co-production. I am curious to know what that means, because the people in the Ryns, in the Machers and Wigtonshire want to make sure that they are working together and not being told what is going to happen to them. I am curious about the co-production issue. I appreciate and apologise for the use of language that some people find quite unhelpful. I echo the concerns of the people of Wigtonshire in terms of the use of that language myself. Co-production is effectively about us working with people to design the future shape of our services. It is absolutely about us saying, how do we work with our local communities to have an honest conversation with them about what the risks are, what the challenges are, what the possibilities are around the future shape of services, and to really genuinely engage with people. It is not about us within statutory services or indeed with our partners in the third sector coming up with new ways of working and then going and consulting with people on those new ways of working. The co-production is about the people that we serve involved in the development and the design of the future shape of services. That is something that we are working really hard to do in Wigtonshire, getting out there, engaging with our communities, not just the traditional ways of engaging with elected members and community councils, but actually getting out there and talking to people in our communities about what matters to them and talking to them about the challenges that we are facing as a health and social care system so that they can work with us around the design, because we recognise that there are going to have to be difficult decisions that are taken in the future. We have talked about the financial challenges that we face. We have talked about the recurring financial deficits that we are facing. There are going to have to be some difficult conversations taking place. We feel that the best way of us having a chance of success in terms of being able to deliver new ways of working is to have the community involved at the outset in terms of the design. That is what we mean by co-production. I was interested in the drug deaths in older people. Obviously, they have other issues as well, same in Glasgow and in the west as well. However, the other point that I wanted to make was about the alcohol. I was on the board of an inquiry and most of the people who had problems with alcohol and alcohol deaths were 55 and over. I wonder if you had found that and a lot of it was to do with loneliness and isolation, that they were not going out. They were buying, drinking and sitting in the house. I wonder if you had seen that as well. I do not have figures, so I would not be able to. What we do know is that we have a number of older people who are experiencing loneliness and isolation. Quite often, as a result of that, people can turn to alcohol and misuse alcohol, so we are doing a piece of work within our communities around addressing loneliness and isolation in older people in order to promote their engagement with other community activities. However, I do not have the details in terms of a number of service users that are admissions in relation to alcohol, but I could certainly provide that to the committee after this. First of all, congratulations on the hospital. It forms no part of the briefing that we have today in order of the internal audit Scotland report, but it is a remarkable achievement. We are well done for that. We are not good as a panel at recognising things that have gone really well and learning lessons from them. We are well done. Two of the issues that were mentioned were in relation to Brexit. First recruitment is about to be impacted by Brexit. I would appreciate it, but you mentioned before the cost of medicines, and I think that you said that potential, because of the coming out of AMC, possibly a three to four times increase in terms of medicines. However, you also mentioned in relation to New Zealand where they could sometimes get cheaper prices, that they did not have the kind of infrastructure of drugs companies and pharmaceutical companies. We do in Scotland, and I just wonder whether there is more scope to work with the pharmaceutical companies who have a massive impact in the economy by coming to some agreements with them in the right way, which recognises their contribution, but also allows them to be more certain about the businesses coming their way. We have a fairly unique situation, probably in the south-west and the north-east of Scotland, and surely we should try to use that to our advantage, especially to mitigate what seems to be quite a chilling prospect of a three to four times increase in costs. Yes, I was referring to particular products there, not across the board. I think that if we are in a deal scenario for Brexit and we have a transition period, I think that those type of negotiations can be very productive. The concern for the health service at the moment is primarily focused on the no deal scenario and essentially a hard Brexit on 30 March next year, and then it will be quite difficult to replicate our current supply line arrangements. The price that we will be able to buy products at will reflect our desperation for those products. There is a real concern about that no deal scenario and our ability to provide business-as-usual services in that context. It is not so much to do with understanding what you are saying about the two different scenarios with Brexit and no deal or some other kind of deal. I am not sure that this has to wait to find out how bad Brexit is going to be. The idea of perhaps a new deal with the drugs companies, whereby their contribution to the economy is recognised in some way that allows you also to strike a deal with them, it would not just be yourselves. I appreciate that it would be across Scotland, perhaps even across the UK, but if there is not some scope there to try and address what seems to be a big problem for you guys just now. I think that there could well be scope and that is a very optimistic and positive way to look at future relationship. I guess we have to look at the reality that we are moving from being potentially very large purchaser of drugs to being commensurately smaller purchase of products and our bargaining position commensurately deteriorates. These are manageable problems, I think, and what you are talking about in potential opportunities is exactly the right way to look at it. The unmanageable, from my perspective, and the issue that is making health services across Scotland very uncomfortable at the moment is that 30 March position, if there is not the ability to work, as you suggest. Thank you very much. I thank you to our witnesses for your evidence this morning that has been very helpful. You have offered to provide some more information following the meeting. I noted CAMHS tier 4 alcohol and drugs action plan and work on loneliness and also something further on the recurrent and non-recurrent savings as that becomes clearer. We may also have one or two further questions that we will put to you in writing after we've had the opportunity to discuss them. I thank you very much for your attendance this morning and we will now suspend briefly for a couple of minutes and then when we return we'll move into private session. Thank you very much.