 Good morning, everyone, and welcome to the 27th meeting of the Health and Sport Committee in 2017. I could ask everyone in the room to ensure that their mobile phones are switched off or switched to silent. It's acceptable to use mobile devices for social media but not to take photographs or record proceedings. We have apologies this morning from Sandra White and I welcome to the committee Ash Denham and Emma Harper. The first item on our agenda is for them to make a declaration of interest. In accordance with section 3, the code of conduct interests relevant to the committee have to be declared and any declaration should be brief but sufficiently detailed to make clear to the listener the nature of the interest. Thank you, convener. Good morning. I have no relevant interests to declare. Thank you, convener. I do have relevant interests. I am a registered nurse, currently not practicing. I'm a former employee of NHS Newfries and Galloway and although I'm not practicing right now, I am seeking opportunities to volunteer in order to maintain my licence. Okay, thank you very much. I'm going to put on the record our thanks to Marie Todd, Tom Arthur and Claire Hawke for their work whilst they were members of the committee. The second item on our agenda is to choose a deputy convener. The Parliament has agreed that only members of the Scottish National Party are eligible for nomination as deputy convener of the committee. That being the case, can I invite nominations for the position of deputy convener? I congratulate Ash Denham on her appointment and look forward to working with her over the next few months and years. Agenda item 3 is NHS Governance. We have a session on NHS clinical governance this morning, and we welcome to the committee our panel Dr David Chung, Vice President of the Royal College of Emergency Medicine Scotland, Dr Peter Benichir of the BMA Scotland, Sarah Conroy, professional advisor, charter society of physiotherapy, representing allied health professionals, Federation Scotland, Lorna Greene, policy officer at the Royal College of Nursing Scotland and Dr Gordon MacDavid, medical legal advisor at the medical protection society. I was reading the official report as a new member for this committee last week. At the evidence session last week, members explored the implementation of standards and guidelines on how that is transferred from the patient groups into practice. I am interested to hear what your views are on whether there is adequate knowledge of the standards relevant to the work across the sectors. How do we transcribe that information? How do we educate the educators? Go on, Peter. You look ready to go for it. That was me looking about for who else would I like to answer that one. I suppose that the place to start with that is that whenever there is a new guideline, it is usually fairly well promulgated across the health service. My email in box is filled with notification of when new guidelines and standards are coming into place. It is also fair to say that it is difficult to keep up-to-date with everything that is coming through. You will have seen a theme through quite a few of the written evidence that, in the health service at present, it feels a lot like the pressure of work has us doing crisis management rather than having enough time to step back and give proper consideration to new guidelines and to have sufficient time to really concentrate on the CPD, the continued professional development that is essential to good practice. Leadership within nursing teams is a really important thing there in terms of communicating any new standards or updates with the wider nursing team. From that point of view, we would see senior charge nurses and team leaders as a linchpin between standards that have been developed and how they get delivered as part of the service that is patient facing. We would see them as a really integral part of that system. To echo that about CPD as well, that for our members to have the time to undertake their CPD and training to stay and their revalidation with the NMC is a really critical thing there. Is that their practice stays in line with the most current standards and best practice? Good morning. Hi, I'm Gordon MacDavid. I work for NPS, the Medical Protection Society, and we're a defence organisation, so we represent our members. We're a membership organisation, a mutual and a not-for-profit. In essence, doctors and other healthcare professionals who are in membership with us come to us when they find themselves in difficulties or when they're looking for advice and support with a medical legal or an ethical issue. As the largest defence organisation in the world, we've built up quite a lot of experience around issues where adverse events have happened. I think that that ties us nicely into the really good work that this inquiry is looking into. Around your point on education and guidelines and implementation on those, it's certainly something that is difficult to achieve. There's no easy answer. I don't think that it's just about setting aside time or just about ensuring that people have protected CPD, although that's absolutely vital. However, what we need to see is more of an overall change in culture within the NHS in Scotland, starting perhaps even from the leadership within NHS Scotland where they're moving towards a willingness to allow their staff to learn about guidelines, to develop guidelines and to be much more open about things when they go wrong, so that they have an opportunity to scrutinise the systems that they're working in and feeling able to bring up issues as they come about, without fear of blame or personal recrimination, which our members are telling us is a bit of an issue for them. I think that I would echo what has been said. I don't think that there can be any doubt that there is a challenge there between new guidelines coming out. Yes, it can be up to date, but do you have the resource to put them into practice? I think that a lot of short-term funding from Scottish Government support very successful projects for pilots, but budgets still seem to be very siloed, so rolling that out can be a huge challenge for the HPs. We're not always got the biggest budgets to start with, and although we can show we can make an impact, I think that all too often it's a nursing budget or a medical budget and nobody wants to let go. I think that everything in an organisation is as big as NHS Scotland. There's going to be variation, so there are some good things and some things that aren't quite as good, but I think that as a culture within NHS Scotland, there has been a lot of reasonably positive work to try and address the issue of how you promote guidelines, good practice, et cetera, so initiatives like the Scottish Safer Patient Initiative and Healthcare Improvement Scotland. I think that people understand much more than even a decade ago that how you promote quality, the method that you do it. There's various people within bits of various departments in hospitals who are taking a lead on quality improvement. There are SPSP fellows, so the culture is out there and the awareness is improved a lot. People understand that there has to be certain good ways to try and get good practice brought in. You don't just tell somebody to do it, although that still obviously happens. You do get your emails, et cetera. There's some good work here, but everything else that we've alluded to is the trade-off between resource allocation and quality, which is perennially issuing any healthcare system across the world. In the past five years, because of some of the limitations with regards to funding, it feels like there's been not quite the same amount of space, whether it be in terms of time or money, to develop it as it used to be. However, a lot of good work has been done. As a nation, Scotland has shown that it is willing to adopt a leadership role in this in some ways, compared to other places. We've adopted it and embraced it perhaps better than some other places, but it's getting that through to become completely part of the normal day-to-day challenge, depending on some of the things that we've spoken about. It is incredible being a doctor with my protected CPD and all the rest of it, watching my nurses come in on their days off, because they have to come in on their days off to do courses or such like, because they can't do it as part of their normal work. It's completely unfair. Things be on. I'm aware of sign guidelines, and there's a sign guidelines app, which is great when it's immediate. You can access it from your iPad, but we're not just talking about national guidelines, there's procedures, policies, new ways of managing insulin, sliding scales, which are not sliding scales anymore. The challenges are, how do you get the information directly to the front-line staff? Education delivery can take one minute, and I know how that's been piloted in some areas. How do you get the guidelines directly to the staff if the staff are coming in on their days off? I know that that happens, but I also know that there's a protected time by some departments as well. I think that there's lots of people who talk about death by performer, but there's lots of policies that are much more prevalent. The documentation people use usually incorporates guidelines nowadays. For medical patients, the medical clerking sheet is to give an example, have several bits. Here are the things that you should be measuring, here are the ways that you should be doing it. Lots of places, I work in Asia, but I know that Glasgow has a very good internet-based clinical guidelines for the junior doctors to refer to, and policies and procedures and such like. The challenge, especially in emergency medicine, with a high turnover of staff over a few months is that the challenge is to try and reduce the variation that new doctors bring by getting as many policies in place and making your systems work so that they slot into it rather than they can bring unwanted variation and poor practice. We're much more used to being, within secondary care, happy to do what the guideline says rather than, I'm this independent practitioner and I know better than the guideline. That culture has shifted a wee bit. I'm not so sure that I have no experience of primary care, so I can't say. It's much more accepted now than it was even 10 or 15 years ago. It is important to remember that particular guidelines for individual conditions have limited to no relevance when you're dealing with a patient who has multiple conditions at once, and this is one of the core messages of the CMO's realistic medicine document. It's important to strike that right balance, and doctors are dealing with us on a day-by-day basis. There's what the guideline says, but you've got to have an awareness of where the evidence is actually not fully supporting what you would do in a particular situation. Thank you, convener, and good morning to the panel. As a brief supplementary, Dr Chung, in your submission, you say that the data-ex-reporting system has, in some cases, hindered rather than helped. It's not easy to use a system of incident reporting required to drive learning and to help to shift the culture. Dr Bennie, in your submission, you say that the culture within the NHS in Scotland does not encourage staff at any level to challenge perceived wisdom, so just to go back to Gordon McDavid's point, is there a cultural resistance to learning from mistakes within the NHS? You go first. Can I ask about the data-ex-reporting system and whether the data-ex-reporting system has the confidence of the staff who use it? I've got to say in my experience, so I'll qualify that, but no, not really, because it's quite cumbersome. To give some examples, feedback is crucial for quality improvement of any kind. You need to know whether you're doing something right or wrong. I think that part of the problem that has been alluded to by my colleagues on the NPS is that virtually the only real robust feedback mechanisms within the NHS are negative, so staff only get told the bad things, whereas the means to give positive reinforcement is not as good. Going back to data-ex, I've moaned about it for virtual of my working life, and people said, oh, we'll make it a bit better, and it gets down to—but it's still compared to any other form of IT that you might use, is very cumbersome and not there. When we've tried other things as well, you do come up against—it's a bit of a diktat that you must use it, so every now and then you'll get someone to go, well, let's just have a positive or a nameless form. It's quick and easy to fill in, just filling a form and put it in this box. That would seem common sense, so let's just do that. I've seen something, it didn't quite go wrong, but we need to learn from this, let's start learning stuff, and people get told, no, we're not permitting you to do that, you need to use Datix because it's been bought by the NHS and you have to use it, so people just go, well, I'm just not going to do it then. Whereas when we had old IR1 forms back in 20 years ago, okay, you would sit in the big pile of them, but they were easy to fill in, so you would get those done. And likewise, if you're trying to bring in things like positive reporting—so I've seen examples of this in emergency departments in England—very successful, but if you see something good, see somebody give a good learning point, just write it down quickly. But we're told you have to use Datix, it takes a lot of doing it, and it creates such a trail and then it creates more problems for you because people come back to you. It's not a very slick system, so it is a barrier. I would say that it's definitely a barrier to get in proper feedback and learning. I'm afraid. Is that unanimous across the piece? Well, let's ask her of it then. Gordon? I really just want to echo what David said. When I worked as a doctor in the west of Scotland around various hospitals that were exactly the same, it was sort of feedback when things go wrong, and then actually we don't take it to its natural conclusion. You don't get feedback on your feedback, which again doesn't complete the cycle, so you probably don't get the useful learning out of an event. So I think there needs to be, again, broken record, I'm sorry about that, changing culture. Let's get people open, let's get them highlighting the issues they come across, both good and bad, both staff and patients, and have a process that allows that to happen and allows them to then have the learning coming out of that. It's exactly as MPS members tell us on a regular basis. They feel very worried about things going wrong and very worried about what's going to happen to them when things do go wrong. If I may, I just wanted to pick up on the education point that we'd raised earlier. Obviously, everybody learns in a different way, and I think it's important that, as well as setting aside the time and giving people the space to learn about the plethora of guidance that's out there, it's also important to make sure that it's in different formats and ways for others to learn. Certainly, for members of MPS, we have online learning, as well as workshops on mastering risk that we roll out to our members across Scotland and around the world. I think that it's important that they have different ways of learning so that they can really capitalise on the information that's available. I'm not sure that I want to say anything vastly new, but whether or not you're talking about data, the importance of having a system in which people can log their concerns is a vital part of any improvement culture. To raise that issue there about a feedback loop, that is very important to our members. We hear it a lot from nurses who, not just in terms of raising concerns but in terms of measuring against standards or indicators, nurses will often be the ones who collect that data and put that in. Then they don't benefit from hearing about what that data was used for or how it is part of an improvement culture. That, in terms of just encouraging people to continue with those good practices or good behaviours, is a really important thing that they hear back. On that, I just wanted to raise the idea of time to report and then authority to act. Again, we'd link it back to leadership within nursing teams and senior charge nurses but across the multidisciplinary team, that people have the time to raise the concerns and then they have the authority to act on the information that has been gleaned from the feedback given. Just a couple of extra things about that. One of them is the importance of looking carefully at near misses as well as situations where something has gone wrong. Often you can learn more from a near miss and if you do it well you can learn from the near miss before the actual catastrophic error occurs and you can resolve the issue beforehand. In general terms, I don't think that we're good in the health service at doing that. The other one is that we've talked a little about people being unwilling to pass bad news up the line. Some of what we've talked about is a fear that there'll be consequences if you do that. For me, it's more a culture around in a lot of the health service of learned helplessness, the sense that passing on bad news will have no effect and therefore what's the point in doing it. That tends to be pervasive across the system so that even an individual who's never had the experience of doing that will pick up from colleagues what's the point in doing that and often that's a problem at both ends because it's absolutely not the case that all senior managers in the health service don't want to hear bad news, they do, but they often don't hear it because those who are there to give it to them feel there's no point. In the data, I have direct experience with data entry and the redesign of the system to track and manage pressure ulcers because they take a long time to heal and patients might come in with them or develop them and then end up going through care home back to home processes and things like that, so there was a way of reviewing the processes around it, but are we able to track individually in NHS boards data, status, facts, figures, feedback, all of that? The main purpose, the front line staff perceived data is exactly that, so it's a great way to collect data to analyse or to show or to demonstrate, but in terms of providing the feedback loops for learning, that's where it doesn't seem to work well at all, so there is sometimes a cynical attitude that it's just there so you can say, well, we've got this many data, and we'll say we've got this many slip trips, falls, we've got this many, whatever, but it's never really analysed to a degree where it changes thing, which again, so people say, well, why bother if the feedback falls down, but the data is all there and it is relatively easy to access from those who are familiar with the system. Good morning to the panel, thank you very much for coming to see us today. I'd like to turn the discussion on to the target culture and whether we're getting that right. I met with David Chung last year and the Royal College of Emergency Medicine and they opened my eyes to the fact that it's not as black and white as it may appear in terms of the four hour A in the waiting times, and actually that's an indicator of the wider health of the hospital if there's no inpatient beds to admit, then that will cause people to stay longer in A and E waiting for somewhere to go. I'd like to hear from each of the panel what, first of all, the reaction to the report of Harry Burns last week in terms of the target culture, but also other examples of where targets are perhaps getting in the way of the wider story and not as good an indicator as we might think they are. Who would like to—maybe David, perhaps you would like to pick up on that. I think the four hour target is a good one to choose because it's not really so much as I've made the analogy, it's very much more like an indicator than a target in as of itself if it's alluded to. So if you try and focus on achieving the target for its own sake, it won't work, whereas if you observe it and say, well, how well are we doing the same way as when your engine warning light comes on in your car or the canary in the mine, those analogies are the ones to view that target, as per say. There are probably within an emergency department you could choose other things to measure, which might actually tell you how well the job is being done, but there is always, I think, a slight tension between those targets and other targets elsewhere for elective care and for those waiting times or such like. I think that for targets to work, there needs to be—the clinicians need to own the standard, as it were, and accept that it's a good thing. So for the emergency medicine for our target, that's pretty much a given, and as time has gone by across the world, the evidence shows that if you measure something to do with how long patients stay in an ED, that has got some safety, whereas you might hear other clinicians elective say, well, I've got to treat them by this time, but that's a bit daft because normally I'd give them another couple of months to see if they get better. So you're sort of driving practice you don't need to be. So it depends on the clinical engagement and the ownership, and is it a valid target to the doctors and the other clinicians and staff? Do they think this is a good thing to be doing or not? Sometimes if it's arbitrary and imposed on someone above, then any target like that is going to be not that successful, and perhaps cause some unintended consequences, because they all will. So the forehead type will cause unintended consequences to somewhere else, even if it works for us. Elective targets might cause unintended—you know, for us, so people might—tests might be—you very often see this. Acute patients can't get a particular test done, but at the same time, other people who are well are getting an elective test done because that target has to be met as well. So the clinical urgency is slightly overridden by the need to meet another target. There's always a slight tension. It probably always will be—you won't be able to factor that out unless you have completely separate systems. But I think it's that idea of where does the target come from? What's the evident space behind it? Is it proven to improve the care for patients, but the people who are working to it, do they agree it's a good thing? And if all of these things are in place, then it's probably a good thing. If they aren't, if any one of them are missing, then it might start to cause tension or waste of resource or such like, I would imagine. Yeah, a few things about this. Maybe just to look at the four-hour A&E target first, because it is a good example and there are so many broader aspects of the system that are crucial to be working well for us to be able to achieve that target, which I would agree has within it a core validity. You spoke about you're not going to be able to achieve it if you don't have the hospital beds, but it goes beyond that because you're not going to have the hospital beds if you don't have the community supports to be able to move on those who are fit and ready to come out of the hospital and also if you don't have fully functioning, very effective primary care that can prevent referrals up to A&E in the first place. Focusing just on the A&E department alone, the emergency department alone, is never going to resolve all of that. The other thing I would say in passing about that particular target is that it is reported so often that it becomes a real bugbear for clinicians on the ground, that it becomes almost the sole way of measuring whether the NHS in Scotland is functioning or not. As you are well aware, it becomes a hot topic on the floor of the Parliament very, very frequently, usually without getting that broader picture on it. Looking at Harry Burns' target review, just came out last week. We're still digesting it. It's a very interesting take on the whole target culture. There's a lot that he has to say outside of his recommendations, which we would certainly be very much in favour of, along the lines of the broader message about what is it we're trying to do in terms of improving the health of the population and how we do that. The key messages about how that actually requires contributions from well outside the NHS and from all other departments of government, and in particular how crucial it is to ensure that children are getting a proper start in Scotland and to look at the importance of measuring, recording and doing something about adverse childhood experiences because of the huge impact that that has going forward. My clinical job is as a psychiatrist and almost every adult patient I see I find myself thinking if only we could have done more when this was happening when this person was four and we were picking up the pieces 20, 30 years later, so that's a really key message within it. Turning to the targets themselves, Harry has quite a bit to say about what he calls co-production. In other words, some of what David was saying that if you're going to have a valid target, then have proper input into it from the staff who know what they're doing because they're professionals and from the patients who are going to be affected by that target rather than having it seeming to be set in an arbitrary way. Build into any target the need for clinical judgment to overpower some of the more stuff on the margins of the target again, the kind of things that David was talking about, people who end up getting treatment or an investigation, not because they need it there and then, in fact they probably need it less there and then than someone else, but because the target says that has to be achieved and be aware of the potential for gaming whenever you've got a target system. If you've got that specific target to achieve, you may try to achieve it in ways that will simply meet the target rather than actually improve patient care. I suppose that taking all of that together, I think as much as possible about the whole system rather than individual targets is what we would be asking for. In relation to the gaming of the system, last week we saw the Cabinet Secretary release a statement in relation to what appears to be gaming of the system in St John's hospital in the A&E department. I don't know if anyone can comment on that or maybe have some idea of what's been going on. I'd be planning to do the opposite to be honest with you, which is to say, yes, we're aware of that, we have to wait and see what comes of that, but yes, the Cabinet Secretary did seem to be suggesting that there has been something happening there that was addressing the target rather than necessarily patient care. Derek Bell is looking into that on behalf of the Government via the colleges and we'll need to see what comes of that. In every submission that we've got, people refer to staffing pressures, people under pressure like never before, shortages, systematic shortages of staff in the system, overnights where you can't get an extra pair of hands. Those are all quotes from different submissions. Is that the key thing that's going on in our NHS at the moment, because certainly from constituents, friends, family who work in front-line care, they are continually raising issues of short staff? Is that the key issue at the moment? Can you maybe elaborate on that? How does that impact on the care that we give, whether we can deliver the standards of care that we want to give? How does it impact on morale? How does it prevent people sitting down and learning and improving things, not getting their CPD? All of that stuff, so that's what we want to know. David, first. You're absolutely correct, so you've just summed us up quite nicely that that is the problem. I would say that there are problems with staff and well-documented issues with medical staffing and vacancies, but I'd say that it's more pronounced in nursing and other professions rather than that medicine does work somewhere now. It could certainly be better, but I think that in terms of what affects globally patient care—we're talking about for our target or whatever—it is going to be, are there enough staff to provide decent home care, are there going to be enough staff in the wards downstream, and also are there going to be enough staff in the EDs? I do know specifically with regards to emergency medicine that all of the college organisers are clinical directors for them twice a year, so not every CPD was represented, but most of them were all in the room, and I actually did say to all of them, what's the biggest thing, and they all said nursing staffing, without exception. That was there, but they felt their biggest issue in terms of being able to provide the best care within an actual emergency department. I also know that the wards downstream of Wales are feeding it just as much, and if you don't have that many staff, you cannot release people to the time and space to drive quality improvement. It just says that. I think that, as that joined up thinking, I think that from an HP point of view, we would like to be up there too, in parity of esteem, and we think that we can make a big difference. For example, the four-hour target in A&E, I went to a patient flow event last week and I listened at length to what the medics could do, how we could free up theatres and what the nurses could do, and really at the end of the day, when patients sit in A&E, the patients that are sitting there in hospital beds waiting to go home but can't because they're immobile or don't have a care package arranged or just generally can't get out and they're not independent, that's where HPs come into their fore, yet we're not really round the table discussing this, so there's a four-hour target in A&E that we do believe that we could have an impact on, but more often than not, HPs aren't round the table, and probably coming back to the whole target culture, we've a target for MSK, so podiatrists and physios that outpatient MSK will be seen within four weeks, and I come back to what was said, where did the figure come from who decided four weeks, and so what happens if we don't meet it, because I think across Scotland at the moment there are areas that are maybe sitting, a good area at 8, 10 weeks, but we also have areas that are sitting nearer 40 or 50 weeks, so there's a target there and staff are under pressure and we're prioritising, prioritising and treatments are becoming shorter, yet we're still having to make 5% crest savings and lose, for example, in one health board recently another 10 members of staff, yet we're already sitting at over 30 weeks' weights, so we've got a target, we can't make it meet it with the staff that we have, so we've got no chance of meeting it now, having losing another 10 posts, so I think there's something there around the targets, what do they mean, who's buying into them and are we talking about quality, are we talking about a tick box, and from an HP point of view, I would say that we feel we've got some solutions, but we're not often round the table. Lana, did you want to come in here? Yeah, I've got two points. One around the targets is just to echo what's been said there, that in the development of targets the importance of having real meaningful engagement from the professionals who will be working to those targets and how that would help to develop something that is perhaps more meaningful to the people on the ground and the people receiving the care. The second thing is just to pick up on that point there about to what extent targets can actually capture quality, and at the heart of it that is what we would want, is that people who are using services have a good quality of care that is safe and that helps them reach the outcome they need and want, and how often do targets obscure the quality or get in the way of a meaningful engagement with quality. Just to pick up on the staffing. We know that having the right number of registered nurses is linked to better outcomes for patients and their care, but in our centenary survey that the RCN conducted with its members in 2016, it showed that staffing levels were their biggest concern, and that's probably not a surprise when we know that the vacancy rate is at its highest ever, with one in 20 posts vacant in Scotland. Again, a link to work that the RCN has been doing with our membership, our safe staffing report, which came out in September, showed that half, just over half, 51 per cent of the respondents to our survey said that they felt their last shift was not staffed to the level planned, and 53 per cent said that care was compromised as a result. That speaks volumes about the link between staffing and quality of care, and it also tells us about what our members are extremely concerned about. They want to be able to go into work and deliver high quality care and take care of people in the way that they were trained to do. They are being impeded to do that because of the high vacancy rates and the shortage of staff around them. Yes, staffing levels are a major problem. Snapshots about one in 10 consultant posts are vacant. One in four GP practices have got at least one vacancy. Let's turn that round and look at some of the things that we can try to do about that. You will be aware that the BMA is just concluding negotiations with the Government on a new contract for GPs, and that is far more than a contract of it terms and conditions, although that is in there. It is about a completely different way of working in primary care, and it is about maximising the opportunities and the experience of particularly allied health professionals, as well as nurses, so that you are providing care to patients from the people who are best placed to do it, and you are having GPs moving to a position where they are primarily working as expert generalists in a team with other staff who are doing the other work with them. That is a way of looking at the situation that we have, where there simply are not anything like enough GPs and it is increasingly difficult to recruit people into general practice because of the crisis and saying, okay, we have to improve the quality of care for patients by involving the whole team, and that will also make the experience of being a GP better, as well. Okay, Brian. Is it on this point, Brian? You on this point? No, not at all. Sorry, I'll take Alec first then. Thank you, convener. It was just as a supplemental to my first question, as the corollary to that. In terms of improvement in the target culture, I was surprised to learn that of all the health boards, Lanarkshire seems to be the only one that is actually doing reasonably okay in terms of cancer waiting times, and the reason for that is that when they log delays, they log the reasons for it and steps they'll take to mitigate that in the future, but they seem to be doing that in isolation. No other health board seems to be following that pattern. It really struck me that in terms of improvement, if we're measuring something, what's the point of measuring it if we're not learning from that data and taking steps to do it? Perhaps I'd like to ask the panel other examples of other good practice where that's the case? How do we extrapolate that across the 14 health boards that are fiercely siloed at some times and don't like to be told that another health board is doing things better and they should really follow on from that? Gordon? I'm not sure I can offer any specific examples of health boards. I'm afraid, but I wanted to really echo what my colleagues had said about buying from staff. I absolutely take the point that you need the right staff numbers. That's almost a given, but it's part of the puzzle of how we improve governance within NHS Scotland. I think that if we don't have buy-in from the staff so that they don't understand why the targets are there and there's no positive incentive, even something like knowing that meeting a target and doing a good job is going to feed into good patient care, those messages for whatever reason seem to be getting lost. I think that we'll take that very good example. If that could be shared more widely, better communication amongst both staff and patients, then I would like to think that we'll have a positive impact on the governance of the NHS as a whole. It's part of a wider issue and part of a wider problem, so it's just one piece of the puzzle. Anyone else like to come on to that point? To answer your question, it is a frustration that you'll find good practice throughout NHS Scotland, but it's isolated. That is the challenge as a healthcare system, how do you spread it out across the entire nation? That's a little bit of the things like SPSP and health improvement Scotland attempt to do that, but the trouble is that people are always able to put a buy-in and say, yes, that works in annusia, but it will never work in annusia, for reasons, whatever, to give an example. That's the trick, is overcoming those barriers hypothetically, why it might happen or not. Removing or trying to minimise unnecessary variation is recognised across globally health care improvements, so the big guns in the Institute of Healthcare Improvement in the US and all the rest of it. That's basically what we're trying to do, but how you actually square that circle has proved challenging across the entire world, even within the States. They're struggling with the same thing if you've got somewhere good and everything else appears to be the same. How can you roll it out? It's tricky, because you would think that it would be common sense if a doctor saw or a clinician of any kind said, I want to be good at my job and I see they've done it really well over their access to success. Can't I just copy them? For some reason, you'd find, well, they've got an extra thing you haven't got or there's a resource issue that they've got access to different funding you don't have or it's operationally, is where the will is there. I think people, if they knew there was an easy way to do their job and improve the patient care, would want to do it. It's creating those networks so people can learn about that, and that is a problem as well, so you could argue as part of the job of royal colleges or other organisations to say, this is good practice, this is what we're trying to do with Arkham Scotland, because we're small enough as a nation to say, but it's creating a network so that if somebody does something that's good, everybody else knows about it, just knows about it, and then they can decide if they want to follow that example or not, and then own it, as opposed to being told to do it. But it's a challenge and it's been a challenge worldwide and nobody's unfortunate appears to have the magic bullet as yet. You could say, well, can't we just all be like McDonald's and standardise it that works up to a point, but medicine's complex. I initially was attracted to that and thought, yeah, why can't we, but patients are complex, medicines are complex, it isn't aviation, it's so much more complicated, so the analogies that people use aren't quite as transferable as we kind of hope they were at the start. Peter, briefly. I was just going to add that, at least in theory, the tentative moves towards regionalisation could make a bit of a difference to this, because health boards working to their own agenda on issues that are actually broader, that may change, remains to be seen in practice. Okay, Brian. Thank you again every morning, panel. This is kind of slightly off-piste a little bit, but in terms of trying to establish an environment where learning is, or learning from our mistakes, it becomes more the norm. I wonder where, in my opinion, I think becoming a much more litigious society. I wonder if that is starting to drive certain behaviour within the organisations that prevents us from even discussing to an extent where we could learn from perhaps things that have gone wrong. I'm happy to pick that up. Obviously, litigation is what we do at MPS and certainly our figures. More from across other nations within the UK, we'd suggest a huge increase in the number of claims coming in. What that feeds into in our view, and the way that members express it to us, is that it sort of feeds into this fear factor that they have when they're working. They're a little bit scared of what's actually going to happen if they say, for example, speak up or are honest when something goes wrong. Are they going to be sued? Are they going to face a complaint or a feral to the GMC and potentially lose their livelihood? You know, those are the sort of issues, I guess, that are going through the minds of MPS members. It's very difficult when you're working in that sort of environment to then say, okay, I'm happy to stand back and be very open when I see that there's an issue here. Is that fear of blame and personal recrimination that I think is a major problem in? Yes, but how is it addressed? Again, I don't think there's an easy solution at all. That was my next question. I've got my psychic hat on today. But I think it's got to begin with coming from a change in culture. It's got to come from the leaders in organisations within the NHS in Scotland to begin to show that it is okay to be open and it's okay to communicate. And in fact, it should be encouraged. It should be positively incentivised, as they have done in other industries, to say, you know, let's speak up when we see things that might not be just as good as they could be. Let's speak up and put things right perhaps before they go wrong when we get into the situation of someone trying to sue someone else. David. There is an unfortunate example that Gordon might be able to elaborate on in the last year or so. I think that in England a GP trainee wrote a reflective practice log on an incident that didn't go as well as it should have, but for her learning in the part of her portfolio, this is what happened. And it was used as evidence of negligence, which she was then prosecuted for. So with that, again, on the intended context, if trainees are thinking that, they're never going to write anything honest. That's going to make them liable in the future. I don't know if you've got anybody else got more detail on the case, but that's what people are starting to worry about now, if I'm honest. I'm just creating evidence against me. I really just would echo that point. I guess it's a concern. I can't comment on it, the specific case. I don't know the details of that particular case, but well, exactly. If you're sitting and working and being asked to reflect on what you've done and be open and honest, but in the back of your mind, there's a little voice saying, well, actually, I'm writing down basically the case against me and I'm going to find myself in court being sued. Those two are not sort of compatible, are they? So I think, a sentence brings to mind that Harry Brown said, and I can't remember when or where he said it, but it was that, if you do something well, tell everyone. If you do something really badly, tell everyone. The idea being that learn from both examples, and that for us, I suppose, is what an improvement culture would look like, and that's what we need to get to, and move away from a blame culture. Part of that would be for organisations as well, to start looking at ways that they could address things like human factors and system failures. And a human factor, for example, if you have a nurse who hasn't had a chance to have a break and stay hydrated or even run to the loo, is that going to impact on the care she's able to provide? Possibly. So what an organisation can do is just make sure that there's time for their staff to step aside, have a drink of water, get a chance to run to the loo quickly. Those things can start to make a difference, and it can tell staff as well that they are important, that their health and wellbeing is important, and again, contributes to a culture within organisations that says you matter, and that can help as well in terms of making people feel they can trust the leadership in terms of then reporting errors or near misses if they were to occur. Similarly, with system failures, IT systems are something we keep hearing about, and how clunky IT systems are getting in the way and causing red tape, and preventing people getting the right care that they need at the right time from the right people. Those things are steps that could start to take place as part of an improvement culture, not gradually, but, hopefully, speedily, moving away from what might now be more leaning towards a blame culture. On that point, the BMA's submission says that there is a near complete disconnect between high-level strategic risk management activities that nationally and regionally dominate management and the shop floor co-face activities of the service. What you have just said there appears to me to be an ideal that we want to work to, and everybody would agree with that, but what I sense is that we are a billion light years away from that at the moment. Certainly speaking to NHS staff every week that I do, people who are known and my circle of friends, people who come to Surgeys, it is so far away from that. I see that disconnect. I think that for our members there is a frustration there, because they can see where areas of improvement are and where the areas of address need to be. Again, not to keep making the same point, but that for us at the Royal College of Nursing and speaking about nursing, that is where leadership and nursing teams are so important. That is why senior charge nurses and team leaders in the community need to have authority to act, that when one of their team members comes and raises an issue, or when the data that they are getting back shows there to be an area for improvement, that those team leaders within nursing are able to act on that and can support their team, so that their team then continuously feel listened to and that there is a feedback loop in place. I just want to push you on that, because we took evidence from NHS middle managers, who are telling us that they are getting pushed from a top through the targets culture, that pushes them to do certain things, and then they are managing on the ward and they are dealing with their staff on a day-to-day basis, who are attempting to deliver good care, and they are stuck in the middle, unable to make any other decisions because they are getting stood on from a top, so we have a real problem. That is exactly that point. The authority to act is not there for our senior charge nurses. I think that another aspect to bear in mind here is that a lot of people working as health professionals have exceptionally high personal standards of how they feel they should be practicing, and so I was just really struck with that kind of model of looking after yourself. So many of our members will pretty much abandon their own self-care when they are in work. They will work hours and hours beyond where they are supposed to be and still go home thinking about, if I had only stayed another couple of hours, I could have done this and this, which is a product of trying to run a health service that is not sufficiently well resourced. It is important to remember how poorly resourced we are by comparison with similar nations in Europe. We are at the bottom, both in terms of numbers of doctors and in terms of health spend per head of population, and that is the cloud that hangs over all of this. Those of us working in the service are desperately trying to do as much as we possibly can within our own limited personal resources, and many of us are working way beyond what we should be doing, which then eventually leads to burnout, vacancy, sickness levels that are higher than before, and it becomes far from a positive cycle, it becomes a negative cycle. David. I recall that I used previous incarnation as a clinical director, and I remember hearing various management sort of things, there is a phrase discretionary effort, which is used by chief execs or that kind of strata, and it's kind of filters down, and what it actually means when you actually get to the bare bones of it, it means we want people to work for nothing. I think that I've reflected over this, and part of that has been a professional up to a point, but it's unfair. I do wonder, I think, very often we think, why are so many doctors going to other parts of the world, what have they got there? One thing they do have, they have much better staffing levels, so lots of the other negatives are there, but they have much better staffing levels, but then they come back and they say, oh yeah, but if I do this or whatever, I always get paid for it and somebody thanks you, and I think well in Britain full stop we expect lots of the public sector to work for nothing, and then slag them off in the press or whatever, and it's a morale, and the only feedback they get is a complaint, a significant event, the adverse event thing, whatever, there's nothing positive, they're under the caution all the time. Even just to recognition that you pay them for the work they do, or if they do it extra, there's a reward somewhere, even praise would actually be, they aren't looking for money, they're just looking for acknowledgement, and I think that kind of positive feedback is definitely lacking, and that's bringing them all down. Peter, you said about investment levels and comparisons with other countries, could you maybe provide the committee with some evidence of that at a later date, and also in relation to staffing levels? David, that would be really helpful. We will send you the figures. Thank you, thank you, Ivan. Thanks, convener, thanks, panel, it's been an interesting discussion, so I think everybody's kind of agreed on what the issues are in terms specifically of the improvement process, how we take opportunities for improvement and funnel them through the process to drive change in the system, being that small issues are larger issues, and I suppose I just wanted to explore the next kind of step on that, and you've kind of covered some of this, but maybe gone in a bit more detail. If we're all going to move forward and fix or make progress in this area, there's a number of things that could do, I mean there could be issues about culture, there could be issues about the way that organisations are designed in their role perhaps of health and improvement Scotland, and that's something that we've heard in earlier sessions. Is there an issue with leadership in the health boards? Is there an issue with the Scottish Government given clear direction? Is there a need for legislation to change the way that we do things? Is there issues with IT systems? I mean what part of that would you start with to try and make some progress here? Peter, do you want me to go back? It's never great to just repeat an answer, but sometimes what we have to do is to think broadly about what's the whole system situation here, and that's very much what my colleagues and the BMA and GP negotiators have done. They're not just going, well, we're stuck with this situation and we'll tell you what's wrong with it. They're saying, let's think broadly, let's use all of the resources that we have already, while still at the same time saying that we need more resources again. I think that that is a good example. It remains to be seen whether it will be one that finds favour with the GPs of Scotland, although the initial feedback at road shows that are happening just now is positive. That's a way of saying, here's the situation as it is, let's do the best we can within that situation, while still also making clear that we need to improve the funding position. I think that it's echoing that to a degree, so it does come down, unfortunately, we are some like a broken record, to resources because, and I think even you asked me, off the top of my head, I think in terms of doctors per head of population, there's only like Slovenia and Albania have less than the UK, and certainly into the hospital beds it's the same to everybody else has got more of that, but this is a very difficult problem to solve because it's not just about government or healthcare, it's society as a whole. We have the most efficient, and it is the most efficient healthcare system by the Commonwealth Funds. Efficiency is very good, and it's to be lauded, but the, let's say, patient-centeredness and efficiency are usually diametrically opposed when you analyse it to a degree. If you want to spend a lot of time with one person, that's kind of why people sort of like things like alternative medicine, the biggest impact is somebody spends two hours listening to them properly as opposed to 10 minutes in a GP surgery or less, but it's going to be very difficult. The whole is such a big societal issue, it will be difficult. People will have to accept how much healthcare actually costs, understand what it's going to take to pay for that if you want it to be high quality, or choose not to do that and unfortunately have to live with the kind of healthcare that you're paying for, it does come down to that, but I think there's a mismatch or a problem with perception about what the cost of high quality healthcare looks like in an OECD country and what we're paying in the UK, and we're getting very, very good value for money, and a lot of people are working very, very hard on the behalf of their patients to make that happen, but unfortunately we need to find more money from somewhere to do what we have to do, and that, as I said, that's societal, governmental, all the rest of it. Everybody has to think about that. Yeah, I think I would completely reiterate what Peter said. It's about having a joined up approach, and I think that the narrative is, or from our point of view, we sometimes feel the narrative is very doctors and nurses, and I think that what the new GP contract does is recognise the contribution that many professionals can make, and so there's some lovely examples in there of where EHPs are working alongside GPs taking significant parts of their caseload and leaving them to the real doctoring that others can't deliver, so it's about the right person doing the job, and I think that that would be a start, so if we're looking, for example, going way back to when we talked about four hour targets in A&E, it's about looking at that across the piece rather than just looking at that, what's happening in the emergency department. So yeah, changing the narrative and looking at budgets, because I think all too often I think I've said that already, but budgets are set, and there's this bit of budget and that bit of budget, and the new approach might be something new and innovative, but there's not a budget there to cover that, and perhaps by losing, dare I say, another post that the right person could then step up and deliver a safe, effective service that the patient needs. Thanks very much. I think that you've hit on one of the most important questions of this inquiry, and that is how do we fix it? We're identifying some issues, what can we do, and I absolutely agree with my colleagues that it's got to be increased resource and staffing, et cetera, but alongside that, we've got to make sure that we do address the cultural issue and make sure that there's an openness and ways and means of staff members and service users being able to have open dialogue and discussing what's their experience, what can they learn from their experience, and how can we address some issues with systems. I don't doubt it is about communication, it's about having better informed staff, better educated staff and good leadership by example, where those in the NHS in Scotland are showing a willingness and incentivising everyone involved in healthcare to point out when things aren't going as well as they should and what we can do within the confines of our finite system to address those. Education is going to be one of the key components if we're looking for one or two staff members. At MPS, we run loads of different mastering risk workshops and really at the heart of each of those different topics is around good communication and making sure that you're identifying and speaking to your patients to make sure that they know what's going on and that any issues are flagged up very early and it just stops it going snowballing into the claims that you were talking about. I was going to say that on terms of legislation. The RCN Scotland is calling for safe staffing legislation, which is focused on ensuring safe, effective quality care through the provision of appropriate staffing. For us, that would be a major step. The other thing that I think is worth raising here is that we're talking about healthcare delivered as part of an integrated health and social care system now and anything that gets delivered as part of primary and community care will be overseen by integration authorities. We haven't talked about them at all today and I think it's really important that we flag it because we're hearing from work that we've done with our members that there's a need to move towards more robust clinical care systems within integrated health and social care. Some IAs have done this work, but there are some that really need to get started on it and that it's not to a level that our members feel assured by. From the point of view of a service user, people should have the right to expect the same levels of clinical care governance and transparency from services that are commissioned or delivered by integration authorities as they would services delivered directly by NHS boards. For us, that's a major area that we need to start looking at in terms of understanding how care across all of acute and community and primary is delivered. Alex, you want to—no, you're okay. In terms of driving all this ambition for change and the like, whose role is it? Whose responsibility? I know you'll all say it's all our role. I know you'll all say that. That's the answer that we expect, but is ultimately the job of health improvement Scotland? Do we need an independent regulator or do we need the health boards to up their game? Will there be integration authorities? Who's going to be held accountable for it? I think it's everyone's responsibility. I don't think we can say it's who's going to. Everyone does it not end up no-ones. There's that risk, for sure. Regulation legislation serve its purpose, but at the end of the day, healthcare is already a very heavily regulated profession. Our members are talking about multiple jeopardy, one clinical incident leading to a complaint, a fatal accident inquiry, a GMC referral, press intrusion, and all sorts of other issues arising from just one clinical incident. I'm not sure that necessarily more regulation is going to be the key to getting what we're looking to achieve and finding a means of using those processes that we already have in place for looking at and regulating and checking the levels of safe practice and embellishing those, making those more fit for purpose and involving the different levels of staff within the NHS in Scotland. I don't think necessarily that you can say there's one body or one person who's going to be able to have full and appropriate oversight. I'd certainly counsel against further regulation. It's useful to look south of the border at the CQC, which does external investigations of all different health premises. The experience of BME members south of the border is that that's often a negative rather than a positive experience. It's also very clear from the high-profile scandals of extremely poor care that many of them had very positive or certainly passed their CQC assessments not long before it became clear that there had been systematic problems for years. An external regulator coming in to look will often miss what's really going on and what will change what's really going on is ownership by managers and clinicians on the ground. I'm just under the current system. David, in your paper, it says that some of our members and fellows working in Scottish emergency departments have reported that duty funding constraints, organised approaches to clinical governance, have been significantly diminished or abandoned altogether. I refer the people who are saying—I'm using my new experience here as well—seven or eight years ago that it was a better support staff network and gathering information to measure. If you were looking to drive clinical governance in an emergency department, you might identify five or six key things that you want to be good at because it's very important, things like times of things or compliance with sepsis bundles or alluding to the work that comes out of things like SPSP and HS, but you would have people who would help you do that. There would be somebody who would say, right, let's create an information system and we'll help regulate it and we can have run charts or SPC charts or all the things which can be good. That's gone. Those people aren't around. If you say, can I get that, then no, we're not funded to do that anymore, we're not resource to do that anymore. There is an element of support staff who would help you implement and measure to give you the feedback to improve your systems that's not there anymore. It was five years ago, it's not now. I can't. The things we're measuring are slowly being eroded, so you are measuring less because—and therefore it's very difficult to say, well, how well are we doing? It's very time consuming. Your alternative is then, as a clinician, to try and take more time to laboriously collect stuff which should be very easily because the electronic systems will probably give the answer. Yeah, I don't know. It would appear to me that from the conversation we've had this morning there's sort of two areas. One is culture and the second is resources. And probably the culture one is where the answer is everybody is responsible. Everybody needs to feed into changing that culture and turning it into a true and meaningful improvement culture. The second one on resources perhaps has a more direct line of responsibility. That's one that, you know, we've all said that the right quality of care can't be delivered if the right people aren't there to deliver it. So we don't want an independent regulator. We can't identify a key organisation to drive that change. It's all going to come about by everyone holding hands. Is that how— Most specific. In my ED, if I was a CD, I would be responsible for providing good care as a clinic. Every doctor is responsible for doing that. People have various interests of things they like more than that. If someone was an enthusiast, they'd do a better job. So there is a general consensus, I'd say, certainly with the emergency medicine, of what good care looks like, what elements should be there, what staffing level should be there, which members of staff should be there, what standards you should be aiming at. But the difficulty then is, as I said, setting up the system and then measuring it to make sure you're providing it. Before you just relied on doctors being good eggs to do the best, whereas that's not good enough, you need to find some way to measure it. But the resources to measure the things you want to measure, they're not as good as they were. They're still there, but that's how you would attempt to do it. So I think certainly every doctor should be—it's part of good medical practice, it's part of your appraisal, all these sort of things—is to keep up to date. So there is an individual, but also a systemic depending on where your responsibility lies. And one of the submissions don't get—had an appraisal? No, well, appraisals again can sometimes be a box ticking exercise, but I think the intrinsic motivation amongst most staff—it's a large organisation, there'll be staff who aren't like this—there will always be stories—there'll be an anecdote for every situation, every story will be true, but it's a question of what's the majority. The majority of people, I think, want to do well and they know what they need to do to do well, but there's something stopping them and isn't what's coming down to resource a lot of the time. So are we saying then— It is everybody on an individual level, on an organisational level, and above that I say things like SPSB sign, using NICE as an example in England. I have somebody to set a standard, a consensus standard, those are there, it's making it happen and most people accept them. So is the key element hard cash? I'm afraid so. It's all like a broken record and we would say that wouldn't we, but it's a big deal. Yes, of course it's very important. I know what a lot of them are. I just want to, yes, but also to make the same point again, that staff have authority to act, that they can make changes and act in relation to the feedback that they get or that they have exposure to. So if learning is coming back through to nursing teams, for example, does their team leader have the authority to make changes that means those improvements can be implemented? I'm sorry, Alison, I forgot about you. It's been a really interesting evidence session. Thank you all very much. I think there's much we'll take away from this morning. Last week, we heard from witnesses from Action for ME, from Down syndrome Scotland and from Age Scotland, and I think there was general concern about patients who had found themselves being treated without dignity or respect. The particular case raised by Down syndrome Scotland, for example, is if a parent had taken their child for a vaccination and they'd been asked a lot of developmental questions to which they constantly had to answer no, and they just left feeling really downhearted and distressed. This is an area where there's not a lot of regulation around treating people with dignity and respect—something that we would all expect. I just wondered if you have a view on what needs to be done to ensure that all patients are treated with dignity and respect. I'm really glad that you've raised that. I put down three points that I wanted to make sure I put across the day, and one of them is that this is about patients. Dignity and respect suffers in the circumstances that we're in. My example comes from my own clinical specialty of psychiatry, where it is frequently the case now that, when we have someone who requires emergency admission, they will be waiting for hours and hours with no indication of where that bed is going to be, often being fed what little information we have. We think that we might have a bed in Perth—I work in Paisley. We might have a bed in Edinburgh, and then you don't. We've got people who will be not admitted overnight but on the ward waiting on a sofa to get a bed. At the time, when that individual and their family are in a real crisis to be admitted to a psychiatry unit, you've got to be very unwell. It's a complete failure to treat people with respect and dignity when they're at their most vulnerable, and that's exactly the same situation with the example that you're giving. It flows from a situation in which we are constantly having to deal with the lack of availability of appropriate care. Others on the panel will tell you about that, and that runs across the health service. No one's being treated poorly, deliberately, and very few are being treated poorly through thoughtlessness either. It's mainly through systems that simply can't cope. Is that a view that's shared by other witnesses? As the HPs twice a year, we do the care audit, and across the HP professions, our scores are actually really quite good. That was a tool that was developed for GP trainees, but did you feel listened to? Were you able to ask your questions? Those are skills that are there, but it comes back to pressures on people. Therefore, if you're feeling under pressure, if you're not quite comfortable or feeling very confident with the patient that you have in front of you, that's when these errors or poor communication starts to creep in. It's things like supervision sessions and even doing your annual KSF reviews. You can see these as a tick box exercise, or you can see them as a useful learning exercise, where you have time to reflect and talk through the learning that you can take. If somebody did have a session like that, where you're asking question after question, they would be no. I would be saying to my juniors Phil really, how could you have changed that? How could it have been better? That's about having that time set aside to actually have that learning on the job. As Peter says, nobody wants to carry out that bad consultation, but I think that they happen probably due down to the pressures that are on staff and through their not having access to proper supervision and learning. Sam H, last week, highlighted that they'd undertaken a survey and 40 per cent of respondents had said that they felt that they'd been treated disrespectfully. They may have been engaging with your service, Dr Benny. I know Lorna Greene mentioned nurses who may be dehydrated and haven't even had a chance to visit the loo. I do understand that this is a complex area and I suppose there's the frustration that it's impacting on patient care. Your view is that this really is a matter of resource, obviously it's a matter of culture and an understanding that every patient has to be treated with respect. In line with the NMC code, all nurses should be delivering care that is dignified and respectful of the people who are receiving that care. Certainly, as colleagues here have said, resources, pressure on time, staffing will all have an impact on the quality of care delivered and that is not desirable from anyone's point of view. The other thing to mention here is to speak about the extent to which all experiences are captured and how they're used as part of a feedback loop to people delivering care. If it was a case that someone just genuinely hadn't realised their action was interpreted as disrespectful, was there a mechanism by which that person could raise their concern and have that go back to the member of staff and have it dealt with in a really kind of proactive and productive way that meant that they could ensure something similar didn't happen again. We're again talking about feedback loops but they're so important in terms of any kind of learning actually taking place in a meaningful way. We have to look at whose feedback we get in terms of service users, how much are we listening to children and young people, how much are we listening to people with disabilities, people in prison who receive care, whose voices are making it back in the feedback. I think that's something to always keep an eye on because that will have an effect on how learning can improve the care that they receive in the future. I suppose that there are two aspects to this. There is the fact that staff are under increasing pressure and it's also difficult to address some of these issues if we don't have sufficient time for CPD. That's fine, convener. Thank you. Before we finish, I want to say thanks very much for being a really interesting session this morning. I'll give you 30 seconds each to tell us if there's no more money coming forward and if there's no more staff, then how are we going to deliver on some of the priorities that you have suggested this morning? You just described the status quo, so this stuff will happen in a fragmented way, in an ad hoc way, because things will still happen, perhaps to everyone's satisfaction, but the staff won't stop trying. That's been relied on to try and get us through, but we need a better system than that. Peter. The one thing that we've maybe not talked as much as we might have done about is trying to foster better engagement between managers and clinicians on the ground. I talked a little bit about the learned helplessness concept, what's the point in telling them they won't do anything, often if you tell them they will try to do something. We've got to foster a better, more positive culture across managers and clinicians on the ground. I would just simply say that it is the right person at the right time to deliver the care, and so therefore, don't forget about AHPs around your table. I think that the impact on staffing will continue to hit hard and there will be an increase in vacancies, either through sickness or people leaving the profession, if they don't feel they can deliver the care that they were trying to. Thank you. I would suggest a three-pronged approach. I will go for leading by example. Let's empower the leaders. Secondly, let's educate staff and patients alike about feedback. And three, let's make feedback commonplace. Let's have it open. Good and bad feedback is coming in from both staff and patients and being acted upon. Okay. Thank you all very much for coming this morning. As agreed, we will now go into private session.