 If 감사 원 peth pol Children to the 21st meeting of the Public Order at Post Legislative Scruptionary Committee in 2017, I want to ask everyone, in the public gallery, which as Nobody there at the moment, to switch off their electronic devices or switch them to silent mode so that they don't interfere with the work of the committee. Gender item one is a decision on taking business in private. Do we agree to take item three in private? Yes. Hyderbynau'r dod yn arry i nhw Gideunigustrindiau Yw'r Extreme Dqacks palenedd, Erwyn 22 ariydolwch chi, oedd yn gwir diododus yng Nghymru Cymruuno Yw'r Fioneng Cys. этогоch chi nodi'r peruf o Daenuh darkness cyniais perffredegedd, Ac yn cael lapid thymwr ar gyfer dda'm gwir yng nghyngngung cyffernidau MFF mag delayo. Hesthiswch amais cael gwir amranydd dros ein Pwrdd i cefnaiín Lleil ar taith ac, yn ymlaen, o bobl cynlluniaeth, yn cynhyrchu cyfrifau sy'n nosydd. Yr awdwyd ymddangos yn ddechrau'r ystod yn 2019, ac mae'n allwch yn dros gyfwyrdd y cyfnodau cymorthol yma, byddai cyfnodau a'r gyffredinol. Mae gweithio'r pethau yn gweithio ar gyfer y Gwyl Gwyl Gwyl Gwyl Gwyl Gwyl Gwyl Gwyl Gwyl Gwyl sy'n cyd-dill, ond mae'r cyllid ystafell yn fwy o ffordd o'r rhan o'r ffordd. Mae yw cyllid yn cyd-dill ar y cyllid 13 o'r rhagor. Fy fyddwch yn cael ei gweithio gadeithasol o'r Ffng Caerdydd ym Mhs yn ystafell yn ystafell ffasill, ond mae'r cyllid yn cyrraedd a'r rhan o'r ffordd yn cael eu gweithio'r rhan o'r ffordd. Mae'r cyllid yn cyllid yn cyrraedd o'r Ffng Caerdydd yn cyllid yn cyrraedd. rhaid i £6,500,000,000,000, but most health boards overspent against their pay budget, and agency staff costs are increasing. The Scottish Government intended to publish a national workforce plan for health and social care in spring this year. The plan is now being published in three stages, with the first part published in June covering the NHS workforce. I've highlighted in previous reports the need for a clear workforce plan to ensure the right staff with the right skills for new ways of working. The published plan doesn't set out detailed actions to deliver this workforce, instead it provides a broad framework setting out the challenges ahead and further work to be done. Demand for health and social care is expected to continue rising, but neither the Scottish Government nor NHS boards have adequately projected how this will affect the workforce numbers and skills needed in the longer term. The Government's processes for determining training numbers are largely placed on replacing current numbers in the workforce, with some consideration of previous year's growth. There are also concerns about sustaining the current workforce. Vacancies for some consultant and nursing positions remain high and are proving difficult to fill. In addition, upcoming retirements may increase vacancy levels in parts of the NHS. For example, over a third of the nursing and midwifery workforce is over 50, while the number of newly qualified nurses in Scotland available to enter the workforce fell by 15% in 2014-15 and a further 7% in the following year. The national workforce plan recognises that between 2017 and 2020, the number of existing students entering the workforce won't be enough to meet demand and states that around 2,600 additional nurses and midwives will be needed by 2021-22. This figure may be an underestimate. As I said, insufficient work has been done to determine what future demand will be and there are shortcomings in the data on how many nurses may retire in this period, as well as other factors such as the impact of Brexit. Finally, responsibility for NHS workforce planning is confused, shared between the Scottish Government, NHS boards and regional planning groups. The development of health and social care integration authorities and new elective centres may add to this confusion, and separate planning processes for doctors, nurses and other professional groups make it more difficult to consider how skills across different groups in the workforce will complement each other. The NHS is undergoing major reform, but the funding needed to support this reform does not clearly identify the expected workforce costs associated with the changes. To improve workforce planning, more clarity is needed on lines of responsibility, the workforce supply and skills available and the needs of the Scottish population in future. Convener, as always, my colleagues and I are happy to answer the committee's questions. Over all, the report is not a bad report, but there is a bit of deja vu here. It seems that, for years now, we have been talking about proper information gathering and effective information gathering in the NHS. Has there been any improvement at all? The first thing to say is that I share that frustration that we know that the workforce is central to delivering health and social care. We have known that these challenges are coming for a long time, and there have been recommendations from us and from others over a long period about tightening up the planning, getting the detail in place and basing it on the analysis. I think that there have been some improvements, and we are certainly seeing the plans coming through being more detailed than the visions that we have seen in the past, but there is still a way to go. Richard, do you want to add to that in terms of the specific improvements that we have seen? In terms of some of the modelling that carries out that we have talked about in the report as to how the Scottish Government arrived at the numbers that they are going to put in, we have seen some increase in how they are using data around retirements from the workforce, etc., to build a clearer picture. The report says that there is a lot more to be done to bring together the information that is needed and the data that is needed to make informed decisions around the workforce. Within the national workforce plan part 1, which mirrors our recommendations in the report, the national health service education for Scotland is going to have much more control over building up a picture of the supply chain of doctors and putting together the various bits of data that are held by different people. We illustrate that in exhibit 10. Some progress has been made, but it is not sufficient to be able to build a full picture of what the workforce looks like now, and that is very important to understand what you need in the future. I am looking at Paul Gray's submission. Does that fill you with confidence? I think that it reflects the position at the moment, which is that we have the part 1 workforce plan published in June and a lot of work to do to get the second two parts out by the end of this year and many commitments within the workforce plan itself for the work that is needed to fill in the gaps and to get the detail in place. What I would say is that the commitments are the right ones. The timescale is ambitious and we will be looking closely at the progress that is made as we are working towards our second report in this area late next year. Just to pick up still on Paul Gray's report, he is talking here about allocations in terms of funding for the reform of services in future years. That is the last paragraph in his report. When will you be looking at that yourself? We are, as I say, planning to publish a second report looking at workforce planning, particularly in primary and community services next year. That will also include an update on progress against the commitments that are made at the moment. It is a theme that comes through in our annual report on the NHS as a whole every year. We provide a high-level picture there not only of what the workforce looks like and the level of vacancies and so on, but also the progress with putting in place the detailed costed plan for reform and transformation that we have recommended in the past and that the Scottish Government has accepted the need for. There has been some progress on that but we have not yet seen again the level of detail in terms of cost, staffing, infrastructure investment and so on that is needed to make a reality of it. Turning to staff costs that you mentioned in your initial presentation there, spending on NHS staff increased by 11 per cent. Is that in real towns? That is quite a lot. Is that the agency staff? Yes, the team will keep me right but I think that it is total spending on staff. Agency staff, obviously, as you highlighted, have increased by 107 per cent in six years. Of the £171.4 million in 2016-17, in paragraph 22 in your report, you say that the nursing agency costs have risen from £4.2 million to £24.5 million in real terms. What is the balance of nearly £150 million in agency costs? Do we have a breakdown of that? We cannot break it down as much as we would like to because there is only published data on nursing agency costs but Nicola can talk you through what data we have as far as the figures are able to support that. The only data that is published is that nursing and midwifery agency costs. For total agency costs, we have taken that from the board accounts but it does not break it down by staff group at all. We do not know how many people that is, we just know an overall cost. As part of one of our recommendations, we have talked about the importance of collecting more detailed information on agency. That is ridiculous, it is nearly £150 million. Shall we know what we have spent it on? We know in broad terms that the bulk of it is likely to be medical staff and members will have seen in the press reports that some very high sums pay to individual doctors where it has been essential to fill a particular gap but that information is not analysed and published across Scotland in ways that we can use in the same way that nursing agency costs are. As we say in the report and I think as you are reflecting, that is an important So, do we know if the Scottish Government is moving towards publishing a break now? I suppose that this is part of some of the data things that we have highlighted in the reports, part of the need to improve some of the data around. We highlighted in part 52 of the report that very issue around the published data, not being there sufficiently by staff groups. We also talked about the published data on vacancies and needs for improvements there. I think that there is an acknowledgement by the Scottish Government that more needs to be done to collect the information that they need. If one of the things is to look at more specifically at vacancies and also how to control agencies costs, we would recommend that this is the type of data that they should be collecting at that more granular level. Presumably Orbit Scotland asked for this information, but it was not available. Absolutely. As Nicola said, the information that is available is what is in the individual health boards accounts. Their ability to break it down varied. That raises its own question about how well people are able to manage these costs, particularly in the context where we have the new managed agency staff network being put together to try to bring them down safely across Scotland. The starting point should be a good analysis of what we are currently spending and where, so that we can tackle where the pressure points are. In your report on paragraph 22, you talked about nuisance agency costs rising from 4.2 to 24.5. It was mentioned just now that that includes midwifery as well. Do we know the breakdown between the two? I do not think that the figures break it down that way. They treat nursing and midwifery as a single group of staff, which is another feature of the lack of precision in the data that makes it harder to tackle the problem. Still, in that same paragraph 22, the cost of agency nursing staff, and I am assuming that it is nursing staff as opposed to midwifery, is £8,000 compared to £38,000 for directly employed staff. That seems a huge differential. It is nursing and midwifery staff rather than just nursing staff because the data is pulled in that way. Your right is a huge differential. It reflects the way in which agencies are private organisations that are operating within a market, as opposed to the NHS managing its own staff more directly. In many cases, it reflects the fact that, where there is a gap that has to be filled by agency staff, there is very little room for manoeuvre. The staff member of the nurse needs to be in place, and therefore the bargaining and negotiating power is not as high as it would be in other circumstances. In the course of the audit, was there any indication that NHS were endeavouring to control those costs? Yes, I think at both levels, both nationally and at health boards. I will ask Richard to talk you through what the team saw in that area. We covered this a bit more from paragraph 23 around a group called MasNet, which is the managed agency staffing network, which was put in place from December 2015. A name of that was to look at this a bit more closely and at a variety of levels. Our agency is a process by which you approve agency costs, as well as when you use them and what is happening behind them. Although agency costs have risen, we saw a small drop in them in the last year, which is in the report of around 3 per cent. What they are also trying to do is to look at ways in which they can work more regionally. If there are more than one NHS board in a particular region and one is requiring staff and they do not have it through their bank, they can look to their partner NHS boards in the region to see whether they can pool some of those resources. As I pointed out in the director general submission in the national workforce plan part 1, two of those regional boards have been set up from March 2017. We will see in due course what impact that has on agency numbers. I wonder if I could just touch on some broader issues about what they are doing and what they have been as a member of the committee a number of years ago. The reports that you give to the committee are excellent, but we always ask a question about what happens next and how we see the benefits and improvements that you are hoping for, recommending and so on and so forth in here. Do you think that we need to still strengthen that part of the audit cycle? We know that the purpose of the audit, the key principle of audit, is to promote continuous improvement. We will spend a lot of time, your organisation will spend an awful lot of time doing that good work. The Scottish Government will respond to it and then what. I am always keen to see, convener, should there be another stage in this process where someone, the Government, the committee, yourselves, revives at something like this perhaps in a year and gives us another report about where the evidence is for improvement with the issues that you have raised. Do you have any thoughts on that and how we could even make that process even better than we have at the moment? It is a really good question and when we think about a lot in Audit Scotland, as you would expect, we spend our careers doing this work and we do it because we want to make a difference, not just because it is a cosy way of making a living. I think that there are two levels at which it currently works. One is that our auditors do follow up at a local level, what individual health boards are doing as a result of the recommendations in our national reports. The second is the role of this committee, and I think that this committee is very powerful in its expectation of Government directorates and other public bodies that they will accept the recommendations and act on them or be very clear why not if they think that we have got it wrong. I think that it is worth consideration about whether we can strengthen both parts of that. There is one caveat. We do in many areas follow up the work that we have done in the past and we will track progress in this report with the one that is coming next in 2018-19. The more follow up work we do, the less new areas we can look at. There is always a trade-off between picking up new areas that are rising in importance or simply new to public services versus following up what has happened in the past. We would be very happy to have that conversation with the committee and with your clerks to think about whether there are things that we can tighten up in the system here and how we can learn from things like the Westminster Public Accounts Committee and the Welsh Public Accounts Committee. I am reminded, convener, of one of your former colleagues, George Fuchs, who sat on this committee. That was George's frequent question now what we will see next time. Despite the fact that you have said there that you will look at whether those recommendations are being carried out if they are accepted and so on, how would we see it as a committee and how would the public be generally made aware? Would it be useful if the NHS, for example, had to produce something like this a response to this, perhaps for this committee or for the public at some stage a year so that we could scrutinise where gains may have been made? Would that be a helpful part? I think that it is well worth considering. I am conscious that two members of the committee were in Wales on Monday this week talking to their counterparts in other public audit public accounts committees. I am conscious that in Westminster there is a specific role called the Treasury Officer of Accounts, whose job it is to provide an annual update to the Westminster Public Accounts Committee on progress against national audit office recommendations. It is done in a systematic way that helps the committee to keep track about the impact of the work that it has done. I think that that is something that is worth considering within the system that we have here in Scotland. Just on a specific example last question, convener, on page 9, I am not picking this very in particular reason but there is a little diagram there of the whole workforce numbers and it is broken down by various groupings. If you look at the figures that you have on the right hand side of it, admin services, support services and other unknown accounts for 37.5 per cent of the entire workforce and NHS. I am quite staggering, actually. Supposing that some improvement process was looking at that, how would we know that there are improvements in that area? How would it be evident to you and then to us? I think that the first thing to say is that we have not looked in detail at that those other groups of staff and I think that it is entirely possible that they are all doing important jobs that help to keep health and social care services running. Equally, it is unlikely that there are not either savings or efficiencies ways of working better given the number of staff involved there. All that we would be able to do is to report the change in the number of staff and the breakdown of them in the next place that we go but I think that it is an entirely appropriate question to ask of government in the approach that they are taking to making sure that all of the staff are having the maximum impact on patients' experience and well-being rather than being a cost that could be better used in other ways. If you do see improvements here, you are having a look at this post-follow-up inspection or verification. If you do see improvements in one particular health board, do you then try to find out if those improvements have been evidenced with another health board? Is that really up to them to embrace those changes? We work quite hard at sharing the good practice that we see where we do see it, both through those reports and through engagement in a range of ways that is not visible to the committees. Increasingly, the teams that do the audit work are talking at conferences, going out and engaging with local NHS boards, working alongside the auditors, working on the annual audits of the accounts to help them to understand what they are seeing when they are looking at the numbers there. We do some of that, but there is a trade-off between how much of that we can do and how much new work we can do on your behalf. First of all, follow-up. I think that we should write to the Government asking for the breakdown of those two figures about the admin staff and the support staff, because they are large numbers. We should get asked the Government directly, since no doubt we will be inviting Paul Gray to discuss the report. Can I start with agency nursing and ask for clarification? There was a rule that people living in the particular health board area, nurses, could not be employed as agency staff for that particular health board as a result of which costs have increased because, by definition, agency staff have to be recruited from outwith the health board area where they live. I had a recent case, for example, where an agency nurse living in Fort William was an agency nurse in a central belt health board area. In addition to the cost of their shift and they were getting about 80 per cent more than the nurses who were working beside employed by the national health service, they also got the cost of their travel to and from Fort William, the cost of their overnight stay, the cost of their bed and breakfast and dinner, etc. Is it still the rule that an agency nurse has to come from outwith the board area in which they live? Our understanding is that it is really up to the NHS board as to what their policy is. The general direction is that they prefer the additional staff to be met by the bank as opposed to agency because, as we are pointing out here, it is cheaper to do so. They want to encourage nurses to be part of the bank first. In that way, you can end up with a situation where a board can say, we do not want to overtly encourage people to join an agency before a bank. We want to use our bank resources first. There are occasions where that happens. The growing picture that we mentioned before around regional banks was to be able to further control that effectively by being able to pull on banks between particular areas. One of the things about agency costs is, as you point out, that it is not just the cost of that nurse or that doctor, it is getting them there, keeping them there. Those are all additional costs. The role is that we ensure that you still have that flexibility that a bank and agency allow in being able to cover shifts and keep services running, but in the most cost-effective way. The NHS view and the Masnets view that I mentioned earlier are very much to encourage bank over agency wherever possible. I know that, but the point is that that rule is adding to the cost enormously in individual cases. Given how much the NHS is strapped for money, it clearly is something that needs to be looked at quickly in order to reduce the cost. In the example that I quoted, the cost would be exorbitant, not to mention the impact on the NHS-employed nurses on their morale of working beside people who are getting substantially more money for the same work and the same length of shift as they are getting. On bank nursing, the bank nurses are people who are already employed as NHS nurses, but they do not get substantially more when acting as a bank nurse than the people who are working beside them. Clearly, they are living within the border area, so it seems a bit daft to say the least that we have got this rule, which in this day and age I would have thought is adding to cost unnecessarily. It is certainly something that we should ask about when we no doubt have Paul Gray in front of us. I want to clarify on page 15 again on agency nursing. At the top of the page, nursing agency costs have risen from £4.2 million in 1112 to £24.5 million in real terms, so that is the money going to these private nursing agencies. That is their fee, so £24.5 million has been sucked out of the national health service into the fees for these private nursing agencies. When I was a health secretary, I specifically asked that we arrange agency nursing inside the NHS—the way that we do bank nursing—to avoid having to pay those fees, and clearly that has been totally ignored. That is £24.5 million that we could save pretty quickly by bringing the whole operation indoors inside the NHS. It means that £24.5 million would be circulating inside the national health service instead of among these private nursing agencies, which by the way recruit for eight boards down south and internationally. We are feeding them the information and the people, some of whom get taken away from the Scottish health service to work in health services south of the border or abroad. I know in my own area that there is one advertising a big exhibition at the moment to come and join us and get new nursing opportunities all over the place. The very people we are paying to do this are also simultaneously sucking away and encouraging nurses to leave the health service in Scotland to go elsewhere, but I just wanted to clarify that point. I am now going to a slightly different matter and looking at the overall issue of supply to the very helpful exhibit 10 on page 30, because very clearly we will continue to be short of consultants and GPs and other medics if we do not have enough of a feedstock coming in from the very beginning right at the top. In other words, at the moment, there are nearly 5,000 medical students in Scotland. We have got 5,500 consultants and we have roughly the same number of GPs just under that, about 5,000 GPs in Scotland. Clearly, if the feedstock, if the pipeline of people coming into training is not sufficient, then by definition we won't end up in 5, 10 years' time with the number of people, let alone the specialities that we need. Can I ask three bits of information about the bit above that were the number of medical students? First of all, in terms of the number of people who apply to medical school from school, is it possible to get the figures in and out? If we are to general, we can't do it, maybe the clerks could do it through spies. How many young people apply to medical school from Scotland to medical school in Scotland with the qualifications for entry but who do not get accepted into medical school? My understanding of that figure is probably about 90 per cent of those who apply and who have the qualifications to get in and don't actually get in. One of the issues is that we are not creating nearly enough places for Indigenous students to get into medical school in the first place. I am not talking about dumbing down the qualifications, I am talking about people who are qualified to enter. I think that we need that information. Secondly, what are the drop-out rates in years 1, 2, 3 and 4? Clearly, the drop-out rates can be quite significant. The third missing part of that is the place of origin of residents of the applicants, because there is clear evidence internationally that medical students very often tend to end up practising medicine in the country where they were before being a student. There is also clear evidence that students from rural areas end up practising a high proportion of them, compared with the population as a whole, end up practising in rural areas, not necessarily the one that they came from. My understanding is that there is a very high proportion of places in medical school in Scotland that are not for students from Scotland. My view is that we do not take away from the other students. I think that there is a lot of benefits in having students from down south and elsewhere, but we need to create more places for people from Scotland. If we get that information either from the auditor general or the Scottish Government, I think that that would give us a better picture. It seems to me that if we are looking long-term and we have to look long-term, given that it takes about 10 or more years to go from being a student to being a consultant, if we do not have the big enough pipeline at the beginning, we are continually going to end up with shortages as we go forward overall and in certain specialities, including GPs. I do not know whether you want to comment on that auditor general. We did not look at those issues in detail as part of this order, but you may recall the report that we did on higher education a couple of years ago, which shows that it is getting harder for Scottish students to gain a place at Scottish universities because of the way in which the number of places has changed and the link with tuition fees. There are questions that are to be asked about the medical school intake particularly around it. Richard may want to come in in a moment around it. The other thing that I would say has gone straight out of my head, so I will hand over to Richard right now and see if I can remember it. There are a couple of things about that. One of the things that you talked about was drop-out rates and understanding the pipeline better. That is exactly what we are trying to map out in that exhibit at 10. One thing that we recommend is a better understanding of how all those bits fit together. At case study 2 on page 29, we talked about how, for nursing, which is a shorter pipeline than a consultant in time-wise, national health service education for Scotland is able to track nurses through the system so that they can see where people leave and where they go. Within the national workforce plan part 1, Nes has been given that same responsibility for medical workforce to look at more detail alongside GMC and other partners to see if they can get a better understanding of where people are going and when, because sometimes people may leave the pipeline but then return to it at a later point. Understanding that is really important because what you feed in here is what comes out here, so you need to understand what happens in between. The other thing to say is that, as well as numbers going in and Scottish student study, there is also an emphasis on getting students from the right place in Scotland. Nes has been looking with GMC through what is called UK Med, which we have mentioned in the report. Part of that is going to be considering whether you are getting people from the right geographic areas of Scotland to study medicine to take that interest because there is some evidence out there to suggest that people are more likely to return to those areas, which will help with some of the rural type areas or some of the specific pockets that we have in Scotland, where vacancies are particularly acute. The final two questions—there are loads of questions that I could put, obviously, convener, but clearly there are other factors that influence both the supply of medics and nurses and allied professionals. There are three issues that I would like your opinion on. Number one, I think that there is now evidence anecdotally that the differentials in money remuneration between agency staff, including locoms for medics and agency nursing, is creating a vicious circle where people who are working for the health service, leave the health service and go on, if they are nurses, on the books of an agency because they are going to get much more money. They can choose their shifts much more. They do not need to work the shifts and the number of shifts that suit them rather than having to be obliged to do certain amounts. Therefore, as more leave the employee of the health service and become agency nurses, that puts further pressure on those who are still working for the health service, and that pressure in itself feeds further erosion of staff from the health service to agencies and other places. I think that this is a vicious circle. I think that it is the same with locoms. The locom thing used to be genuinely fulfilling gaps, maternity leave and all that kind of stuff. The locoms have become an industry in its own right, and it is the same issue. The locoms are getting paid far, far more money than the doctors employed by the national health service. I do not know if you have gathered enough information to be able to give us additional information to look at the links between the impact that those policies are having in terms of remuneration and the impact on the leaving rate of the health service and the stresses that there are in terms of shortages. Another factor in relation to medics is that we very clearly had a policy decision two or three years ago that new recruits for consultants would be at least an eight to two. In exceptional cases, seven to three in terms of the ratio between being a consultant and the training time allowed, because clearly that was beneficial to everybody. I noticed that 43 per cent of last year's consultants recruited are still on nine to one contracts. I suspect that most of that is greater Glasgow and Clyde health board because they have a policy of ignoring national policy, in my view they need to be brought to book, because there is clear evidence that eight to two is far more effective in delivering services and in recruitment. I do not know if you have more evidence in that. I would be interested to know if that 43 per cent figure, if most of that was greater Glasgow and Clyde health board. I will start on your first question and then hand over to the team for anything that they want to add on the second question. First of all, the question of pay differentials with agency staff is a really interesting one. As you would expect, we could not get good data on that. The agencies are private companies and we have no access to their data. Anecdotally, I think that it is likely that most staff working for agencies do not earn much more most of the time. There are situations, as we were touching on earlier, with Mr Beattie, where a member of staff is urgently needed to fill a gap in a very shortish specialty where the agency will offer more to the staff member as well as charge more to the board. I do not think that that means that all staff working for agencies are being paid markedly more than their colleagues in the NHS are. If you talk to nothing staff, they tell you the opposite. I think that what they will be focusing on is those instances where there is somebody on the same shift with them earning twice as much or an awful lot more because there is a specific need. As I say, we do not have data, so I think that we are both working on anecdotal evidence. The anecdotal evidence suggests that not all staff working for agencies whether nursing or medical staff are earning much more all the time. Those agency staff value is flexibility. We know across the NHS workforce that younger professionals coming into the profession are much less likely to commit to full-time careers for life. It is one of the big issues that is starting to come through in the work that we are doing on primary care, where doctors do not want to commit to being partners who are committed, certainly all of the working week and still in many cases for longer working hours than that, because they want to do other things with their lives. That is not just about young women who want to bring up families or take primary responsibility for that. It seems to be an issue right across younger professionals. One of the challenges is how we make banks much more attractive in that way, in giving people that flexibility at the times in their lives when they want it. That is very much driven by their needs and preferences, not by assumptions about young women at particular points in their careers. Maddenett has got the potential to do that. In fact, I think that the evidence shows that we did see a slight dip in agency costs from 15, 16 to 1617. It is still very early days and we cannot show the causation yet, but it seems to me that there is a lot that can be done around simply making the bank an attractive place to work and integrating it better with those staff who do still choose to be employed on a permanent basis by the health boards. Richard, do you want to take it on from there? I think that, as far as the agency workforce is within this report, we have not got the data that says the specific motivations of why people choose to work for agency. Again, anecdotally, we hear around flexibility benefits, there could be pay benefits attached to that and so on. I think that as part of the work, as far as gathering the information that the NHS needs to make decisions and to look at agency more detail, that might be something that we choose to pursue and find out more about. The view is that the agency is great for flexibility. We are filling those gaps, but it should be used where necessary and where bank cannot be used, and also in a way that is cost-effective. It is brought up in the director general submission as well as around looking to use framework contracts wherever possible, which are contracts that have to set terms and conditions agreed with the Scottish Government to manage those costs as well. Insofar as the nine, one and eight contracts, from our conversations and from what is in the report, for example, the Royal College of Physicians for Edinburgh raised this as being a concern because it impacts on their ability. The one bit is the bit that they have for everything that is not their direct work and that might be the administration, the training and all the rest of it. I do understand why there is an appeal to get consultants on the floor as much as is possible, but there is something to look at there around the use of 8.2 to increase that training time and to have a better balance within the workforce. Can you say anything about the Greater Glasgow question? I don't have the data in front of me of how that breaks down, but I do have it, so it could be provided. By board, the ones that had the highest proportion that were taken on last year on 9-1 were Dumfries and Galloway, where all eight were taken on at 9-1, and Lanarkshire were 90 per cent, which is 37, were taken on 9-1 contracts, but I don't have the full breakdown in front of me. If you could provide that, that would be very helpful. In your written submission, the Scottish Government and NHS boards have not planned their NHS workforce effectively for the long term, and in your opening statement you suggested that responsibility for that planning was confused. As you know, I am always rather uncomfortable with the lack of accountability, so are you in a position to say who has dropped the ball? Is that responsibility the same? Is the conclusion the same across all boards? Are there different lines of responsibility, different levels of failure across different boards? I think that the overall approach to workforce planning within the health service is obviously the responsibility of the Scottish Government. Although we have seen progress in improving it over the past seven years or so, as Richard was outlining earlier, what is lacking is still the detailed understanding of where the pressures are and what future demand is likely to look like that would enable the Government, the health boards and the new regional planning networks to be taking the action necessary to make the workforce more sustainable for the future. The challenges come in a number of ways. First of all, most of the planning so far has been focused on filling gaps in the existing workforce rather than thinking ahead to what the future demands will be as a population age. As we see more people with chronic and complex health conditions and, as we are looking at new ways of working across health and social care with the new integration authorities as well. Secondly, the fact that we still plan separately for medical staff, nursing and midwifery staff and for other allied health professionals makes it harder to do that joined up piece. The overall responsibility sits with the Scottish Government, but we think that it is equally important that the health boards, the regional planning groups and now the integration authorities and the new elective centres understand what part they are expected to play in that. It is a complicated field and if people do not know what their responsibility is, there is a risk of either duplication or of things falling between the cracks. Thank you. This troubles me the planning that you refer to. We have a statement from Paul Gray just a couple of things he says. He says that the health and social care delivery plan makes clear that scenario planning will help to inform decision making about how best to use those skills. He goes on to say that we will publish refreshed guidance to boards early next year, which will set out the refinements boards need to make to the planning that they currently do and how to project forward the future workforce. The reason why that troubles me is because it is like this is a new idea. It is like scenario planning and workforce planning has never been thought of before. My question at this stage is not one of the key functions in your view of a board to do scenario planning and workforce planning. I think that it is one of the key functions of the board and I suspect that members of the committee are bored of hearing me say that in terms of financial planning I am not seeing enough of that and it is critical for health boards to be planning ahead their likely costs and revenue over a number of years and thinking about what could affect that and how they would respond. I think that the picture is slightly different for workforce planning because of the national input into training, particularly medical staff, nursing and midwifery staff, and the length of time that it takes to train a professional from when they first leave school and go into university to when they become a fully fledged member of the profession. For some of the specialties that we are talking about in medicine particularly, the numbers involved are very small across Scotland and it is hard for health boards to be doing that individually 14 times around the place, plus the Golden Jubilee national hospital, plus the other elective centres that we are seeing being developed in the future. For workforce planning, obviously health boards do have a role and one of the things that we say in the report is that their projections have tended to be too low in the past, but there is also a very strong national role to make sure that the numbers entering training are as right as they can be given the uncertainties there will always be about future demand. You are quite right. Historically, NHS boards have underestimated the size of the workforce at page 19 of your report. Workforce planning has been a statutory requirement since 2005, so that suggests that I am struggling with the idea that on a board member of an NHS board on a salary that will be not inconsiderable, know that something has to be done and has had to be done in statute since 2005 and has failed to do it. Is that a fair conclusion? I think that it is not fair to say that people have failed to do it. It is certainly fair to say that they have not done it well enough to make sure that the workforce is sustainable at health board level and nationally. I will ask Richard to talk you through why we think some of that has happened or not happened. One of the things that we are saying in the report is around the workforce planning and the stages that they have to go through, and I think that we have set that out to Exhibit 6, the various points to that. What we find is that NHS boards have plans and they consider things like what is happening in terms of the demography of their area and other factors that will be. Our concern is that that is not being projected through into the future coming years. One of the links that we make around that is the fact that there are one-year budgets and that the plans under guidance have to be affordable and achievable. There may be part of the fact that they know what the budget is for the next year so that they can make more realistic projections about what they can get and what they need, but beyond that they are making projections based on what they have effectively got now in the absence of that. One of the central planks of this report is around understanding future demand, both for recruitment decisions but also in how to prepare a board and regional level. We note in the report that there was a PAN Scotland report done by Scottish Government, for Scottish Government in 2014, which included scenario planning and some suggestions of options around what should be done. I understand that we are coming to 2017 and we are making the same recommendations, which are now going to be taken forward. The refreshed guidance hopefully will help with that around what they are going to do in the projection of the future years. One of the things on a more general level is that it is a big period of reform and how things will work with IJBs and elective centres and levels of responsibility there. We mentioned that in the background, which is why we are looking to do a second report on NHS Workforce down the line. Scenario planning is something that we recommend that should be done. Actually, if I might take you to that 2014 report, because certainly in the current report, at paragraph 60, you state quite clearly that the Scottish Government does not adequately consider long-term future health demands through its workforce planning process, but Mr Robinson, you quite rightly point out that in 2014, I think that I am right in saying that the Scottish Government recommended in a report to itself that it should carry out long-term scenario planning with health boards, but it does not appear to have done that. Why? I think that in a way that is one to ask the Scottish Government directly as well, but I think that what we are saying here is that within that context of reform, I think that there are a number of things that they were looking to put in place around understanding the workforce that they have, but I think that our recommendation is that that should have been actioned in 2014, and that is why we are asking for it again in the report here in 2017. Final question, then. We are talking as if this is a year zero. There were various recommendations. There have been statutory requirements since 2005, but we are where we are. You have quite rightly alluded to a period of change, a period of transition, if you like. Have you any confidence that we all will not be sitting here in the next year, the next three years, having exactly this conversation, saying why did not they act on this? I think that it is certainly a particular feature of this report, that recommendations that we have made going back a number of years and recommendations from others have not been acted on or have not been fully seen through. We have seen the series of plans and strategies that are set out in Exhibit 4 of the report, and we still do not have the detailed understanding of current staffing, numbers and spend, and the detailed forecast of future demand that would let all those strategies start to turn into detailed plans that would have an impact. We are looking closely at this ourselves, and we will be interested in the evidence that the committee hears from the Scottish Government on it, and we will certainly report back next year as planned on the progress that we are seeing. It is a very important area for the health service, so there is no doubt about that. Just to pick up on a point that Liam Kerr just raised on the requirement to submit workforce projections, I am quite interested in the report that the reference that has been made to two of the NHS boards, Ayrshire and Arran and Lanarkshire, which is my local board. I see that they have only projected their workforce for one year rather than the required three. I think that there has been some explanation given as to the reason for that, but I wonder if you could comment on that further. What are the risks of them? What are the risks that could arise? The repercussions have only provided that one-year projection. I think that if we look back, one of the things that we did as well as looking forward is looking back to what that means for what workforce they have versus what they use. On that first point, what we are saying is that they are traditionally spending more than that. One of the points that we make is that there could be a link there or a reason behind why some boards are overspending against their pay budgets, because is this about their information about what they know for the future and, obviously, their projections are going to link to what their costs are going to be. I also think on a larger level, on a regional level and a national level, that if there is going to be better lines of responsibility and closer working between them to work out what their medium and long-term needs are in the workforce, it is important that the Scottish Government of the regions are assured that the projections that they are getting from NHS boards are realistic and reasonable, because what we would like to see is that those are the basis on which they are making decisions around training, around skills mix, about how to use the workforce within a reformed NHS. In a situation where a health board is only doing a one-year projection, does the Scottish Government have to give such a special permission for that, or does the health board have discretion? I am not sure on the details of that question, if I am honest. I know that some chose to, and the reasons they were giving it was because they were undergoing reform, so it was not realistic for them to make those projections in their views. I am not sure as to how that fits in the requirement side of things. Elsewhere in your report, I think that it is paragraph 50. I do not understand why you say that you are talking about the risk that could arise from the sheer number of workforce plans and the number of different workforce groups that could become a barrier to effective working. I can see the potential for that being quite a cluttered working area. I do not think that you have made any particular recommendations along with your observations, as I just wondered what you think could be done to mitigate the risk of that clutter. Is there an overabundance of workforce planning groups? I think that the relevant recommendation in the report is the one about clarifying the responsibilities for workforce planning. It goes back to Mr Kerr's question earlier. All those people have a role to play, but it is important that they understand what that role is and how the plans come together. They build up to the national picture, the regional picture and the very local picture even within health boards. That is confused at the moment. We say in the report that there is a risk that it becomes more confused with the new integration authorities and thinking about the workforce that they need and the new elective centres that are being established across Scotland. In many ways, I think that that is part of the answer to actually seeing progress and action in that area. At the moment, an awful lot of effort is going into developing plans and not enough into understanding and filling in the gaps in the data and then using it to genuinely look ahead at what skills, what professional groupings will need and what that means for the training that is starting now and in the immediate period ahead. So what simple things can be done to avoid fragmentation where people are working separately but we are not getting that holistic overview? Responsibility is just a big thing. Richard, what do you add to that? So agreeing with that really, but obviously within the national workforce plan part one, there will be a national workforce planning group which will be formed to look at some of these strategic decisions and decide what level of planning should be done at what level. So, for example, that regional workforce plans may appear like a more strategic document, it might set out different things like what is the overall skill set of the workforce that exists within that region and how best that can be used. The other thing, I think, is about the national workforce forum which will be about supporting these various parts and seeing how they fit together. So some of this will be around responsibility and around clarity of lines. So looking at how your integration, the first lot of integration authority plans came out this year, so how are these going to fit into what's within an NHS board plan and what's in a regional plan? I think there's work to be done there and decisions to be made. So just to reiterate the point, I think it's about being organised and making sure that there's clear responsibility in what workforce plan will have what in it. I take the point about that need for clarity over responsibility. I suppose I'm wondering who is responsible for making sure that that happens. I think the Scottish Government is responsible for clarifying the roles in the system as a whole. They do lead the system. Beneath that the individual challenges and problems will be different in different parts of Scotland. We've touched on the challenges in rural Scotland. The report talks about shortages in some particular medical specialties. I think once it's clear who's responsible for what, it's much easier to get in, analyse the data and make sure you know what the problems are in your part of Scotland and then be clear who can take the action that's needed to resolve that. If it's about having more doctors going into training, that's something that can only be done by the Government. If it's about making the local bank for nurses more flexible, more responsive to individual nurses' needs, more of a place where people feel an allegiance, that's very much down to local leadership and there'll be solutions all the way up and down the chain, depending on the particular problem you're trying to solve. One of the things that I struggle to understand is that we're told often that staffing levels in the NHS are at their highest ever level. If that is the case, why is it that the workforce is still struggling to cope with demand? A big part of that is the fact that we've got an ageing population and within the larger number of older people, people tend to have more complex health conditions, chronic conditions that last for a long time, several things wrong with them at the same time. The multiple comorbidities is a horrible phrase that professionals use but we can all recognise it in our own parents and relatives and that means that the number of people needed to deliver the health service keeps on increasing as the amount of money that we're spending on the health service does and it's still struggling to keep up with the demand. There are solutions to that in thinking about new ways of working, the integration authorities are intended to be a key part of that but they will only be able to have an impact if they've got the right staff in the right place to work in new ways that will help to keep people safe at home for longer, for example, or to get them discharged more quickly and safely after they have had to go into hospital and we're seeing slow progress on that part of the mix. Reflecting on what we've already heard today, would it be correct to conclude that the Scottish Government has failed to adequately plan for the right mix rather than just the numbers alone of skilled staff? Yes, I think our conclusion about the inadequacy of the current planning would cover both the range of skills and the range of professionals needed as well as straightforwardly the numbers. I think that the Government has recognised that the answer to the challenges facing the health service isn't simply to keep on growing the number of staff, it's about people working differently in different roles and different teams in future and that obviously increases the premium on getting workforce planning right. So, are you saying that there's been a failure to adequately plan for the right mix of skills that the NHS needs? Yes, if I can point you at the report itself, I think that we say very clearly at the beginning of key message 2 that so far the workforce planning hasn't been effective and the reason for the report and the tone of it is because that's obviously key to the health service being able to meet the needs of people right across Scotland in the years ahead. Okay, thank you. Are you satisfied that the plans currently placed by the Scottish Government to produce a three-stage workforce plan over the next year will be sufficient to address these problems? I think that the overall approach is a sound one. As members across the committee have hinted, there is a lot still to do and the past track record hasn't been encouraging. So, we're watching progress closely and I'm sure the committee will want to explore that with colleagues from the Scottish Government. And I'm looking at exhibit 2, the workforce pressures in the NHS and with that in mind, some of the staff survey statistics there, what will the consequences be if this workforce plan doesn't meet up to expectations on demand? So, we're setting out some trends there and I suppose if we look at things like how staff feel about working in the NHS, we want that to be as positive as possible as does everyone else. I suppose on the specific levels, we highlight in part 3 of the report some of the potential scenarios or projections that could happen if some of the issues with the nursing workforce aren't dealt with over the next few years and how that could affect things like vacancies. Obviously, as this report demonstrates in this conversation, a lot of these things are linked between vacancies and use of agency and morale of staff. So, these are some of the potential reasons why those pressures are important and which is why we think that workforce planning and the improvement of it is something that's urgently needed. The one that jumps out for me from the 2015 staff survey is that only one-third of staff feel that there are enough staff for them to do their job properly and I think that that is quite concerning. Others have briefly touched on allied health professionals so I wanted to pick that up. I'm interested in the fact that it's not the Government who sets the numbers of university places for AHPs. Is that something that you think has to change? It is something that, in the national workforce plan part 1, the Scottish Government has said that they're going to explore. AHPs is an umbrella term for a number of different smaller groups and so, as such and so far as controlling the numbers in a way that you may be able to within a larger nursing workforce or a medical, the challenges would be different. Also, AHPs work a lot across NHS and social care so some will work within local governments, for example. There are some complications to a straightforward control number. It is something that the Scottish Government is going to look into. I think that what we're making clear in the report is that the AHPs have a role within that skills mix and we highlight some areas such as radiography. There are also shortages within certain areas of the AHP workforce so it's for the Scottish Government to consider alongside that future demand what's the best skills mix to address that and then to ensure that they get the right numbers through the system, however that is decided. Okay, thank you. If we're expecting the next five to ten years that the nursing and doctor workforce will begin to grow, what impact will that have on AHPs? I don't know the answer to that question, I'm afraid. I guess I'm supposed to be wondering if we're moving towards a community-based model of care and we've got more doctors and nurses available to make referrals if we're not keeping up in terms of the supply of AHPs and what does that mean for patient care? Sorry, I understand that. Sorry about that. One of the points that we're making in the report is about recruitment and how it's sometimes a bit linear as far as what's done in terms of medical and nursing and AHPs. I think that fits here because that question is around multidisciplinary working and how the skills groups are going to come together and if the numbers of one increase is what happens to the effect of the other. I think that if the decision-making process and some of the recruitment decisions don't have that joined up view around considering that skills mix, I think that that is a risk which I think is why it's important as well as looking at demand to consider how different groups of people are going to work together in the future. Given the challenges that we've already heard and you've recentifacted at AHPs, there are a number of different professional organisations there. How realistic is it that we can get to a point where we can have this holistic approach that captures all of that? Is it just too difficult? In a sense, I think that it's essential. It will be difficult partly because of the lack of data at the moment but partly, as Richard has said, because AHPs work in a range of different settings and they are different professionals. If you think about the 2020 vision for keeping people at home as long as possible, occupational therapists, physiotherapists, speech therapists can play a huge part in assessing what people's needs are and helping to put in place the sorts of support that keeps them at home. Equally getting people at home safely after they've needed to be in hospital, they're the people often who can make a difference. It's why we're focusing here as well as you said on the absolute numbers, also on the mix between the particular professions and the way they work together is so key. I think that it's your right, it's complex, not least because the mix of people needed in different parts of Scotland will be different. What you can do in a city like Edinburgh is very different from what you can do in a remote part of the Highlands but you do need to have both that local picture and build it up to the national picture to be able to plan the number of people going through training and give yourself a fighting chance of having the right staff in place to deliver health and social care quite differently in future. Thank you. Bill Bowman. Thank you convener. I think that a number of the topics I'll probably speak about are ones that we've already touched on so excuse me if I repeat any of those. Looking at your summary, your key message number two is perhaps one that I would have had as number one and that's the confused responsibility for planning. I was going to ask was that confusion of the legal structure and or the operational working of the planning and I think you've said that it's not the legal, it's the Scottish Government that holds that. I think that Monica Lennon asked if there was anything sort of quick hit to reduce that confusion and to me it would be demonstrable leadership now from the Government to deal with this. I see in your messages that they're talking about setting up a national planning group, national workforce planning group. It doesn't perhaps fill me with confidence given that you mentioned the agency workgroup that was set up two years ago and of course the cost of that of sort of spiral since then. Can I just ask a question then? It's maybe not being covered so far. When you talk about workforce planning in a trust what does it actually look like on the ground? Is there somebody in a room with a spreadsheet? Is there a department or is it part of another department that deals with this? The term earlier was used I think something like supply chain for doctors. When you think of supply chain you think of purchasing and payments and you think of a process that's very well-ordered, it's got checks, it's got balances, it's got controls. How would you compare workforce planning in that sort of context? I'll ask Richard in a moment to talk through how local workforce planning works. Firstly, for the record, I think it's important that I'm clear that since the masnet system came in a couple of years ago we've actually seen a slight dip in agency cost. We've seen a significant rise over the last seven years but a slight dip lately that we're keeping a close eye on. Richard? NHS board arrangements will vary from board to board as it expects but ultimately the HR... Should I expect that? I think that some of the issues that they'll deal with in rural areas will be different to within... But in terms of processes? So in terms of processes each will have an HR director who will be ultimately responsible to plan together the workforce plans and those will involve other conversations with medical directors within the hospital for example. Also on the ground and it's something that's referred to in the report as well. For nursing there's a suite of nursing workforce planning tools but there's I suppose more day-to-day tools to look at what skills are required on that particular day given the basis that they have. Within the NHS boards they'll work at a variety of levels so going from sort of operational tools to assess what type of skills and workforce they need on that particular day to the HR directors making those decisions around what the workforce plan will look like for the hospital. So that sounds like the sort of day-to-day management of who goes where but in terms of pulling together the plan and feeding it into the Scottish Government who then presumably aggregate it or in some way I mean it's all different? From that would be the HR director sorry for not clarifying. And the information that the data will be in different forms is there a standard reporting format for the Scottish Government? The workforce plans will be put into a format as per exhibit six so they'll set it out against those six steps so that's the format so they'll start by defining what they're trying to achieve what their service changes what their required workforce is and understanding that workforce availability etc so they will look each workforce plan will look slightly different but it'll be based around those six steps as per the current workforce planning guidance which will be refreshed. It's as simple as that or there's more detail. You're talking about steps? Yes so I mean each of so one of the things that we're raising the report is that within these steps we can see quite a lot of detail within some of the workforce plans talking about understanding what workforce they have and talking about what challenges they have within the areas in terms of the demographics or the makeup of the types of things that they're dealing with. Will the trust have any controls over the information that's in that? Do they check it internally? I would expect that they will check it internally it does go through the board in the ones that we've looked at not sure beyond that. Does that just mean you don't know if they have internal checks on the numbers to see that they've captured all the information they need it's in the right format? I think our impression is that they and it is an impression we didn't audit in detail but based on the annual audit work and establishment totals are an important part of their financial controls and the data itself will be good enough for that purpose. Our concerns are more the ones set out on pages 20 and 21 of the report which are firstly that they're only looking a very short period ahead and secondly because of the link to affordability they tend to underestimate their future requirement for staff. There are some specific gaps that we pull out in paragraph 34 of the report where individual boards haven't done the fulfil the requirements placed on them but more generally it's those two sets of concerns that we've got in the individual plans that boards are producing. Some boards have services provided by other boards don't they? Has that dealt with the same way on both sides? It should be being picked up in the steps set out in Exhibit 6 where they're clear what services they are planning for and that should come through. One of the points we're making though about the new elective centres and the new integration authorities is that it runs the risk of either things being covered in more than one plan or not covered in anybody's plan. Can I just go back to one earlier thing I think when someone was asking how those points are followed up and should we have another report from the NHS? I would have thought that also the Scottish Government itself should have some internal means of checking that presumably if you were an external organisation you wouldn't like getting comments from you like that and someone would be keen to see that they're dealt with there is nothing like that. We would hope so too and I think our experience is variable. There you go, I wonder whether I could just finish up just to clarify a couple of things just for my mind. Is the case ultimately then that the Scottish Government are the ones that determine the number of places they require for doctors and nurses and they instruct the Scottish funding council accordingly? I think that by any measure the Scottish Government have not been terribly good at workforce planning in the past. We obviously hope that it will improve but that will have had an impact on decisions in the past. Decisions made maybe five, six, seven years ago are potentially coming home to roost now. Would that be a fair comment to make? You're absolutely right in principle that decisions that we're making now will be affecting the number of nurses available in three or four years and doctors available in ten years. If we have some data in the report and the team will help me point you towards that of the impact of decisions about nursing training and Exhibit 13 sets out the experience of nursing training over the last few years where we've seen exactly that knock-on effect on the number of staff available to join the nursing workforce. I remember a period of maybe five, six, and it might be seven years ago where health ministers at that time actually took decisions to cut the number of training places for both doctors and nurses and there was a bit of an outcry at the time. Obviously, decisions taken way back then on the basis of potentially evidence that wasn't very useful and now coming home to roost now. I'm very aware that workforce planning is therefore a long-term issue, but we have symptoms that you've described, increasing agency costs, increasing number of vacancies that tell us that the workforce planning now is critical. What urgent measures are you aware of that the Government might be taking to address this? Are there return to practice courses? Are there flexible working to try and encourage people not to retire so soon? What is in place because there's a sense of urgency about this? In paragraph 84, we highlight a couple of initiatives that the Government has under way. First of all, adding on additional nursing and midwifery training places to address the likely shortfall, we welcome that. As I said in my opening statement, we think that there is a risk that's not sufficient to fill the gap depending on the patterns of retirels that we see over the next few years. Secondly, increasing funding for return to practice schemes. Again, that's a very helpful measure. It is a short-term measure initially, and we're keen to see more of those measures to fill the particular gaps that we see around Scotland and moving upstream to make sure that workforce planning itself is more comprehensive and more sustainable for the future. We've considered the financial risks and things that need to happen. I'm wondering whether you've assessed the patient risk in that. The reason I ask is that I'm very conscious of my constituency post bank tells me that the waiting list guarantees are out the window from services, from orthopedic services through to cancer services. We just are not coping with the people presenting as patients. Is there clearly a patient risk because of a lack of workforce planning? That's obviously the most important question. We looked at what correlations we could find between the pressures on staffing and both patient experience, staff experience and the old heat targets, the targets for access to services. In most cases, I think it's fair to say that we didn't see a direct correlation. In paragraph 18, for example, we talked about the performance against the eight performance targets that are set for the NHS in Scotland. The NHS as a whole didn't reach seven of those last year, but we found no correlation between boards with higher levels of vacancy rates and other signs of pressure. We also looked closely at the care inspectors and healthcare improvements Scotland's reports to look for any indications of problems in the quality of healthcare being delivered that they linked back to staffing shortages or other staffing problems. We found a couple of relatively tenuous links, but again not that direct sense. I think what we're probably seeing though is staff working harder and harder to keep the service running as we all recognise that health service staff do day in, day out. That's hugely to be commended, but it's not a strategy for the longer term and it's why that longer term investment in planning and understanding what staff we need and then developing for them for the future is so important. I wonder whether I could invite you in perhaps a future piece of work and we'll certainly raise this with the Scottish Government when they're before the committee to look further at this because let me just share with you NHS Greater Glasgow Incline waiting list for orthopedics treatment over 52 weeks directly linked to staff shortages. Whilst the Government has given money, that money is employing a locum, so we are perpetuating the problem and people aren't getting treated and that has individual consequences. We recognise that absolutely at a local level for individual specialties or particularly rural boards and we'll keep a very close eye on it. Thank you very much. Any other questions from members on that basis? Oh Alex Neil. The rural issue, it used to be many years ago that medics and others working in rural areas were paid a differential salary and that was scrubbed, I think, as a result of the 1994 negotiations. Is there a case now, do you think, for returning to a period where clearly rural Scotland has a very high percentage of the long-term vacancies and shortages? Is there a case for looking at returning to a differential so that there's an additional incentive for doctors and nurses and others to work in rural areas? I think there's a case for considering it. As always, I guess, caution that starting with the data is the most important thing. If we look at exhibit 8 in our report, it's clear that some of the boards with the highest vacancy rates are rural boards but equally the board at the other end of the spectrum is Orkney Islands health board. So I think there are different things going on in different parts of the country. Rurality is undoubtedly one of them but I think that the analysis needs to be more nuanced than that and so does the response. But it should be considered. Absolutely. Can I thank you very much for your evidence this morning and I'm now going to move the committee into private session.