 Good morning and welcome to the ninth meeting of the Public Audit and Post Legislative Scrutiny Committee in 2017. Can I ask everyone, including the public gallery, to please switch off their electronic devices or switch them to silent so that they don't affect the committee's work this morning? Before moving on to our formal business, we understand that today is likely to be Gail Ross's last meeting as a committee member. Can I put on record my thanks to Gail for her work this session? Item 1, our first item today is to decide whether to take items 3 and 4 in private. Do members agree? Thank you. Item 2, we will now take oral evidence on the Auditor General for Scotland's report entitled the 2015-16 audit of NHS Tayside from Leslie McLey, chief executive, Professor John Connell, chair of the board, Lindsay Bedford, director of finance and Andrew Russell, medical director and deputy chief executive of NHS Tayside. Before I invite an opening statement from NHS Tayside, I want to put today's evidence session into some context. We last took evidence from senior officials in December to seek an assurance on their ability to manage the very serious financial challenges facing NHS Tayside. Since then, the picture has worsened in some respects. In December, NHS Tayside projected an £11.7 million deficit for this financial year, which would be met by loans from the Scottish Government. It did not anticipate any impact on the level of services provided. The Scottish Government has since confirmed a further £1.5 million of loans for this year to avoid the prospect that NHS Tayside would otherwise require to take cost-saving action, which would impact delivery of patient care. That was the Scottish Government's words. NHS Tayside has asked the Scottish Government for a further £4 million loan for next year. Indeed, that sum is already included in its draft five-year plan. That would take NHS Tayside's overall loan debt to more than £37 million. However, it is not clear whether the Scottish Government will grant that £4 million. Staying with the next financial year, £5 million of the £45 million savings that NHS Tayside has to make is classed as high risk and £12 million identified as medium risk. We do not know what that means for on-going service provision. In December, NHS Tayside told us that it fully anticipated repaying all Scottish Government loans over five years. Its five-year plan now apparently shows £2.6 million of loans still outstanding at the end of that period. In December, NHS Tayside told us that the Scottish Government thought that its five-year financial plan was credible. However, we now know that the Scottish Government is asking for independent assurance on the ability of the transformation programme to deliver the change that is required. In February, the Scottish Government told us that NHS Tayside is to receive £8 million annually for the next four years, which was not in its previous plans. All that has to be said is within the context of NHS Tayside also having to make efficiency savings of around £175 million over the next five years. Finally, we know that senior Scottish Government and NHS Tayside officials met this Monday and that one of the issues for discussion was whether patients in NHS Tayside could face longer waiting lists. That is a brief summary of the current position. We will, of course, explore all those issues in depth until we are completely satisfied that NHS Tayside has a grip on the situation. I invite an opening statement from Professor Connell. I thank the committee for the opportunity to make an opening statement. I know that, as a convener, there are a number of issues that you will want to cover this morning and I and my colleagues will answer those questions transparently. With that in mind, I will keep this statement brief. 2016-17 has been a pivotal year for NHS Tayside, in which our staff have continued to demonstrate their absolute commitment to high-quality, safe and effective healthcare services for patients, their families and the communities. Our financial plan for 2016-17 will deliver just over £45 million of efficiency savings for the whole system. That has been challenging, but our priority in that period has been, as always, that we will seek to ensure patient safety and patient experience. In that regard, I can assure the committee that our performance in terms of waiting times and patient experience has been maintained and, in many instances, improved over the past year. Very brief examples. We have an improved position on our 31-day and 62-day cancer targets, a much-improved position in terms of delivering alcohol and drug treatments. We maintained our position as the highest performing board in Scotland for four-hour waits in accident and emergency. Indeed, when we compare our position with the other major teaching boards in Scotland, we are either first or second in 12 out of the 17 national standards. As you would expect, we have been in regular dialogue, and you have confirmed that with the Scottish Government Health Department regarding our forecast outturn for this year and the future. On the basis of those discussions, I can confirm that we have agreed to seek further brokerage of up to £1.5 million. That is in line with the forecast that Mr Gray gave you when he appeared before the committee in February. We have worked very hard over the past couple of months to ensure that there has been no impact on patient care and patient services, and it is against that backdrop that we agreed to seek the additional brokerage. Our difficulty in fully closing the savings gap reflects on-going pressures on the challenge in reducing the level of delayed discharges within our system, which lies some way outside our full control and on cost pressures in our prescribing budget. We have put into context that the sum of £1.5 million equates to 0.18 per cent of our annual revenue resource. That is not to minimise the sum, but to put it into context and demonstrate the margins against which all health boards operate. We have submitted to the committee our one-year operational draft delivery plan and our updated five-year transformation programme, and we are happy to answer detailed questions on those. We have already acknowledged that we will require the continued support of the Scottish Government and it is my understanding that Mr Gray has agreed that he is willing to sanction up to £4 million of additional brokerage for the on-going financial year in question 1718. In addition, the board is very happy to welcome an assurance advisory group that has been agreed with the Scottish Government that will work with NHS Tayside to provide challenge, provide advice and assurance on our five-year transformation programme. We believe that that is a positive step. The wealth of experience of those in the group led by Sir Lewis Ritchie, who I have already spoken to, will bring further external perspective to the planning and delivery of our transformational programme. Against the scale of the challenges that we face, we acknowledge that the group will bring additional capacity and will support our staff who work hard to deliver day-to-day care and treatment for patients, families and their communities. Lastly, I can give you my assurance, as I did at the last appearance in December, that the board remains committed to returning to financial stability. I think I said at the time that that was a long-stage plan. It will not be achieved overnight. That remains the case. In addition, I also gave an assurance around our position relating to patient care and experience and I would like to place on record now our commitment to ensure that the people of Tayside should be aware that our staff will continue to deliver safe, high-quality and effective care. Professor Connell, I will open with the first question. I outlined in my opening remarks some of the financial pressures and loans, brokerage and debt-facing NHS Tayside, but you appeared in the local press in December just before Christmas saying that there would be no impact on patient services. Can you make that guarantee now? I can confirm that financial pressures have not had an impact on patient services. I am happy to give examples of that, but we have not changed services as a result of financial pressures. Clearly, services have to change that reflect other pressures, availability of beds, pressures of delayed discharges and the ability to recruit and retain staff. Patient services always reflect those pressures, but they have not been modified as a result of financial constraints. That is over the last six months. You made that statement on the front page of the evening telegraph in December. It is now March, even less than six months. We are looking at a five-year plan that NHS Tayside has put in place with, as I said, no guarantee that all the loans can be paid back. Can you guarantee that, over that five-year period, there will be no impact on patient services in NHS Tayside? I think that it will be foolish to give you a guarantee for five years on anything. I cannot account for what our budget will be in five years and that will depend on national and international financial changes. I cannot give you an indication of what Tayside's budget will be in accurate detail in five years' time, but, to the best of our ability, we will maintain and support patient services as appropriate within the financial envelope that we have. That guarantee that you made in December, what was the timescale of that guarantee? The guarantee that I gave in December was that, based on what we were doing at the present time and in the foreseeable future, which, generally speaking, in the function of an NHS board within a one-year period, we can predict exactly what resource we have to spend and how we will spend it. We will maintain patient services as efficiently and as effectively as possible. Patient services will change as appropriate in the light of the national clinical strategy and the document from the chief medical officer of realistic medicine. So, that guarantee was valid for the first year of the transformation plan? I do not think that it is appropriate for me to give you a time limit on a guarantee. I am guaranteeing that the board will do its utmost to maintain patient services within the financial resource available. Paul Gray said when he came to this committee on the 9 February that it was, I do not know if he used the word inevitable, that patients would have to wait longer in NHS Tayside for treatment. Is that the case? This has not been the case. Could it be the case over the next five years? The likelyest impact on patient waiting terms, I suspect, will be our ability to attract appropriate high-level consultants staff to deliver those services. Our biggest waiting time at the moment, I believe, is in urological surgery. That reflects a difficulty in attracting consultant urologists to Scotland and to Tayside. That is not a financial issue. But could other waiting lists be impacted by the financial situation? I will ask my medical director to comment further on this, but my understanding would be that, at present, we do not see an impact on waiting lists based on a financial situation. Clearly, our ability to attract staff, retain staff and manage our bed complement will be impacted by that. Before Mr Russell comes in, Paul Gray does see that there is going to be an impact. I would reinforce the view from Professor Connell that changes to our clinical services will reflect our ability to embrace contemporary clinical practice and to embrace an evidence base that says that we should be offering different range of services to patients with different outcomes. That is not principally driven by the financial concerns but will be driven by our ability to offer best outcomes within the resources that we have available. Dr Russell, do you think that there will be an impact on patient waiting times in NHS Tayside as a result of this financial situation? I do not see there being an issue that is directly related to the financial position because, as Professor Connell has stated, the determinants of our ability to deliver are determinants principally around workforce and our ability to be in a position to have particularly the consultant staff available to provide the interventions that are counted as part of treatment time guarantees. Why do you think that Paul Gray thinks that patients will have to wait longer as a result of this situation then? I wonder whether—again, I cannot speak on behalf of Mr Gray and you may wish to ask for further detail from him on that. I would say that the position that we find ourselves in is one that the availability of the workforce will be the principal determinant of our ability to deliver our service and that we will be focusing particularly around outcome. Thank you. Colin Beattie. I have read through the year 1 and year 5 plan here. I have to say that there is not a lot of solid indications here as to how you are actually going to achieve the savings that you occasionally pepper throughout the document. It is more a declaration of intent than a pathway to achieving what you are looking for. Do you wish me to comment later on those questions? I would be interested to get your views on that. First, I would suggest that the 5-year plan has, by necessity, got to be a long-term vision. I do not think that any health board in Scotland could give you a 5-year plan that had very detailed delivery of services costied over a 5-year timescale. A 1-year plan is different. I believe that, in the 1-year plan, we have outlined the key areas where we see savings being made. Key areas, but you have not gone into it in any depth. I am still none the wiser as to how you are going to achieve the actual efficiency savings that you are talking about in each area. It is just declarations of intent. As a board, I think that we have struck a balance in producing a plan that is not so detailed as to be unreadable, but gives indication as to where the savings will arise. However, I will ask my chief executive, Leslie McLeod, to give your comment on the granular detail of where the savings are. So, Mr Beattie, our plan is a draft plan, and we will be submitting it formally to Government tomorrow. The plan has been built up through the services, through our clinical leads, our general managers, our professional leads, and underneath each of those service areas, there are detailed plans. It was key for us in the 1-year plan to get the planning principles right, and those planning principles have determined the risk assessment that you will see within the plan in terms of high risk, medium risk and low risk. As a board, we are discussing with Government in particular our high-risk areas, and we are also expecting to work closely with the assurance and advisory group on the detail of those high-risk areas. In summary, we have detailed plans that are set underneath each of the service areas. We recognise the importance of working with Scottish Government and the group that will be supporting us in a bit more granular discussion around the high-risk areas in particular. After that, we will then intend to publish the plan formally. Given the undoubted seriousness of that, the committee, back in December, asked for detailed plans. What you have given us here is sort of a, as you said yourself, sort of headlines. There is no way that we can look at this and say, oh well, you've got a decent plan in place and it's going to work. We can't. It just doesn't do that. You call it a draft plan. Who have you consulted on this plan? This plan has been put together with our front-line staff and our managers and our clinical leads within the organisation. The plan also reflects the strategies that the board has already approved. We have detailed plans for older people, for mental health, for our planned care and scheduled care. What you are seeing is the summary of the areas that we will be delivering in 2017-18. However, I can assure you that there are detailed plans sitting underneath it. However, because it is draft and because we recognise the importance of the risk assessment particularly in the high-risk areas, there is further work that we will be doing jointly with Scottish Government and our intention. Certainly, in our board discussions over this month, we would then formally have that back at our board in our May meeting. You mentioned consultation with staff. Have you had consultation with the unions and other stakeholders? Yes, indeed. They support that. I have passed to my chairman who did a conversation yesterday at the area partnership forum in relation to the plan. The area partnership forum is considered our financial framework twice over the past month. In the first instance, the area partnership forum considered the financial framework against which the plan has been developed over the next year, so they are aware and have approved the notion that we have to find savings across the board in our acute sector and in our partner IJBs off the order of magnitude shown in the plan. The draft plan that you see now was looked at by the area partnership forum yesterday, which I attended. The partnership forum jointly agreed that it wished to work together in partnership to produce the final version of the plan, which will be agreed finally by the Scottish Government, so it is a partnership document. Would it be possible for the committee to see more detailed plans on this, to see what is underneath this? Given that this is a very serious situation, we have to ensure that we have understood the full position that you are in. Just recognising that there is still draft. We recognise the importance of the role that the group that is coming in, the assurance and advisory group, and the challenge that they will bring to that. That will clearly be happening over the coming weeks, but the draft plans are there and we would be happy to support you with that information. In response to a question from the convener, you said that patient care would be unaffected by any of this going forward. However, on page 11 of your one-year plan, you said, for our patients, that means removing any elements of their care pathways that do not add value to their experience or outcomes. Can you give me an example? I think that I will ask the medical director, Russell, to answer that. One area where we are clear that there is cost that is inappropriate within our patient service relates to our pain pathway. That might be a good example. I am happy to give you additional detail, Mr Beattie, on that. If we were to look to the way in which we offer services for people with pain within Tayside, we are particularly dependent on the use of medicines and the use of a tertiary service around our pain clinic. If we were to compare ourselves with other systems, there are a greater range of alternatives available within the community and a greater range of alternatives available to the use of medicines. As we move forward, we will put less emphasis around the use of medicines, and we will put greater emphasis around the use of some of the alternatives. Here you are saying that removing elements of their care pathways is not moving to alternative medicines in order to save money, it says that removing elements of the care pathways. Can you give me an example of what you would remove? With respect to that particular pathway, we would remove elements of the prescribing which we do not think add the level of value and outcome with regard to the patient's experience, and we would be seeking to invest in other areas of that pathway in order to bring about better outcomes. So you would be removing drugs that you felt were not—are you over prescribing at the moment? We are not over prescribing, but we find ourselves in a position that we have less of a focus around some of the alternatives to the use of medicines and some of the health board systems. If you look to the evidence as to what produces best outcome for people in terms of quality of life and ability to function and return to the places of work, it is a much broader set of interventions and something that simply focuses on the use of medicines. Historically, in Tayside, we have had a particular focus around our pain pathway working with our tertiary pain service. I am still not very clear about removing elements of the care pathways. We will park that for the moment. Do you have any benchmarking in respect of your costs versus other elements of the NHS, other boards? Do you track that? There is no mention of that in here. We absolutely do. We have cost comparisons in benchmarking across a whole range of areas in that we are on prescribing at the moment. That might be a good area to stick with, where we do have very accurate, updated benchmarking on our prescribing costs across a range of indicators of chronic complex disorders such as diabetes, chronic respiratory disease and asthma, atrial ffibrillation—that is irregularity of the heart, high blood pressure—and on the perhaps asthma medical director to expand on that benchmarking that we have. With regard to the six most common chronic disease areas that we have in Scotland, we are in a position now to look at those disease areas from a cost perspective in terms of the cost of the medicines prescribed to each individual patient rather than a nominal amount allocated as was undertaken historically. We also know that the prevalence, the level of disease in the community at any one time that is being treated is different in different parts of Scotland. In Tayside and 12 of the 16 areas, we are at the top end of levels of disease that are being treated in our communities. We benchmark that against the chronic disease registers that are made available for the quality and outcomes framework from general practice. What that means is that we are in a position around those chronic disease areas that our cost-patreated patient is comparable and in fact is lower than the majority of Scotland, but when you take into account the fact that we have more patients requiring treatment in those areas, we have significant cost pressures. If we were to have the same level of prevalence as the rest of Scotland, that would take £3.5 million off our prescribing budget. Just coming back to this document, I have to say that there is nothing here that convinces me that you are going to reach your target, which is why I am quite keen to see some more detailed plans. The indication, as the convener said earlier on, is that the Scottish Government also has some reservations about whether you can achieve what you are proposing in view of the fact that it is looking at having an independent review, which I think is quite prudent at this point. Has that review started or is it...? No. The Scottish Government agreed that the members of the review panel with us on Monday, the members of the review panel were contacted on Tuesday. I spoke to Sir Lewis Ritchie, who will lead the panel this morning. I spoke to Steve Logan, the chair of NHS Grampian yesterday afternoon. Paul Hawkins, who is the third member of the panel, has been in contact with her chief executive. Lewis Ritchie anticipates that the panel will meet together for the first time probably early next week and will then begin to engage with NHS Tayside. I cannot remember now. Is there a target date for completing this review? Three months. We will await the outcome of that and hopefully we will get some more detailed information here, which will give us some reassurance on this document, which at the moment is fairly weak, as far as I can see. Thank you, Mr Beattie. In addition to the assurance group that the Scottish Government has put in place, has the Scottish Government given you any extra managerial support in terms of people going into NHS Tayside to support the work that you are doing here? Yes. In the recent weeks, we had an independent review carried out by Dr Gregor Smith, who is a deputy chief medical officer and a general practitioner with an expertise in prescribing, so he has already been in and has worked with our prescribing management group and has actually looked at our prescribing costs. He has submitted a report to Mr Paul Gray on that, which I have now seen. That report essentially concludes that our analysis over our cost pressures is correct. He identifies that we have areas of high cost that are accounted for by what the medical director said was the increased disease prevalence, where our cost per patient is often lower than the benchmark. However, he also confirmed our view that we have areas where we do need to contain costs, particularly around chronic pain. That is an area that he recommended that we focus on. He also confirmed our view that we need to institute a Tayside formulary to constrain the choice of drugs that are available to general practitioners, and that, again, is a work in progress. In addition to Gregor Smith's review on prescribing, has the Scottish Government given you any—have they seconded any staff to NHS Tayside to support you? I will pick that up. Over the past 12 months, we have had support in terms of subject matter expertise from NSS Scotland. We have had some programme management support around our transformation programme, and then we have had individuals who have come in to specific programmes in terms of our catering programme, our outpatient work that we are doing, so we have been fortunate and we have welcomed that opportunity. It has created additional capacity for our staff, who are clearly delivering their front-line job as well as doing the planning and then the redesign as well. Have they seconded anyone to your level of management to support the work that you are doing specifically? No. Thank you, convener. I have a supplementary question to your own line of questioning about the evidence from Paul Gray. Just to go back to this question on waiting lists, Paul Gray advises committee that reducing treatment rates is one of the contingencies that NHS Tayside had raised with him as part of improving your own financial situation. I will quote you what you said to the committee. That is what I want to discuss with them, whether and how they will deploy some of these contingencies. There may be some that are appropriate and some that are not. I just want to be sure about that. The convener, does that mean longer waiting lists? Yes, let's not beat about the bush, of course it would. In that spirit, is this a contingency that you have discussed with him? Two, what other contingencies are you looking at to help to improve that financial situation? I will ask my chief executive to comment further. In brief, we did discuss with Mr Gray whether we could control costs in the short and longer term by essentially taking actions that would result in longer waiting lists. We felt that that was an appropriate and he agreed and therefore we did not take those actions. Those actions would include closing theatres, reducing operation availability time and making patients essentially wait longer for necessary surgery. We believe that to be inappropriate and we still do, so our challenge is to find ways of saving money without impacting on patients in that way. I do not have much to say on what side. The only other point that I would make if you looked at our 16-17 plan and where we have invested money, NHS Tayside, in fact, over the past three years, has put on mobile theatre capacity on to the site in Ninewells. That was just in recognition of how we were trying to bring all our work in-house and take out our private sector work, which we did. That cost to the organisation is probably somewhere in the region of £1.7 million. That was a commitment that we made in 16-17 and that has allowed us to hold our performance, particularly around some of the access targets. It would have been an option, but it was an option that we were not prepared to take. Obviously, significant savings have to be made. I am trying to tease out exactly what the negative impact is going to be on the quality of care and the performance as well as a result of that. I am trying to find out what alternatives and contingencies you have discussed with Mr Gray, and if you could enlighten the committee to what those are. I will start off from then and then pass over to Lesley McLean. If I could first make the observation that other health boards have made decisions to take savings and have impacted on patient waiting times. Our outpatient waiting time has been held stable. Other health board waiting times have gone up very substantially. There are decisions that health boards can make. We chose not to impact on patients. There are other savings that we can make, particularly around day-case surgery, making surgical patient access more efficient. I will ask Lesley McLean to add to that. That is a key feature of our 17-18 plan. Mr Beattie talked about benchmarking, and we have been looking at the productive opportunities that are there within the organisation, working again closely with Scottish Government colleagues and also using the discovery tool, which is a national tool that is available. That allows us to look at the performance in every other board in a whole range of areas. In terms of our planned care, service plans for 17-18, we have set targets to increase the number of day-case surgery. There are areas in which we need to improve around our pre-operative stays, and that is a productive opportunity. By doing that, people will come in on the day of surgery. That allows us to reduce our bed days, which has caused pressure in terms of bed numbers, et cetera. We have, in 17-18, quite a number of those opportunities that will drive the efficiencies without impacting on quality of care. I guarantee that the convener was looking for it. Following on from Professor Connell's own remarks, we are being told today that, given the significant savings that have to be made, the significant amount of money that has to be paid back in debt, there will be no impact on patient care and quality of care. You are saying that to the committee today and also to the public today. Can I perhaps expand on that? As far as it is within our power— As much as we can, can we have a direct answer to that question? Yes, I am going to come to that question. As far as it is within our power, we will give that guarantee, but there are factors that are outside our control. Over the past, at present time, we have six day blocked beds in Perth and Cunross alone. That means that we cannot have access to surgical beds for patients in the way that we would like. If we could have those patients not in NHS beds, but as they should be in the community, we would be able to deliver much more efficiently on our financial targets and on our patient waiting times. Does that factor rather than a finance that constrains us? I do not hear a patient there, Professor Conalys. That is an issue for Perth and Cunross Council and the IJBs. That is an issue that has to be solved in partnership. It appears to me that NHS Tayside is still very much in financial distress, but we have heard in evidence today that patient experience and waiting times remain fine. I want to return to staffing. Colin Beattie touched on it earlier at the committee's meeting in Dundee in December. We heard from local trade union representatives, and it was not a pretty picture at all. They raised some serious points. Looking at those draft plans, I know that you have said, Professor Conal, that the area partnership forum was consulted yesterday and everyone is on board. However, there will be a real pressure on staff to achieve the transformation that you say is vital. Can you give us more detail about the consultation and what partnership looks like on the ground? Who is on the area partnership forum? Did anyone at all raise any significant concerns that echo what we heard in December about Lowe Morale? I will pass to Leslie Clay to give you a full answer on that, but I was at the area partnership forum yesterday. Obviously, staff partners are concerned about the impact of the financial plan on what that means for staff, their jobs, their ways of working, and how the savings will be delivered. The partnership forum agreed that that would be developed jointly with them. As our chief executive said, that plan is an evolution, and therefore it will be developed as a partnership. It will be owned by the partnership forum. In terms of consultation and relationships with our staff partners, I will pass to Leslie Clay. The area partnership forum met yesterday. Were they seeing the draft plans for the first time at that meeting? That was the first time. That document had been seen. The board saw it for the first time on Monday, but the partnership forum had seen the financial framework and the financial underpinning of the plan earlier in the month. What is key to the success of the plan is the leadership that we get, not just from our clinicians and our managers, but also the leadership from our trade union partners. The board a number of months ago took a further step to enhance that. That is now that the area partnership forum members and the area clinical forum members of NHS T-Side are core members of our senior leadership team. That was to move us forward, not just in terms of having our area partnership forum monthly meetings and our consultation, but getting them into the heart of the actual build and looking at the performance of the organisation. Already, I can see the benefits that we are getting from that. There is something about owning that plan, rather than just getting to a point where you are consulting on it. We will continue to build on that. Let us look at some of the detail on page 40 of the five-year plan that you mentioned, extended hours of working for additional clinic capacity at weekends and evenings. Do you think that this can be managed within your current staffing complement and have unions raised any concerns on that particular point? Excuse me. Page 40 of the five-year plan. Sorry, I apologise. My plan is only up to page 32. The issue is in relation to extended hours of working to increase clinical capacity at weekends and evenings. What have the trade union said on that point? Are you confident that you can manage that within your current staffing complements? So, seven-day working has been a key feature for the board over a number of years, where we have increased our access to diagnostic services so that patients are getting timely access at weekends, where our AHP services, in particular and often over the winter months, are actually there. They develop kind of rosters where we have our staff rostered over a seven-day period. That development is something that is core to the board and we will continue to work with. Of course, in any of those changes, we would do full consultation with our staff and that would be done in partnership, but there clearly are a number of areas where we would strive to provide provision over seven days. On page 16 of the five-year plan, you also say that more of the same in relation to your staff cost basis no longer a viable option and that will involve a reshaping of the size and grade mix of your workforce. Does that mean cuts to staff numbers? It doesn't, and I did talk our December meeting in relation to that. We do recognise that our workforce base is higher than what you would expect, and we are clear that that is driven by the number of hospital sites in particular. I reference the fact that we have 26 hospital sites. Through natural attrition in terms of either retirements or people leaving through the introduction of technology, there are just ways of how we can re-profile the workforce that we are doing with them. There is an example that we will be able to change from the beginning of April 17-18 on what we have done this year, and that is around our theatre workforce. Recruitment to theatres is quite a national challenge across all health boards, and we have worked with our staff for the actually re-profiled roles, and we have created a band 4 role that was not traditionally there. That allows other skill mix that we have to focus on particular duties. In some areas, that redesign could be the creation of new roles. We have also got a strong apprenticeship programme and NHS Tayside across a whole range of services, so we are looking innovatively to see how we can re-profile and make sure that the staff with the right qualifications are doing the right job. How many apprentices do you have? 12. And how many do you expect to have by the end of the five-year transformation plan? I do not have that information available to me, but I could certainly get that back to you. One other question, I guess, is what will this reshaped workforce look like in five years time in terms of numbers? Is it going to increase, decrease, stay the same? Again, at the end of five years, I think that it is probably quite difficult to predict the shape and size of the workforce, partly because of the change in health and social care integration, because clearly much more care is going to be delivered in the community with a different type and grading of staff. I cannot tell you absolutely now how many staff will be employed by NHS Tayside directly, how many will be employed in the care sector through either third sector or other employers. I would not anticipate a major change in the number of staff employed in core services, but the type of staff may well be because of changes in technology, changes in medical practice. It would be foolish for me to say that there will be no change in the total number of staff—it may be higher, it may be lower—and the distribution of staff between hospital and community and, undoubtedly, they will be different. Perhaps we could look at agency staff. In previous sessions in this committee, we have looked at the 39 per cent rise in spending on agency staff, which I think you will all accept is extremely high. Liz McLeod, you said in the last meeting that the number of nurses on your nursing bank has increased from 800 to 1200 nurses. Can you give us an update today on what the profile looks like and has your agency nursing increased or is it more manageable now? I would be happy to do that. Our nurse bank numbers have increased. In fact, the number that I saw over the past week was taking us into the region about 1,300 nurses on our bank. We have also instigated a survey with nurses who have been recent leavers and, having been able to secure a return to practice accreditation programme with the university in Dundee, we are looking to target people back into the practice. We are not resting on our laurels in terms of the numbers that we have at the moment and continue to increase it. In terms of the nurse non-contract agency, we were and still are a relatively high user, but I can advise the committee that overall our use in 1617 is down 22 per cent on what it was in 1516. That has given us an efficiency saving of just under £1 million. Through better recruitment in our nurse bank, through better rostering policy deployment, we have been able to reduce our reliance. That is a key feature of our 1718 plan that we will continue to look to reduce our reliance on non-contract agency. What lessons have been learned in terms of the circumstances that led to that spike, that huge increase in spending on agency nursing? Surely it did not happen just by accident? When you track back, I have to say that it has been quite complex to really understand that. Up until 2013, we were a very low user, so there has been a three-year increase. Part of it undoubtedly reflects the challenges in terms of nurse recruitment. We are working really hard to understand the flexibility that our staff want and look to see how we can deploy employment contracts for them that are family-friendly. We recognise the age profile of our workforce, which we have a high proportion going into the 50 to 60 age group, and we are looking to see how we can create a work plan for them in the past five years to support their continuation in employment. It is something that we will continue to work hard at over the next 12 and 18 months. Do you think that you have under control now? I think that it is definitely improving, and I think that the reduction of 22 per cent is significant, but I am not complacent in terms of our position. I think that our overall use has now come back into somewhere about 10 per cent of overall NHS Scotland's use. Is that correct to you? Last year, for the whole of Scotland, we accounted for about 23 per cent of the non-contract agency spend. If I look at where I expect to finish this year, I expect to be around 15 per cent or 16 per cent of Scotland, but if you look at the month of January alone, then Tethau was at 10 per cent of Scotland, so it is very clear that the action that we have taken since December is changing that pattern of use. You have talked about it before, because it will be realised through the disposal of surplus assets. Indeed, you have talked about what will happen over time as hospitals close. I see from the update that we have had that you have managed to sell a couple of properties since we last met you, including the Murray Royal, £550,000. Is that what you expected to get for that property? It is lower than the original estimate from a couple of years ago. Is that Mr Redford? I think that it is all recognised with all property sales. It is open to market forces. The Murray Royal is with all property sales that is complex. I had a historic grade-a listed building on it, and it is clear that the market for picking up those types of sites recognises the significant investment that developers will have to make. I understand the pressures on developers and development finance, but I wonder what you were expecting to get for that property. The original estimate was around £1.5 million. I do not know that site. I am not local to Tayside, but when I looked at it on Google last night, it looked like a rather large site, which is about 21 hectares. It did seem someone was getting a bargain. On that, when we spoke to Paul Gray, it was confirmed that any money that you get from those properties will not be a clawed back. Asset sales have been used to offset brokerage so far and how much that has amounted to? I think that Mr Redford is the best place to answer that in detail. At this stage, it has not offset any of the brokerage. We have used it to assist the in-year financial position. In this financial year, it will probably cost £2 million. We will assist the financial position to get to the third year. That was agreed with the Scottish Government, and that is the proposal that we have put to the Scottish Government for the next two financial years. Any future asset sales in the next two years will not be used to offset the brokerage. It will be used to assist the delivery of the overall efficiency savings. I have just one last question in the spirit of transparency that Professor Connor touched on at the beginning. I just wondered in advance if today's meeting has the committee received any coaching from any external advisers. No. No, but you did last time. We took advice, I would not have called it a coaching. Okay, thank you. Can I ask about the high-risk efficiencies that are identified in the financial plan for 2017-18? The one-year plan says that you will fall £4 million short, and you have already indicated to Professor Connor that Paul Gray has indicated that he might be willing to pay that. You also state that £5 million of your savings is at a high risk. What does that high risk mean? Okay, and again I will pass that to Mr Bedford. However, if you like, an overview would be that high risk are often areas that we feel are not fully within the control of NHS Tayside in terms of managing the expenditure, so part of that will be within the impact of delayed discharges where we have not the ability to deliver on that absolutely on our own. Mr Bedford, I will give you further detail. There are probably two or three components to the high-risk initiatives. We touched on prescribing earlier. We recognise the initiatives that we are implementing, but to implement that in full in 2018-19, we recognise that there is a risk. That is not to underestimate the amount of work that is going on. You will be aware when we spoke in December that there were five key actions that we were pursuing. The revised formulary will come into place on 20 April. We will probably need time to understand what the actual impact of that will be. Dr Russell may wish to comment further. Describe one element of the high risk. The second element is that, as the member mentioned, there was the level of agency costs. Within our local delivery plan, the Scottish Government is expecting us to identify ways of reducing non-contracted agencies by 25 per cent. What we are certainly keen to do in Tayside is to stretch that further to make sure that the impact of non-contracted agencies on the overall system is less. We recognise that that may be inhibited by recruitment challenges and some of the pressures on the service. That is another element of the high risk. I can see the breakdown, Mr Bedford. The breakdown prescribing counts for nearly two million of the high-risk savings. My question is not where does the breakdown come, but what does the high risk mean that you are unlikely to make those savings? Presumably, there is a risk that you will not make those savings. That is what the high risk means. I think that that is what you are saying. What would happen if you did not make those savings? What we have always foreseen is that, like any plan at the start of the financial year, there is an expectation that, through the work that is going on on the individual programmes of efficiency, they will move from high into medium until we will recognise the actions that are taken. I think that what we recognise with the high risk ones is that the actions are not entirely within our control. The biggest chunk of that is £1.9 million on prescribing. That is completely within your control, is it not? The majority of prescribing costs are incurred in primary care. Primary care lies within the control of the IJBs. We work closely with the IJBs. We have a prescribing management group, but it is still a partnership. They only fell under the jurisdiction of the IJBs very recently. Until about a year ago, they were part of NHS Tayside and presumably were led by policy from NHS Tayside in terms of prescribing. Are you saying that you really have no control over GP prescribing now? No, I am not saying that, but I am saying that there is now a partnership in place and we have to work within the constraints of that, but I will pass to Professor Russell. Does the partnership increase the risk for the budgets of Tayside? Does the partnership with the IJB increase the risk for NHS Tayside's budget? Undoubtedly, in terms of our ability to have delayed discharge patients moved out, yes, it does. In terms of prescribing as well? Professor Russell. With regard to the prescribing, I do not see a specific risk, as you have identified, convener, with regard to the new arrangements and the prescribing, but if I can perhaps give you an example— I think that Professor Connell identified that. Could I maybe give you a specific example that might help try and get us around some of the high-risk elements? If I were to give you an example of a specific medicine, which is a medicine that is used for cholesterol, which should be used as a third or fourth line medicine, when that medicine has been looked at elsewhere, about 25 per cent of those patients have been seen to be inappropriately on that medicine. We have used that as our assumption. We have reviewed 1,200 of the patients, and less than 10 per cent of them are getting that medicine further up in terms of first or second line. The risk is around the fact that we have taken planning assumptions from experience elsewhere, and our experience locally may or may not reflect that. That is why they fall within our high-risk element. Would you agree with Professor Connell that the new governance structure with IJBs makes the saving of £1.9 million a high-risk saving? I perhaps would let Professor Connell clarify exactly what he meant by that, Ms Marr, but certainly from my perspective I do not see the new arrangements directly impacting on that. My comment was principally in relation to the latest charges, where it is undoubtedly the case that IJBs have a key role to play in helping us to move patients from acute hospital sites into the community. Professor Connell, you said that now GP surgeries have moved to IJBs. That is true. That was in response to my question about the high risk. I apologise if I misled you. I did not mean to, but there is no doubt that primary care is now within the IJB. The primary care prescribing budget lies within the IJB budget, so the saving that is set against prescribing within family health prescribing is against the IJB. Therefore, we need to work in partnership with the IJB to achieve that saving. You said that you do not have complete control over that because it is now in the IJB, but it is within your budget that it becomes a high-risk saving. What you are saying is that the governance structure is actually making NHS Tayside budgets more precarious. I asked my chief executive to comment on that too, but there is undoubtedly an added complexity in that we now have three IJBs with three separate budgets that are derived from NHS Tayside and from the local authority. Therefore, the governance of that does become more complex than the governance of a single unitary health board. That is undoubtedly the case. I would not disagree with that. As you indicate, convener, we are just closing out year one of the new governance arrangements. As a system, if you go into our one-year plan, our planning principles are that we will work as a whole system. Our transformation programme is a whole system. That crosses all the services that are devolved into the integrated joint board partnerships. There is a layer of complexity that is now there that we need to ensure that we work through. On those savings as well, there are no savings identified at all on regional working opportunities, but you will have read, as I did in the courier yesterday, about the situation about the exchange of information between NHS Fife and Tayside, and there is a lot of duplication in that process. Presumably, duplication is a cost to NHS Tayside, so why is that not identified as a saving in this table? I am not sure in terms of the actual specific of what the duplication we are referring to is, but we are not reflecting regional working at this stage just because of the maturity of the regional plans. There will be a big focus this year to build a regional local delivery plan, and we are working collaboratively with both the north of Scotland boards and the boards in the southeast region as well. That is emerging in terms of development, but we are not—because I think that it would be high risk at this stage—got specific initiatives with a high level of confidence that we would look to deliver efficiencies in 2017-18. In our service plans, you will note that there is a section that talks about regional or national perspective, and that is either to reflect some of the national initiatives or reviews that have been concluded. One would be the national burns review that will go to implementation, I believe, over the next six to twelve months. There are initiatives coming through both at national and regional that will feature in our plan, but they are not concrete enough in terms of our confidence to take efficiencies from our budget. Can I say on that? There are obviously big savings that you can identify, but every small saving makes a difference as well, given the situation that NHS Tayside is in. I hear from constituents as well that there are cost savings that could be made. For example, action on hearing losses project to fix people's hearing aids in the community. NHS Tayside this year has refused to fund that, despite the fact that its independent evidence projects that it would make £87,681 of savings for NHS Tayside in the audiology department. Why are those proposals being blocked when the independent evidence shows savings like that? I can share that paper with you. I would be more than happy if you would. In relation to that, our service plans are built up from our clinicians and senior managers in each of our specialist areas, so I do not have the detail on that, but I would be happy to look at that. Mr Bedford. Probably just to give a bit of clarity. We have touched on earlier that we have to submit a draft local delivery plan by tomorrow. It is a draft. I think that that recognises the regional planning and delivery of services work that will go on. We have been asked to submit final local delivery plans in September of this year, which will look for regional planning and delivery aspects to be more fully developed. There will be more aspects that will bring forward as part of the plan, but whether I have any cash-releasing saving in 2017-18, then that will come to fruition over the next six months. I begin by putting it on the record. In Annex B, Paul Gray said that there was never a proposal to create a for-profit agency within NHS Scotland to deal with agency nursing. That is not quite accurate, because when I was the cabinet secretary of health, the then chief executive of Grampian was working in a project to bring the organisation of agency nursing in-house, given the cost of agency nursing and some of the big profits made by the outside agencies, we felt would have been better reinvested in the health service rather than going into the pockets of the shareholders of agencies just for the record. Before I go into questions, I can also put on the record as a former cabinet secretary of health that we are not questioning at all. I certainly would not question the clinical performance of NHS Tayside, because for a long number of years now the clinical performance, particularly in areas such as accident and emergency of NHS Tayside, has been one of the best in Scotland. It is only fair to put that on the record. What we are talking about this morning is the management of the resources, particularly the financial resources. Obviously, one of our concerns is to make sure that that clinical performance is not adversely affected by how we manage that particular problem. Can I turn specifically to the five-year plan? Clearly, an objective of this five-year plan, the key objective in some respects, is for NHS Tayside to repay its brokeraging to the Scottish Government and to make significant savings. When you add those two figures together, it means that, over the next five years, you have to make efficiency savings of £210 million, which by any standard is a substantial challenge. When I read the financial projections in the five-year plan, I thought that they had been written by Mystic Meg, because it was a bit of thumb in the air—let's hope for the best. However, I did not see evidence of a strategy to get to £210 million. I accept that, because you do not know your budgets for that length of period of time, it is not always possible to be absolutely precise, but that is not to stop other things happening. I want to go on to that in a minute. Before I do, I would like to clarify a couple of very specific issues. In your opening remarks, Professor Connell, or in answer to a question earlier, you said that the savings amounted to about 1.8 per cent, I think that you said. The £1.5 million additional brokerage for 1617 was 0.18 per cent of our revenue resource limit. Over the five-year period, in the five-year plan, there are actually two figures. One is that over the five years of the plan, approximately £210 million of efficiencies are identified as being required. That equates to 5.8 per cent of the revenue limit. However, the savings target incorporates over the five-year plan close to 1.3 per cent to be returned to the Scottish Government to repay the brokerage. Just to be right, over the five years, we are talking about 5.8 per cent of the revenue budget. Obviously, you do not know precisely what your revenue budget is. That is your estimate of the revenue budget. 5.8 per cent of the revenue budget will be required to repay the Scottish Government the brokerage and to make the savings that you need to make. Is that right? Yes. The second point that I want to clarify is page 30 of the five-year plan, because this is a thing about a gobbledygook that I do not understand unless I am missing something. It says that, in delivering on this agenda, a focus on delivering a step change in mindset and focus is required that will see the organisation transform. How do you focus on your focus? I think that we have to hold our hands up and say that that should have been written better. I think that there is a redundant focus within that sentence. Right. Okay. You can see why we are a bit skeptical about the plan. I just picked that as one example. There are many others. Can I raise two specific points about the plan? When you are writing a business plan, like Mr Beattie here, before I come into this place, I spent a lifetime writing business plans for big organisations and small organisations. The first thing that you do in any business plan is to forecast the demand for your services, because without a proper forecast of the demand for services, you do not know what it is that you are going to deliver. Forecasting these days in the health service particularly cannot be quite accurate with all the softwares available. Where is the forecast? Can we get the forecast for demand for your services over the next five years? In brief, we have a clinical strategy for five years that looks at the demographics of the population, the anticipated shift in demographics with ageing and movement within Tayside and disease prevalence and demand for service. A clinical service strategy is built around the anticipated demand and the anticipated change of service from the acute sector into the community. That is not embedded here in the five-year plan but as a sister document. I think that it would be very helpful if it was embedded because when you are looking at the veracity of a plan, the starting point is the veracity of the forecast. I think that it would be helpful if we saw that because we would then know what services you have to provide to meet the needs of your population. If we could get a copy of that forecast, that would be extremely helpful. The second thing is—I fully understand the point about that you do not know your precise budgets beyond basically next year—I fully understand that point. Are you doing scenario planning? For example, if you look at the totality of the comparative costs right across the board under each of the services, acute community services and so on, in terms of prescribing, I would have thought clearly—I think that you have recognised to some extent—that prescribing is an area where, if you were as good as the best board in Scotland, you could potentially save a significant amount of money if you are able to do that. This is where we have come back to the forecast of a demand in your area. If you are able to do that, it is not in here but is there any scenario planning going on that says that, if we could get to this in terms of prescribing, if we could get to this in terms of more efficient use of staff and agency staff, if we did not need the number of locums that we have because they are expensive and instead had contract doctors permanently working for Teaside health board, is that scenario planning going on? That is the chief executive of Mr Bedford on what modelling we carry out. When you asked that question, my response would be that there is a level of detail of that planning going on, particularly with the health and social care partnerships and the services that are managed by the acute sector from the board. I have got four chief operating officers and they are working as a collective. There is planning that is evident in the health and social care partnership plans in the reduction of emergency admissions. We have talked quite a bit already today about delivering on the 72 hours standard of patients wait time, where those that are clinically fit are discharged to the appropriate location within 72 hours. The IGB partnerships are saying that we can reduce the number of emergency admissions by x and by their new home care infrastructure, home support community infrastructure. What would that mean for the bed base in the likes of Ninewells or PRI? How could we redesign that bed base? Part of that will be reducing the number of beds and being able to transfer moneys out to social care. We are looking at emergency admissions and the impact on how we could redesign. We are looking at the length of stays because there are a number of beds. We have 119 patients just now who are in that clinically fit status but are in an acute or mental health or learning disability in patient bed. If that was not there and they were delivering on the 72 hour, how could we then develop and deliver enhanced services? I have in the planning principles in the one-year plan for the first time put in a statement that talks about the delivery of the reduction in emergency admissions. We are quite early in that journey, but the new form partnerships and because we have now got integration health and social care will allow that to mature. I have also said in terms of the reduction in the number of occupied bed days that we will then be able to take costs out of the kind of infrastructure, some of which is an ageing estate, and we will be able to redistribute that money. There will be efficiencies there, but also in terms of enhancing community primary care. It is definitely evolving. I suggest then for the five-year delivery plan to have credibility when you read the plan that that kind of scenario planning, which eventually should lead to a strategy in each area and an overarching strategy, needs to be in that plan. To be fair, I have the same criticism of the national so-called delivery plan. It is not actually a delivery plan because it tells you where you want to get to, but the whole point of the plan is that it does not tell you how you are going to get to. We will not get there by jumping in the number nine bus in Dundee. We need a plan on how we get there. We need to incorporate that for this to be called a proper delivery plan and to have the credibility. At the moment, as you read it, it does not tell you any of that. We could have written this three or four years ago about where we want to get to. The issue is how we are going to get there because we have not to date managed that. What are the benchmarks? In three years' time, what is the benchmark? Four years' time? Five years' time? What are the benchmarks in terms of measuring progress? £210 million is a lot of money to save. The final question that I have is on the assurance group. Let me say again that there is no better person than Sir Louis Ritchie to head that. I have the highest respect for him. However, the striking thing about the three-person review group, apart from the fact that it is all meant, is that there is not anyone there with all due respect who is a financial expert. Given that this is about resources and management of finances and efficiencies and doing things better, it seems to me that that is a big gaping hole in the membership of this group. I would have thought, convener, that perhaps it is an issue that we should take up directly with the Scottish Government. However, given that this is essentially a financial challenge, that not having somebody with a relevant financial expertise is a mistake, and I think that we should draw that to the attention of the Government and suggest that we rectify the ASAP. I am not talking about the internal finance structure at Tayside. I think that an external person who has the relevant financial expertise and resource management expertise would be a huge advantage in the work of the assurance group. If I might just briefly comment on that, because I agree with you, I think that there are two points to make. First, I think that the chief executive of Fife will provide a valuable comment on delivery and how that impacts on finance, because a lot of the problems relate to delivery rather than adding the sums up. However, you are right that having financial modelling expertise would be helpful. We have discussed that with the Scottish Government, and I think that their proposal would be that the original group of three might well look at where the gaps are and then recommend additional resource as necessary. I would have hoped that, from day one, you would need a financial guy because he is a financial person, because, quite frankly, I have to say that one of my criticisms of the health service is the lack of enough financial expertise in key areas, and I think that this is possibly one. Given that this group is supposed to report within three months, it seems to me that there is no time to lose in filling the gap. We take that up, then, with Mr Gray and Mr Neil. If I could also let you know that the number nine bus in Dundee is a circular route, so it does go round and round in circles. Liam Kerr. Thank you, convener. I just want to come in briefly at this stage on something that was raised earlier. The one-year plan says that, for 2017-18, you will fall £4 million short of the £49.8 million savings target. The convener looked earlier at a number of those savings that are categorised as high risk, which I had Mr Bedford's answer earlier, but I will take it that high risk means that there is a high risk of not being achieved. Does that not mean that there is a fair to good chance that there will be even more than £4 million worth of brokerage, i.e., loans, required in 2017-18? We will pass to Mr Bedford because I think that this comes down to what the word high risk means. I think that in any budget scenario, one would always assign levels of risk to where savings are going to be made and categorise them as low, medium or high. As Mr Bedford indicated, high risk means that, at present, we are still developing the strategy to ensure that we will deliver within a year. That does not necessarily imply that we think that it is unlikely that we will get there. It is just that the planning assumptions are still being solidified, but I will pass to Mr Bedford to clarify that. That is exactly that. I think that we touched on the high risk earlier. For me, it reflects that those are decisions that need to be taken in partnership. I will come back to one that I did not mention earlier. Part of the high risk initiatives is the delivery of the 72-hour delayed discharge target. The chief executive has already given you an indication of the numbers of patients that are currently in hospitals across Tayside. There is something about working in partnership with our health and social care partners to improve that patient flow and to reduce the levels of delayed discharges in hospitals, but those are the decisions and discussions that we are promoting right now in order to enable the significant resources that have gone into the health and social care partners over the past two years to liberate the resources out of the hospital sector. At this stage, as you will have seen from the figures that I quoted today, there are still significant numbers of patients in the hospital sector. Both in the acute hospital and in the beds under the control of the IGBs. There is a high risk that you will not deliver £5 million worth of savings in the next year. That is what the category means. Is that not correct? What always has to accept any budget that is at risk. We agreed with the Scottish Government that we would stratify our risk as we have done. Correct. However, there is a risk that £5 million of the savings will not be achieved. Yes. If that is correct, the £4 million of extra brokerage that you will require is low bowling. I think that that is one of the reasons why we welcome and the Scottish Government has recommended the assurance group coming in at an early stage. Is that correct in my suggestion? Yes. If that is right, we have then got a category of medium risk. What are the prospects of achieving medium risk like savings? I will pass to Mr Bedford to clarify that. I will reflect on previous year's financial plans. There is an expectation that medium risk will migrate in the early part of the year into low risk and will be delivered in full. For the record, you project that over the next year you will deliver 100 per cent of the medium risk efficiencies in this table, £12 million. I think that you will probably end up seeing it as a bit of a mixture. I think that you will see some of the higher risk going into medium and into low. Will they be delivered, the savings? That is the discussions that we are taking forward with the chief officers of the three partnerships and the acute hospitals unit. That is the discussions that we are promoting. You talked about the previous years. How much of the medium risk targets were achieved for savings in previous years? In the main medium risk does migrate. How many were achieved? 100 per cent of the savings targets that were classified as medium risk were achieved. I do not have the figures here. I can certainly provide that information looking back at the early year, the plan at the start of the year and where it ended up at the end of the year. I think that that would be useful. That is a final thing, and I will maybe look to come back later. The Scottish Government told us in February that they expect you to be in financial balance by 2018-19 and to require no further brokerage. Do you expect that? That is the basis of a five-year financial plan. Obviously, that will depend on one or two factors that Mr Neil knows. We cannot predict at the present time because we do not know absolutely what the level of resource available will be. However, to the best of our knowledge, with our planning assumptions that Lesley McLey has mentioned around 72-hour discharges, moving care into the community, we will be in balance. Paul Gray touched on prescribing with him, and I would like to go back to that now in a little bit more depth. In the one-year plan, starting on page 14, also page 15 and 16, can you tell me who is on the prescribing management group, please? The prescribing management group is co-chaired by a clinician from primary care and a clinician from secondary care, and the group has multi-disciplinary, multi-professional representation and therefore contains pharmacists, HPs, managers, everybody involved in the use of medicines in Tayside. We go further down the page, and it says under strategic context, there may be difficult choices and decisions ahead. Can you tell us what those might be? With regard specifically to the use of medicines. Well, just with regard to the context that is written in the one-year plan. So, with regard to the difficult choices around the use of medicines, we need to take cognisance of the fact that some of the opportunities to save money may be around switching patients from some medicine they are on to a medicine that is equally efficacious but is of a different brand type. The choice to do that can be a difficult choice because it involves a conversation, a clinical consultation with a patient, and it involves a level of change that people may or may not be in a position to support us with. So, it is very much within the context of some of the changes that we are required to make. With regard to the application of the formulae, and we have touched on earlier on the importance of having a formulae, what we do not know and we will know over time is whether the level of prescribing that falls out with that new formulae and the level of prescribing that reflects individuals who have chosen to use medicines that fall out of that as a first and second choice rather than having gone through the medicines that are already in formulae and for whatever reason they are not the right medicines for the patient to be taking and therefore they are choosing an alternative medicine. Through that piece of work, we will be in a position to try and understand the cohort of patients who we will need to have conversations with around potentially changing those medicines. I understand that every patient's situation is different and you cannot just prescribe the cheapest drugs to everyone because it is not appropriate. In 2013, you did well with your GP compliance with the formulae, but you also have the highest spending on drugs in hospitals in 2015-16. How are you looking at how the hospitals and wards are prescribing against the formulae? I suppose that there are a couple of things of that. We were thoughtful about the auditor general's data that she submitted. Those data said halfway down the page that there are adjustments that could not be made with regard to a number of things. The most obvious one for us in Tayside is that the population base uses £415,000, but we serve the population of North East Fife, which takes another 50,000 patients into that calculation. We are also a tertiary hospital and therefore our comparator would always be with tertiary boards because there is a different range of services provided through those tertiary boards. By definition, some of those medicines are more expensive than the medicines that would be used in a non-tertiary board. Taking those comparators into account, we do not believe ourselves to be outliers, but with all those types of scenarios, there is complexity within the data once you start to examine it and ask further questions around it. That is specific with regard to the hospital element. We have done further analysis already since the auditor general submitted. We think that there is additional information that we will happily share that suggests that we are not the outlier in the way described. In areas where we are outliers, I want to pick up on, if I may, Mr Neill's point as well, the importance of using medicines within the context of a patient's care and the continuity of that patient's care. We use a lot of medicines that are different to the rest of Scotland around patients who require their blood thinned around anticoagulation. If you looked to the graphs around the reduction in stroke in Scotland, the reduction in stroke in Tayside is significantly greater than the reduction across the rest of Scotland. There is some expense at this end that ultimately will impact upon our ability to scenario plan into the future. We are seen internationally to lead around the use of medicines for hepatitis C. Again, those are medicines that, at the front end, have a significant expense. However, at the other end, should you not treat hepatitis C, you have patients who require liver transplantation, and our rates historically have been lower as a consequence. As we are touching on individual drugs, what is being done to look at the use of particular drugs in hospitals, for example statins or ameprazole or things for diabetes or other long-term conditions? If I was to take you back to the comments that I made earlier on, when we now and the analysis that we have only been able to get from ISD and others since December, and diabetes is a very good example where we can look at the cost patient treated in Tayside, we are just about the lowest in Scotland. However, because we have more patients with diabetes, we have a far greater expenditure around the range of medicines around diabetes than is anticipated with the budget that we are given. What percentage of your budget goes on preventative spend? I probably passed to Mr Bedford if I may, Mr Ross, to answer that question. I didn't quote you a figure this morning. If you have a large number of patients with chronic conditions, it would be sensible to look at how we can stop those patients from getting those conditions in the first place. If it might come back, I fully support and agree with that, and where our ambitions are collectively around the integration of health and social care, it should be getting into that type of territory. I was interested on page 15. You have five challenges and quite a lot of subherings under those challenges. When are we going to see the prescribing strategy that you have mentioned on page 14? The prescribing strategy work has already started and will emerge over the summer. I have tried to describe earlier on the use of medicines within the context of an overall disease, rather than simply looking at medicines in isolation and recognising that, in creating some individual efficiencies in that budget, the totality of the spend and the outcome for patients may be poorer. Do you think that your prescribers feel supported enough to make these changes, and how are you supporting them? The prescribing management group works, first of all, in very closely as almost a professional advisory structure through the area medical committee, the GP subcommittee and the consultant subcommittee, all of whom are on board and around that. We have put significant investment into pharmacy support for practices. The Tayside was one of the early adopters around the practice-based pharmacy model. Historically, the focus has been very much on some of the qualitative elements around that. We recognise areas in which we cannot justify the variation and you have touched on some of that already in the conversation. There are areas of variation in prescribing that we would very much support and would continue to support. It has been clinically the right thing to do in areas in which we cannot justify that. That is the type of area that we will be focusing some of the additional support. Do you have any projections on savings if you had a bigger uptake of the minor ailments scheme? I do not have those details. I am sorry, it is not something that I have been party to working through. Mr Ross, again, I do not know, Mr Bedford, whether you have those details. We are happily to supply those with for you. That would be good, because I know that community pharmacy Scotland are putting a big focus on that just now. I think that there is a pilot number of Clyde to try and get more people in. The savings are certainly in the millions, so that might be something that we could look at. On page 16, we have some efficiency savings. We have got two bottom lines of £6.2 million and £3.8 million. Is that correct? That is the two figures that I see here. In order to reach those, are there any plans to cease prescribing any items at all? I think that Mr Bedford can comment on the bottom figure of £3.8 million, because that is a simple impact of changes of drugs coming off patent. That is correct. Over 2017-18, we expect a number of drugs to come off patent. We expect that, in the current year, that will provide a benefit of £2.4 million. Is that going from a brand name to a generic? With a full-year impact going into 2018-19 of £4.5 million or a further £2.1 million to benefit the board in 2018-19, that will benefit all boards. The other element in relation to tariff price reductions reflects the discussions with the contractors around the prices. We expect a benefit that will be delivered in 2017-18 of £1.4 million. Again, that is a national benefit. However, there are no plans to stop prescribing anything. I will ask the medical director to comment particularly on lidocane patches and pregabalin. The lidocane patches are medicines that are used for controlling very severe pain, and their indication is for very, very restricted use. Whilst we are now in a position that we are complying with that restricted use, certainly within NHS England and in other parts of NHS Scotland, that use is extremely limited, but we have a number of patients who are getting it. So lidocane would be a very good example of where we think that it is in the patient's interest not to be having the level of access to that medicine that they have currently. On the bottom of page 14, it says that the realistic medicine workstream is integral to the five-year transformation programme. Can you tell me a little bit about that, please? The realistic medicine workstream is one of our key workstreams within the transformation programme that is led by Professor Margaret Smith, who is the Dean of Nursing at the University of Dundee, who has a wide experience of health service delivery. She was previously head of nursing in Greater Glasgow Health Board. The workstream is designed to look at not only effective prescribing but effective use of medications and effective use of interventions and making sure that patients are offered only what is most appropriate and are not over-treated inappropriately. Just to go back to the bottom line saving, you mentioned before on another line of questioning that there was now a split between the IJB and what it had to save through the GP practices and what it had to save with the other prescribing. Is there a split in the £3.8 million, or is that totally your saving, or is that an IJB saving as well? It entirely relates to primary care and medicine, so GP. Just for clarity, who from NHS Tayside sits on any of the IJBs? The IJBs are chaired either by an NHS Tayside non-executive member or a nominee from council at the present time. The three IJBs are chaired by members of NHS Tayside board. Chief Operating Officers, two of them are employees of NHS Tayside and one is an employee of D-City Council. The IJB board is populated by nominees from NHS Tayside who are non-executive members or nominees from the council, some of whom are elected councillors. Okay, so there is relatively high influence on the IJBs and so hopefully you'll be able to ensure that they make their savings as well. We are, but I would remind the committee that IJBs are were established as autonomous bodies. Yes, indeed. I just hope that if the total savings are not made, that the IJBs won't be used as a scapegoat, but it's good that if you're controlling them then that won't be the case. Thank you. If I can pick up on that point that Gail Ross was making about the IJBs and prescribing, we touched on earlier that the savings become high risk because 1.9 million of projected savings are on prescribing. Is it going to be more difficult to actually get a grip of GP and primary care prescribing, Dr Russell, because the GP practices now fall under the IJBs? From my perspective, I think that there's less of an issue with regard to the GP practices, but there's more of issues around the governance that we've touched on already in the conversation. We, through the use of formulary, through the agreed protocol, we have for the use of medicines that fall off that formula and therefore the level of agreements and permissions that you need to get in order to do that, are in a position to have a confidence irrespective of where the prescriber sits in the organisation, that the standards of the prescribing and the decisions made, which at the end of the day are made in the patient's best interest and we're all individual and medicines impact on us all in different ways, there should be a degree of consistency around that irrespective of where the prescriber sits. Do you know how often GP practices review repeat prescriptions because there is an issue in Dundee of stockpiling medicines? Historically, the quality and outcomes framework, which was part of the contractual obligations for general practice to work in, placed a 12-monthly requirement on medication review as part of that. The compliance with that was, we determined through a payment verification model where we would sample a number of the practices and go in and check against their books and against some of the patients that those things have happened. So we have no reason to suspect or no reason to consider that that has not been happening historically. Is there still that 12-month review target? So that's still part of the contract, but the GP contract, as members of the committee will know, is out at the moment and I'm probably not the best place to advise you as to where that medication responsibility will land in that. How many surgeries are hitting that target of reviewing their repeat prescriptions on a 12-monthly basis? So I again don't have those specific details, convener, but we have no reason to suspect, but clearly you're giving us feedback and you've given me feedback before that there's been concerns expressed directly to you. You need to make £210 million worth the savings over the next five years. We've been assured that there'll be no impact on patients and staff and indeed in our session in December. We were quite clearly told there will be no impact on patients and staff of the savings. This week we've discovered that the Scottish Government has to advance another £1.5 million in brokerage, specifically to avoid an impact on care of further cost-saving measures. So what's changed in three months? I think that it can maybe go back to the discussion that we had earlier this morning. The £1.5 million was agreed with Paul Gray following his appearance before the committee when NHS Tayside had to look at alternative scenarios. If we wish to close off our financial year, one of the options might have been to reduce substantially elective surgery. We could have closed mobile theatres, for example, and stepped in activity. That would have been an impact on patients. We discussed that with Mr Gray. The board's preference was that we should not impact on patients and, therefore, he agreed that to avoid that impact, he would provide additional brokerage. Yes. You would have to take more borrowing to avoid an impact on patient care that we have been repeatedly assured is not going to happen regardless of the savings that you have to make. Isn't that correct? Yes. I think that, again, I said earlier on that when we appeared in December, our projections were that we should be able to complete the year with the savings of outlending in our LDP. Because of two areas of inability to achieve the savings—notably around prescribing—and a higher level of delayed discharges that meant that we had maintained a level of agency in our spend and that we had to postpone some elective surgery, particularly in January and February, adding cost to the system, we did not meet our savings target. We had added cost because of the two elements that have outlined. I want to look at the direction of travel here to take a smaller example and scale it up. If we look at the five-year plan at page 26, you talk about shifting the balance of mental health care from hospitals to more community-based, and you also talk on the same page about reviewing the larger property portfolio that you have. I have written a few times regarding this mulberry unit at Strachathro, which has been closed temporarily due to what we learned from Paul Gray, in particular staffing difficulties. To avoid the impact on patient care, that has been temporarily closed. Is not the implication of reducing the property footprint and shifting the balance of mental health care in this example to the community that that temporary closure is not in fact a temporary closure at all? It is a permanent closure, is it not? No. Part of the issue relates to two parallel processes. You are right that we had to close the mulberry unit on a contingency basis because we could not safely staff three general adult psychiatry units—one in muddy oil, one in curtsview and one in mulberry. We explained to the committee in December that we were running major risks with the level of medical staffing that we could not have safe rotas at night, so there was risk to patients. Because of that, we made a decision that we could safely staff two units at least until August. At present, we do not know what our staffing complement for junior doctors will be after August, so at present we do not know what the situation will be. At the same time, and in fact two years ago, we put in train a review of mental health services. The underlying principle of that review of mental health services was that Tayside is an outlier in terms of having more emphasis on adult inpatient care and less on community care, which is counter to current practice, and there was a strategy that we should seek to move care where possible into the community. It was also clear that Tayside has too many adult inpatient sites in relation to its ability to manage them safely in the long term when we have seen that repeatedly over the last couple of years, and therefore we have an options appraisal, which is currently on-going, which is designed to look at how many units we can safely staff and where they should be. That options appraisal has yet to report, so there are two processes going on. If we come down from three to two adult inpatient sites or even three to one adult inpatient site, there will be implications on how we deliver care for psychiatry across the whole of Tayside in terms of community care. We will not spend less on psychiatry as a consequence. What we will do is spend the money in a different way. My problem here is in the semantics. I understand what you are saying, Professor Connell, but people have been told that this is a temporary closure. Temporate means not permanent. It means that, at some point in the future, that situation will cease to be the situation. We have sufficient junior doctors to staff our rota in August, then we should try to open mulberry again. However, we have an options appraisal exercise, which is coming down the track. If that option appraisal exercise—and I have not seen the outcome—if it recommends that, in the long term, we move from three units to two, and if that implies that mulberry is not an adult inpatient site, then we then move into the process of public consultation, formal business case with Scottish Government, and planning to establish two units or one unit in Tayside, that will take some time. I agree with you that there is a semantic issue, but the reality is that we are having two processes that are happening at the same time, not through the choice of an NHS to Tayside. Is it possible that, just to take that example, is it possible that Strachathro hospital could be part of the property casualties over the next five years? Breakin, Infirmary, Montrose, could those sites be lost altogether? Do you think, as a result of the review? No. I think that Strachathro is a regional elective surgery treatment centre. It also has the potential to increase its use in community services, where there is a substantial number of outpatient services at Strachathro, and there would be no intention of moving away from that site. We can tell anyone watching this that those sites will not be closed over the next five years. I will not comment at the present on Montrose and Breakin because they are not part of the mental health review. They are community provisions. The Montrose site at present has outpatient activity and a small number of community beds. There is a need for a community bed base in North East Angus, but, at present, I think that it would be appropriate to start strategically planning now the number of sites or where there should be. In terms of the beds—I am moving slightly now—have there been significant changes in the number of beds on wards in general throughout NHS Tayside as a result of your efficiency savings? I should probably pass that to my chief executive. In my initial reaction, in terms of efficiency savings, no, but there have been a change. For example, one that would spring to mind would be a ward in Perth and Kinross locality, which was providing inpatient dementia care. With the development of the community dementia model, we got to a position where we had only one patient in that ward. We were reducing occupancy levels because of an increasing new service model that was being provided, and therefore that ward is closed at the moment because there was no demand for it. That would be an example of where there has been a change. You obviously referenced Breakin. I know that you will have the detail around Breakin in terms of the medical care provided by the GP practice. That was the instigator in terms of the closure of the Breakin facility, although there are outpatient clinics still running from there. In terms of direct efficiency, the answer is no, but either through service model change, or another example in Perth and Kinross, would be the creation of an integrated facility of health and social care. Dal Weem is the example where we had a very old Aberfeldy hostel, a very small bed occupancy, again reducing demand within there, but creating a new facility for health and social care colleagues is going to work under the one roof. The new service models that are coming in are changing the bed base. As I indicated earlier, looking at that planning assumption around reduction in emergency admissions, the length of stay, we should be looking for a change in our bed base within our acute sector. I understand that there is a concept of boarding, which, for someone who is not in it, is where patients who should be on this ward are on a different ward. Have the efficiencies that you have been doing had any impact on the numbers of patients who are boarding? How do you project that those efficiencies will impact over the next five years on the number of patients boarding? In terms of the boarding, what you will be referencing is normal if it occurs within our acute sector beds. We have a boarding policy that we adhere to, but there have been levels of boarding, and you are correct in saying that. The factors that we drive that would be an increase in expected emergency admissions, particularly in the winter period. I go back to patients who are delayed within their discharge process, and, therefore, they are sitting in an acute bed or a surgical bed. If we have an emergency admission, you are in a position where you are either moving that individual patient, which would probably be the normal situation, because it would be the clinicians who would risk assess, who would appropriately move into a different specialty for a short period of time. The considerable efficiency savings that you are making is saying that there is no impact on the number of patients boarding. From where I am sitting this morning, I cannot think of any decision that the board has taken. I will be passed to my medical director for that as well. The key determinant of whether or not an individual is in the right ward for their care is the level of delayed discharge within our system. I will just be absolutely clear about that. The Perthrall infirmary site, through all the predictive modelling that we do, we know can function effectively as a site that deals with the full range of services around medicine and surgery if there are six delayed discharges in the system. We have done that modelling. If, as we have had over the last period of time, there are in excess of 20 delayed discharges in the system, some patients will be finding themselves being cared for in an environment that is different from the ward that is not the ward that is the right one for them as a consequence of that, rather than as a consequence of efficiency savings. I just want to be absolutely clear that the key determinant of boarding in our system of care is the level of delayed discharge. Colin Beattie I will look at page 30 of the five-year financial framework here. I will be correct in saying that any financial model that is at the end of five years is still relying on 40 per cent non-recurring costs to deliver the savings, is unsustainable. I think that we recognise that that is a very challenging situation to be in. Off that 40 per cent non-recurring costs, our ambition was, when we met in December, to say that we wanted to move progressively towards 40 per cent non-recurring costs from the base where we are at at present. It is still higher than most models would like to see. I mean, looking here, it says that £67 million of the savings over the five years will be non-recurring. I see elsewhere in your documents that the property disposals will be £12.76 million, so where is the other £50 million coming from in non-recurring costs? I will pass at that stage to our financial director. I think that it reflects the normal. In your flexibility we have got around management of vacancies. We think that there will always be vacancy management going on. It also reflects the control that we have around the reserves and board earmarks, recognising delays in normal events of the board. I guess that the work force will be one of the key areas, just recognising the normal pattern. That all sounds very nebulous. Well, I think that the experience of the board over the years is that we certainly have a higher level of non-recurring savings than we would want to have, and there is an ambition there to ensure that we get a higher level. It would certainly be more encouraging if the level of savings that we deliver in 1718 is higher than the 50 per cent that we are indicating, because that would then have a significant benefit in the years going forward. I would assist the overall delivery of the return of the brokerage. It seems to me that £50 million, leaving aside the property, assuming that we get that, is a huge sum to take from non-recurring. I hear what you are saying about delaying, filling posts and all the rest of it. Some of the stuff did not really make much sense to me, almost, but the fact is that this is more than challenging. After the year five, even if all this works out for you, how long are you going to be able to continue this? You are not showing any improvement at all in the last three years. It still sits at 40 per cent. It is not sustainable. We have probably made a small step change this year. In 2015-16, we reported a 35 per cent delivery of recurring savings. This year, we are reporting 40 per cent recurring savings. There is an ambition as part of the financial plan, and we believe that it is realistic to deliver a 50-50 split in 1718. We are taking those steps forward. Clearly, it would be beneficial if that step change in 1718 was even greater than 50-50, because I say that that would help the position going forward. A business like this? It is not sustainable. It is not how it works. It is not how it succeeds. You cannot have this level of non-recurring costs. That is certainly an ambition to ensure that the level of recurring savings delivered by the board is as great as it can be. It is fine, but there is nothing in here that shows me how you are going to achieve it. I do not think that any of us would disagree with you. We understand the size and scale of the challenge that we have, and we are trying to be realistic. When we say something that we deliver against that, we know the importance of that. It also recognises that in the five years service redesign, there is a level of planning and redesign work. You end up in a slightly double running as well as you are testing things and piloting them. Once you move, I gave that example around the dementia model, where it is the right thing to do to provide community dementia care at home, earlier identification prevention, and then improve people's quality of life who have that illness. However, while you are developing those community models, you still have your historical inpatient costs and costs that are fixed costs. As we go through these service redesigns and the new services that are implemented, we will be able to release recurring costs out of the system. We are forecasting in five years. I think that we have talked about the risk. You are projecting recurring costs already. Now you are sort of conflating non-recurring and recurring. It seems to me that for non-recurring costs, what you have done is you have estimated that you are going to save so much, and then the difficult bits you have just lumped into non-recurring costs and hope for the best. Our view would be that the five-year plan will be assessed every single year, so the progress that we have made in 1617 is part of the five-year projection there forward in that five-year cycle. We will look at our delivery in 1718 and reassess the ability to whether we can increase it. We know the importance of it, and if we are confident or we believe that we have the plans that will allow us to increase our recurring efficiency, then the board will absolutely take that decision. At this moment in time, given the base that we have started from, what we are endeavouring to ensure is that if we say that we are doing this, that we do deliver against that. You know that this is just a finger in the air as far as these costs are concerned and these savings are concerned for non-recurring. Can we, is it possible to maybe ask for a breakdown of where those non-recurring costs are going to be achieved? Yes. I think that if you can provide us with that, Mrs McLey, is that possible? That would be great. You finished, Mr Beattie. Thank you. Mr Bedford, your financial year ends next week, is that right? It ends tomorrow. And you, at that point, will be all the Scottish Government more than all the other health boards in Scotland combined, is that right? It will be the nearest board to us. There will be NHS 24, which is a board that is significantly smaller than the NHS Tayside. Which had huge problems with its IT system, and I think that a lot of its debt is due to that. The projections that you have given us also in your five-year change programme at page 30, and I touched on that earlier, indicate that £2.6 million of that loan from the Scottish Government you do not expect to repay, is that correct? The forecast shows the position of the draft position over the five-year period, so it only takes up to 2021-22. As we have referenced probably a number of times this morning, we are clear about the 2017-18 budget and the uplifts, and the implications of that. Going forward, it is less clear. The current plan makes no assessment whatsoever of the Scottish Government moving the board closer to its target share of parity. Currently, we are £7 million away from the target share. We are £50 million away from the refinement of the NRAC model, and following an £8 million additional investment in 2017-18, that moves us £7 million. The assessment throughout that whole five-year plan is that the Scottish Government will not be able to take us any closer to that parity figure. If the Scottish Government were to take us closer to parity, that would give us additional recurring resources year on year, so that is not factored in at all into the plan. Just to clarify for that, if they were to give you parity as you describe it, how much money would that involve? It is £7 million per annum, £6.8 million per annum. That would solve the financial problems of NHS Tayside. It would support it, yes. As of tomorrow, you are still a little Scottish Government £33.2 million. The £7 million per year would solve that. That would be assuming that there would be no spiral in costs at all, would it not, if my maths are roughly correct? Convenience, just to make members aware that the area that we are touching on at the moment is an area, including Mr Neil from his experience, that will understand the complexities of the NRAC formula and the way in which the allocation is used. As a clinician, I am not near to that, but there have been representations to me from the clinical community where they do not understand why Tayside is not on parity with the rest of Scotland. They recognise that the NRAC allocation prospectively is against 2013-14 calculations and have legitimately asked the question, what has Tayside's financial position been against parity since that 2013-14 position, and what have been the consequences of that? Just to make you aware, that is coming through the clinical community, and it will bring that to me as a medical director, but clearly we are not the right people to provide an explanation. I am not the right person to provide an explanation. Okay. As well as scrutinising this committee, it wants to do everything it can to make sure that you can get back to financial sustainability without cutting services, so that is something that we can take up with Mr Gray to get clarification on why that parity is not coming as you describe it. However, if I can go back to the £2.6 million that is unlikely to be repaid, Mr Bedford, is that likely? We talked about the £5 million high-risk savings, and we talked about the £12 million Liam Kerr did, the £12 million medium-risk savings. What would you say to the people of Tayside? Is NHS Tayside still going to be in debt at the end of these five years to the Scottish Government? Clearly, the ambition is to repay that level of outstanding brokerage as quickly as possible, but also as safely as possible. The assumption that we are planning at the moment identifies that a very small amount will be left outstanding at the end of 2021-22, and on the assumptions that a reasonable level of savings is delivered in year 6 of the plan, that would repay the entire outstanding balance. By the time that we get to year 6 of the plan, what we show is a five-year plan. If we extended that out, we would see the position being repaid in full. After six years? After six years. You will forgive me for probing you further on that, because it was on 15 December in front of the committee that Professor Connell said that our plans for the next five years, which include the full repayment of any outstanding brokerage over that period of time, are less than six months ago. Less than six months later, we are now seeing that you are projecting that that money will not be repaid. I am concerned about services and jobs in NHS Tayside, and we have looked at high-risk and medium-risk savings totaling £17 million. If, in what is it, four or five months since Professor Connell said that money will be paid back at the end of five years, we are already saying that £2.6 million will not be, and we have identified £17 million worth of savings that are really risky for this year, is it credible for you to tell me that that money will be paid back? If I can pick that up, you are absolutely correct that it was our ambition in December that we would have a five-year plan that would fully repay the brokerage. Obviously, since then, for the reasons that we have discussed, the brokerage has increased by £1.5 million. That places an extra challenge over that five-year period. Also factored in since then has been an understanding of what the revenue resource limit coming down from the Scottish Government will be in this financial year, with no certainty over what will come in future years. Mr Bedford has created a relatively conservative assumption over the level of resource that will be available over that period of time, which is probably more conservative than we had anticipated prior to our meeting in December, which was before the Scottish Government's budget allocation. It is against that revised understanding of what we might expect to have financially, and perhaps a revised understanding of the financial pressures in the system that we have now got a level of brokerage that is, if the plan were to be delivered in fruition, it would still be around £2.6 million at the end of five years. Okay, so that £2.6 million would still be outstanding? If the plan is delivered, as I outlined just, but as we have agreed, none of us can predict at present what the resource limit will be in five years' time. Can I do members have any further questions for the witnesses? Can I thank you, Mr Bedford, for your like to… It's got a point of planification to your point of fact about effective prevention. If you will look at page 50 of the one-year financial plan, you will see that, as part of the outcomes framework resources that we receive from Scottish Government, there is a line on the right hand side of the table effective prevention bundle. So we get approximately £3.3 million in resource for the effective prevention bundle, and it includes items such as the sexual health and blood-borne virus, child healthy weight, adult healthy weight and smoking cessation. So there is £3.3 million that comes to the board in relation to effective prevention. Liam Kerr A quick final question that I think people want to know. What happens if this doesn't work? What happens in five years' time if all of the plans, all of the savings, the efficiencies don't work? What happens to NHS Tayside, its patients and its staff? Okay. I think it would be appropriate to assure the people of Tayside that NHS Tayside, whatever happens, will still continue to deliver safe and effective care. Now clearly how that is managed financially, if this plan is not delivering in the way it's anticipated, will involve on-going and further discussion with the Scottish Government health department, but the NHS in Scotland has a principle that it will maintain healthcare services. Can I thank you all very much indeed for your evidence this morning? I'm now going to move the committee into private session and suspend for five minutes. Thank you.