 The next section is a statement by Humza Yousaf on NHS 4th Valley update. It will take questions at the end of the statement or there should be no interventions or interruptions. I will allow a moment for front bench HEEs to organise themselves. Thank you, Presiding Officer. There is no doubt whatsoever that in the face of a global pandemic these last two and a half years have been quite easily the most difficult of the NHS has ever faced. It is my belief that the vast majority of the public are, of course, understanding of these difficulties but equally they quite rightly expect their health board to provide the required leadership to help navigate through these really difficult waters. Over the course of last year, a number of elected members from right across this chamber have raised a variety of concerns in relation to the services being provided by 4th Valley health board. Today I am providing an update on the actions that we have been taking that we will continue to take to address those concerns. I can today confirm that the Scottish Government has taken the decision to escalate NHS 4th Valley to stage 4 of the NHS Scotland performance escalation framework. We are doing so for the issues of governance, leadership and culture. The Scottish Government has been engaging with NHS 4th Valley for some time in a range of performance-related issues. Members may be aware of recent reports published by Health Care Improvement Scotland in relation to the safe delivery of care in NHS 4th Valley royal infirmary. Indeed, his have carried out several unannounced safe delivery of care inspections just this year due to on-going concerns about the safe delivery of care. His have escalated their concerns to the Scottish Government, as they have not seen the required improvement in 4th Valley since the very initial inspection that they undertook. His is expected to publish its most recent report in the coming few weeks. There are also concerns with the sustainability and integration of GP out of our services in the region. Indeed, we had a member's debate on that very issue in this chamber. Consistently, poor A&E performance against a four-hour standard and there are also issues relating to the integration of social care services. Whilst poor performance in any of those discrete areas is of concern, I expect effective governance strong leadership and improved culture to deliver sustainable change. Unfortunately I have not seen the necessary leadership required to drive improvement in those areas of concern. That is why the focus of this escalation is on governance, leadership and culture. Stage 4 escalation comes into effect from today at Wednesday 23 November and brings direct formal oversight and co-ordinated engagement between the Scottish Government in the form of an assurance board chaired by Christine McLaughlin, the director of population health. The purpose of the assurance board is firstly to support NHS 4th valley and determining what steps are necessary to ensure the delivery of high-quality governance leadership and culture in NHS 4th valley and in doing so to support improvements in relation to a range of performance and quality-related issues. Second to advise the director general for health and social care through agreed governance routes that such steps have been taken with the DG updating me on a regular basis. In delivery of that, the assurance board will seek to ensure that appropriate governance is in place, particularly with regard to providing scrutiny of performance, leadership style and indeed practice. The assurance board will scrutinise the NHS 4th valley improvement plan and hold the leadership to account for the effective delivery of improvement actions in the timescales that have been agreed to. In doing so, we will work to ensure that the leadership is operating in an effective and inclusive manner, particularly when understanding and managing performance issues and that there is a positive and inclusive culture in NHS 4th valley. The group will also consider any lessons learned that can be shared across wider NHS Scotland and will provide advice around the future escalation status of NHS 4th valley, including criteria for de-escalation. The first meeting of the assurance board will take place next week to ensure that improvements are delivered as quickly as is possible. I have asked Professor Hazel Borland, former nurse director and interim chief executive of NHS Ayrshire and Arran, and Dr John Hardden, the deputy national clinical director, to lead the senior-level external support to the board. Healthcare Improvement Scotland will also provide tailored support to deliver on the actions that it set out following recent inspections. Professor Borland brings a wealth of experience, since she will work jointly with Dr Hardden, the Scottish Government directors, Healthcare Improvement Scotland and other delivery partners to support the senior leadership team to deliver those required improvements. That includes supporting NHS 4th valley and the development, agreement and delivery of a co-ordinated improvement plan across the affected service areas. As I have already set out, the Scottish Government has been engaging with 4th valley for an extended period of time across a range of different issues as part of the standard board sponsorship work and a response also to on-going concerns that have been raised. This engagement and on-going support has been crucial in providing the board leadership with the time and space to take responsibility for change within its own organisation. Escalation is a last resort, not a decision that is taken lightly. It is a decision that we have had to take following a consistent demonstration that the NHS 4th valley leadership team is unable to follow through with the transformational change that is required without additional formal support and monitoring. To that effect, John Burns, the chief operating officer of NHS Scotland, Caroline Lam, the director general for health and social care, met with the chair and chief executive of NHS 4th valley. I have spoken to both the chief executive and chair today to convey my concerns, but also to articulate clearly my expectations for immediate and sustained improvement in the period ahead. They have agreed that the assurance board will review and scrutinise the improvement plan developed by the NHS 4th valley leadership team. That will set out short, medium and longer-term actions. I expect the improvement plan to be developed and presented to the assurance board for scrutiny at its first meeting next week, with a focus on completing immediate actions in a matter of weeks as opposed to months. While lasting change will take time, it is crucial that we see urgent and tangible improvements in the coming weeks and months ahead. NHS 4th valley already has a number of clear actions and recommendations against which we expect them to deliver. That includes work to strengthen the integration of health and social care, out-of-hours services to make improvements in unscheduled care and mental health services. I expect the NHS 4th valley leadership to work collaboratively with the council and IJB partners to deliver the necessary changes, including the development of a shared narrative that expresses their ambition for integration of health and social care services in the territorial area. I also expect the NHS 4th valley to take the findings of the healthcare and improvement in Scotland inspections extremely seriously. It is imperative that the leadership team delivers immediate improvements against the recommendations and requirements that are set out in those reports. Of course, I will monitor progress in that regard very, very closely. NHS 4th valley is also one of the poorest-performing boards in terms of psychological therapies and CAMHS, and there has been less progress than we would have hoped to have seen compared to other areas. I have already been providing tailored support to help with meeting the standard, providing access to professional advice and also ensuring that they have robust improvement plans in place, again all being monitored very closely. The actions that I have described today are not exhaustive but provide an insight into the type of change that is required within the health board. I will support NHS 4th valley to remove the barriers that impact on its operational performance and on its pandemic recovery. To close, I would like to put on record my thanks and appreciation to the staff who are working tirelessly across NHS Scotland and NHS 4th valley to deliver the high-quality care that we expect. Stage 4 escalation that I have announced today is not a reflection on staff who are working tirelessly to provide care for the population of 4th valley. However, we must recognise that there are continuing concerns in relation to leadership in 4th valley to effectively respond to those issues when raised. It will, of course, take time for NHS 4th valley to assure the public and indeed the Scottish Government that sustained improvement has been made. I hope that the statement itself provides some assurance that significant work is already under way to address the legitimate concerns that have been raised. I will continue to, of course, update Parliament as progress is made and, of course, I am happy to continue engagement with elected members right across the chamber. Thank you. The cabinet secretary will now take questions on the issues raised in his statement. I will allow around 20 minutes for questions after which we will move on to the next item of business. I will be very grateful to members who wish to ask a question. Where to press now? I welcome this announcement today and I fully support the bullied, broken and burnt out front-line staff of NHS 4th valley, but I also urge patients to continue attending when required because the staff are still excellent. As shocking as the allegations at NHS 4th valley royal hospital are, this is only one example of how the health service under the SNP simply isn't working. We have five consultants quitting in NHS 4th valley amidst a culture of bullying. £2.8 million paid out in compensation at NHS Highland amidst a culture of bullying and complaints of harassment in NHS Tayside tripling over five years due to a culture of bullying. Yet an FOI, submitted by myself to 4th valley, revealed that no NHS 4th valley managers have faced any sanctions. A bullying culture seems widespread throughout our NHS. Insiders at NHS 4th valley royal hospital have called it unsafe, toxic, a war zone with staff working in intolerable conditions, but what struck out to me the most was a quote claiming that an irretrievable breakdown of working relationships had happened between staff and leaders. My question to the cabinet secretary with allegations of a toxic culture dating back to July of last year, will he guarantee action being taken against those responsible and can he commit to a root and branch investigation of this toxic culture in NHS 4th valley, but also across Scotland? The Spanish Gohanny, for his question, can I also associate myself with those remarks and reiterate the remarks that I made at the very end of my own statement, which is that this is not a reflection on really hard-working exceptional staff right across NHS 4th valley, regardless of what job they have in NHS 4th valley. They are an integral part of that health service and a flet health board. What I would say to Dr Gohanny is that the reason why I have included culture within the escalation framework is because of some of the concerns, many of the concerns that he is right to raise and indeed other members have raised very much in this chamber. So immediate improvement and sustained, and that is really important for me to emphasise that word, sustained improvement in culture in NHS 4th valley is absolutely key. I do not agree with his assertion that there is a widespread boolean culture in the NHS. There are, when you have an organisation the size of the NHS, the largest employer in the country, you are unfortunately going to have issues around culture. It is important that we address them and therefore I am committed absolutely to doing that. What I will also say is that having met every single whistleblowing champion across the boards in Scotland, categorically, I note not only support that whistleblowing is an important mechanism to raise concerns, but I would hope that every single member of the NHS feels confident in the whistleblowing processes and their complaints will be taken with the utmost seriousness. Jackie Baillie Let me start on the point of consensus with the cabinet secretary, because today's decision is not a reflection on the dedication and hard work of staff who are working day and night to care for patients. Instead it demonstrates beyond doubt that this cabinet secretary has let down the staff and patients in 4th valley and the facts speak for themselves. The health board is repeatedly the worst performing for A and E waiting times, and that is despite the valiant efforts of A and E consultants and nurses. The most recent figures show that, in September, only 58.8 per cent of patients were seen in four hours. The Royal College of Emergency Medicine is very clear that they have warned that long waits result in poorer patient outcomes and risk lives. In June this year, Healthcare Improvement Scotland published its inspection report. That report flagged up serious concerns about patient safety due to a lack of nurses. This is not a health board problem. This is a system-wide NHS problem over which this cabinet secretary presides. Can he perhaps explain why, given the clear risk of harm to patients, that it has taken six months for him to act? Can I say to Jackie Baillie the concerns around A and E that she expresses are concerns that not only I share but I suspect are shared right across the chamber here and also across the population of Forth Valley. That is one of the reasons why I have asked Dr John Hardin, who is not only the deputy national clinical director, who currently works as an A and E consultant in NHS Lanarkshire. We will bring that specific expertise in that regard. Why has it taken so long? It is a reasonable question for Jackie Baillie to ask. We know, of course, that being in the midst of a global pandemic, our A and E departments right across the country are challenged. Escalation is genuinely a last resource. We have been working with the board to see where we can see improvement. There have been weeks where there has been fluctuations and we have seen some improvement, but that has not been sustained. I come back to that word, which is incredibly important, that we want to see not just immediate improvement but sustained improvement. The reason why we have got to this point and it has taken some time is because escalation is not a decision that you take lightly. It is an absolute last resort, particularly when you are escalating to level 4. I am happy, of course, to keep Jackie Baillie updated, particularly in relation to A and E. I thank the cabinet secretary for his statement. The situation he outlines is serious. I know from my previous career, including managing large transformational change programmes, that organisational culture is set from the very top. I understand that the chair of the board is very experienced, and I am sure that he is aware of how serious the situation is. Can the cabinet secretary therefore confirm that the board and the chair in particular understand the relationship between their overarching governance, leadership and culture, and does he believe that the board is ready to demonstrate what it takes to turn a situation around? Michelle Thomson is absolutely right in what she says. That leadership obviously comes from the top, and people take a view from the leadership in relation to the culture that permeates right throughout the board. In my discussions today with the chair and the chief executive, I have made it very clear my expectations. We have many strategies and many documents, but they are only as good as the implementation. That is why I have asked the assurance board, headed by Christine McLaughlin, to make sure that those are not just words of comfort and reassurance that we are hearing, but that we are seeing tangible improvements from the top, from the leadership, and that is then permeating, as I say, right throughout the organisation. However, we will wait to see what the improvement plan says and the timescales involved. I will be personally monitoring that, as you can expect, but let me be absolutely clear. I expect to see some immediate improvements and those improvements to be sustained over a period of time. NHS 4's valley moving into level 4 is a damming indictment of the board, which requires to ensure that facilities across NHS 4's valley are safe and fit for purpose. In the statement, cabinet secretary, you say that you will ensure that leadership is operating in an effective and inclusive manner, particularly when understanding and managing performance issues. I have heard numerous whistleblowers contact me who have raised concerns that they are not being listened to by management, experiencing place work bullying, poor working conditions, and complaining of a toxic environment. Therefore, cabinet secretary, how will you address the concerns of those whistleblowers going forward and ensure that this toxic culture is stamped out once and for all? I thank Alexander Stewart. He has often raised with me a number of concerns in relation to 4th valley, in fact, the most recent just last week. He has done so in a very constructive manner when he has raised those issues. What I will say to him is that, again, as I said to his colleague, Alexander Skohani, that is why the escalation framework is in relation to leadership and culture. What I will do on the back of Alexander Stewart's contribution is directly meet with the whistleblowing champion and some of those involved in whistleblowing in relation to NHS 4th valley, but particularly the whistleblowing champion, to see if there is any further support that we can offer. I will also speak to Christine McLaughlin, who will be heading that assurance board. She will already know my thoughts on that, but I will reiterate the importance that we place on whistleblowing and whistleblowing being effective in NHS 4th valley. There is much interest in this statement. I would like to get all members in and be grateful if we could bear that in mind. Stephanie Callaghan, to be followed by Richard Leonard. Patient safety is key in all of this. Healthcare Improvement Scotland's independent inspections of 4th valley hospital are very welcome. Can the cabinet secretary provide an update as to the next steps that we can expect to fall in those inspections? I agree wholeheartedly with Stephanie Callaghan. The his inspections and the unannounced inspections provide a great source of information and at times, including this particular circumstance, a great alarm, particularly when we have not seen improvements made in between inspections. I think that if there are a number of inspections that take place and we have not seen the required and requisite improvements, that gives me great concern. It is one of the significant reasons why we have decided to escalate to level 4. I understand that his will be publishing the most recent update on the most recent inspection at the beginning of next month. Richard Leonard, to be followed by Emma Roddick. While we all await the outcome of a follow-up inspection by Health Improvement Scotland, patients are still being nursed in overcrowded wards. Consultants are leaving in droves, and workers are not being paid properly because of management interference in a job evaluation scheme. Why has the health secretary not acted before, given this state of affairs and given this level of risk? I do not agree again with the premise of Richard Leonard's question. We have a good record that we stand on in this Government in relation to staffing of the NHS. There are areas where that has been challenged, but of course we have record high levels of staffing, including record high levels of nursing staffing too. In terms of fair pay, of course our nurses and our agenda for trained staff are the best paid than anywhere else in comparison to anywhere else in the UK. We are still in the midst of those negotiations, as I suspect Richard Leonard will know very well, and indeed those negotiations are on-going. I am very grateful to the trade unions for the concerns that they raise with me directly about staffing, and I am hopeful that we will get to a positive outcome. Emma Roddick, to be followed by Alex Cole-Hamilton. I am sure that members will agree that despite all that we ensure plans for improvement include a focus on reducing pressures on the valued staff of NHS 4th Valley, as we would wish for NHS staff anywhere in Scotland. Can the cabinet secretary say any more about the steps that are being taken to engage with front-line staff and their unions to address their concerns and support the delivery of care in those circumstances? Emma Roddick is really absolutely accurate to mention the workload pressures that are on our NHS staff in 4th Valley, but, right across the NHS Scotland, they are still dealing with the impacts of the pandemic. We know that people arriving in any departments and inter-acute sites are presenting with higher acuity, for example. That is why, yes, I will continue my engagement absolutely with trade unions in this regard. We will also do what we can to increase staffing, and she will know that, in my most recent winter update, I announced further funding to recruit 750 nurses, midwives and the HPs from overseas. We will continue to invest in staffing to help our NHS during what will probably be one of the most difficult winters it has ever faced. The issues brought to Parliament by the cabinet secretary this evening are deeply alarming. I know that staff and patients will want to see a positive outcome from the steps that he has outlined in the statement. One of the most concerning points that the cabinet secretary made is the statement that 4th Valley is one of the poorest performing boards in terms of child and adolescent and health services and psychological therapies. That will undoubtedly impact on those children and young people living there waiting for treatment. I therefore ask the cabinet secretary if any specific steps will be taken to improve 4th Valley's performance in this area, and if he is still confident that, in March 2023, the target of 90 per cent of patients being seen within 18 weeks will still be met. That remains the target, and we will do everything we can to try to meet that target for March 2023. I will not pre-empt the improvement plan, but we would absolutely expect there to be specific and detailed action alongside timelines and timescales in relation to psychological therapies and CAMHS. I assure that there is a written update from me by the end of the calendar year to members across the Parliament so that they can receive that update, but I can also commit to regular updates if there are very specific issues that members wish to raise with me, too. Can the cabinet secretary expand on what help the Scottish Government can provide to support the health board to develop an action plan to deliver improvement? I can be relatively brief, but the assurance board will be critical to that improvement, and that external support that I have already referenced in my statement will also hopefully be able to provide support. I do want the assurance board to be that supportive yet challenge, that critical friend that will challenge 4th Valley's leadership to make sure that they are ambitious in their timescales for improvement, but also realistic. I have mentioned Professor Hazel Borland, the former nurse director and interim chief executive of Ayrshire and Arran, and Dr John Harden, the deputy national clinical director, who I have also provided that support. I think that tailored support from his will also be very helpful in that regard, too. I recently met with RCN to discuss its concerns about the leadership and culture at 4th Valley health board in my region, and I would like to thank them for their open and honest discussion. The A&E has rightly been noted in many questions. Can the cabinet secretary assure me that the improvement will be sustainable and that the input of staff from all sites will be taken into account when discussing improvement and not just the acute site at 4th Valley Royal Hospital? On that latter point, absolutely. This is a 4th Valley NHS 4th Valley escalation. It is not just in relation to 4th Valley Royal Firmory as the major acute site. I can give that absolute categorical assurance in relation to the latter question that Gillian Mackay asks. She is also absolutely right that the improvement has to be sustained. That is why of course one of the areas of concern is A&E performance, but related to that is social care integration. We know that Gillian Mackay has raised again her concerns around 4th Valley with me very constructively over a number of months. We know that if we can see improvements in social care, we will help with that bed capacity and flow through our hospitals. Ultimately, it is better for the individual who is clinically safe to discharge, for example, to be out in their home or in a care home close to their home as possible. I can give Gillian Mackay an absolute guarantee that there is a whole systems approach being taken in relation to the escalation framework. Siobhan Brown to be followed by Rose McAll Thank you, Presiding Officer. The Cabinet Secretary will be aware of recent reports concerning strained relationships specifically among managers at 4th Valley. Can the Cabinet Secretary say any more about steps that could be taken to support culture change for leaders at all levels? I will perhaps write to Siobhan Brown with a detailed written update because we have quite a lot of programmes that help to foster that positive leadership and a positive compassionate leadership, leading to change, for example, of the Scottish Government's national leadership development programme. I was really pleased to launch that earlier this year, but there is a whole range of initiatives that we have. I go back to the point that I made to a previous member, which is that we can have all the strategies and programmes in the world. What we want to see is delivery and implementation on the ground. That is where the assurance board, headed by Christine McLaughlin, will be holding NHS 4th Valley's leadership set at their feet to the fire in order to ensure that we see that leadership change being implemented in a timely manner, but also in a sustainable manner, too. I will continue on a point that Alex Cole-Hamilton made. On 22 September 2016, the First Minister in this chamber said that the performance of NHS 4th Valley is unacceptable, and it has been made clear in relation to child and adolescent mental health waiting times. Today, on 23 November 2022, the statement says that 4th Valley remains one of the poorest performing boards in terms of cyclostitial therapies and CAMHS. That you have been providing a tailored support and you are monitoring closely. Can the cabinet secretary tell me how the Scottish Government has allowed this to go on for so long, and does he agree that our young people deserve way more than close monitoring? It will be more than just close monitoring. As I have just said in a number of answers, what I expect to see is tangible improvements on the ground. I will say absolutely candidly, and I have said this on many occasions before, that we know that there was challenges in relation to the pressure on CAMHS pre-pandemic. There is also no doubt, I do not think, from anybody here that that has been exacerbated by the global pandemic. Of course we will want to ensure that we meet our targets as we have set them out in relation to psychological therapies and CAMHS. What we will also do is invest in pre-crisis interventions too, but I can give an absolute guarantee, as I did to a number of members who have asked a very important question around mental health, that when it comes to the improvement plan for NHS 4th Valley, it will include tangible steps for improvement in relation to CAMHS and psychological therapies. That concludes the ministerial statement of NHS 4th Valley update. Apologies. I would like to draw members to my risk of interest as a practicing interest doctor. Thank you Mr Gilhane. Your comments are on the record. Thank you Presiding Officer. During the urgent question earlier, my colleague Ross Greer referenced the number of votes that were won by ourselves and the SNP and the corresponding number for the Tories, Labour and the Lib Dems. During that question, from a sedentary position, Douglas Ross was heard by several members in this chamber shouting, he's lying. Presiding Officer, I would like to provide a small maths lesson for Mr Ross, despite the fact that he's not here. Of all votes cast, both regional and constituency votes, the total for the Greens and the SNP was £2,640,892. For the Tories, Labour and the Lib Dems, that total is £2,624,835. Ms Mackay, if I may, as I said yesterday, points of order must refer to matters of procedure that relate to the standing orders. Presiding Officer, that was my exact next sentence. Given that this is the second time in a week that Mr Ross has used language to either imply or directly accuse others of lying, could you tell the chamber, is this a breach of the code of conduct and what mechanism can be used to address such poor behaviour? Within months, within months of this Parliament's establishment, the first Presiding Officer, Sir David Steele, set out the position that, while challenges to the accuracy of opinions and facts are perfectly in order, and I will always respect the right of members to make such challenges, the chair will not tolerate an accusation that a fellow member has been deliberately untruthful. I will always protect the rights of members to scrutinise and to challenge each other. However, I will say that, where I am clear that an accusation of that nature has been made, I will intervene. The next item of business is consideration of business motion 6.914, in the name of George Adam, on behalf of the parliamentary bureau setting out a business motion. I call on George Adam to move the motion. Thank you, Presiding Officer, and moved. Thank you. No member has asked to speak on the motion. Therefore, the question is that motion 6.914 be agreed. Are we all agreed? The motion is therefore agreed. There are six questions to be put as a result of today's business. The first is the amendment 6.899.2, in the name of Humza Yousaf, which seeks to amend motion 6.899, in the name of Jackie Bailey, on protecting primary care, be agreed. Are we all agreed? The Parliament is not agreed, therefore we will move to a vote. There will be a short suspension to allow members to access digital voting.