 Good morning, and welcome to the sixth meeting of the Health and Sport Committee in 2019. Can I ask everyone in the room please to ensure that mobile phones are switched off or to silent, and please not to record or film proceedings? The first item on the agenda is an item of subordinate legislation, consideration of a negative instrument, the personal injuries, NHS charges among Scotland, amendment regulations 2019. There has been no motion to annul, and the Delegated Powers and Law Reform Committee has made no comments on this instrument. Are there any comments from members on this item? There are none. Is the committee agreed to make no recommendations on this instrument? That is agreed. Thank you very much. The next item on the agenda is an evidence session with the Scottish Ambulance Service. This is one of a series of evidence sessions, which the committee is holding with both special health boards and territorial health boards, and the committee last took evidence from the SAS on 23 May 2017. This morning, welcome to the committee Tom Steele, the chair, Pauline Howey, chief executive, Dr James Ward, medical director and Donna Henry, specialist paramedic, all from the Scottish Ambulance Service. Welcome and thank you for your attendance this morning. Clearly, the item of great interest to the public, which we should start with, is the changes in the triage system under which you prioritise calls and respond to calls. I would be very interested to explore that. Clearly, critical in the way that is designed is the response to immediately life-threatening calls, and I have seen the research on that produced by the University of Stirling just the other day. I wonder, though, if I can start by asking about whether you intend to do research on the next category of calls, those that are serious and clinically requiring attention but not immediately life-threatening. Has there been any work done on that or is there any work planned on the impact of the change in the system on those types of calls? I thank you for inviting us to give evidence to the committee this morning. I may apologise for my croaky voice. I'm afraid that some pesky virus hasn't got me, but I'll do my best. In answer to your question, I'll refer to Dr Ward, who will follow up on the question and build on the information that you read last week. The answer to your question is yes. In essence, the response model that we've developed is about all of our patients, whether they are affected by something very serious, such as a cardiac arrest or a heart attack, or whether they are affected by any other of a range of conditions that we are required to respond to from a mental health crisis to relatively minor peripheral limb injuries. The model that we've developed is really based at putting patients right at the centre of all of these response decisions. It's based on a huge amount of data and evidence around the requirements of patients right across all elements of our Tribal 9 service. We look at a range of factors that are affecting all of those patients, because we've historically been, had our thinking, dominated by response times, and response times are important, but they are one of a number of factors that affect the outcome for patients. In direct answer to your question, in terms of patients outwith our purple and red categories, which are the ones that you're referring to under the immediate life-threatening basket, there's a huge amount of work being done for patients in our amber category, which is looking at patients affected by chest pain and stroke symptoms, and for patients in our yellow category, who are affected by a whole range of conditions. Thanks very much. Clearly, some of those conditions that you've mentioned, which are in the yellow and amber categories, are potentially very serious. One of the concerns, certainly, that I've raised with me is that a decision that such a case may not be regarded as a priority could have consequences if the individual is on their own, for example, and if an hour later there may be a level of deterioration that wouldn't have been evident at the outset, is that something that is acknowledged and, if so, what can be done to ensure that that's addressed? Absolutely. All the calls that we are talking about around this phase of our response model development are coming in as Tribal 9 calls. Those are all priority calls. One of the challenges when you're a clinician and providing clinical care is to make rational decisions about the acuity of that response. For example, if we have two patients who are the same age and one has an ankle injury and one has severe crushing chest pain, I think that we would all agree who we would send the first ambulance to, but we would obviously keep this other patient in mind and be looking to get a timely response to that person. We're continually reviewing our responses both clinically, as I mentioned, but also in terms of time. In particular, we look at our average response times and the extent to which we get to 90 per cent of our patients right across every one of the categories, but not just that, we also look at the patients who are beyond that 90th centile. 90 per cent is pretty good, but there are patients beyond that, and they matter as well. We're continually looking at exceptional circumstances, refinements to triage, safety netting within our army's control and a whole range of issues around making our service delivery as effective as it possibly can. I recall a long time ago, as a member of the Audit Committee, perhaps in 2001, looking at issues of prioritisation and categorisation of calls and significant changes were made then. What is it about the changes now that are qualitatively different from the changes that were made a number of years ago? The system that we had up until October 2016 was based on three categories of response, category A, B and C. Category A represented about 33 per cent of our call volume, and our target for the category A was to respond to these patients within eight minutes, and that was about the B all and end all. Listening to staff and patients, there was a lot of frustration around such a large proportion of our call volume being determined as our highest priority. We set in place a process to look at all of these patients right across the whole Tribal 9 family, if you like, which is divided into over 1,200 codes. What we sought to do and what we did do was understand some very important parameters within these. For every single code, we can tell you the cardiac arrest rate, we can tell you the conveyance rate, we can tell you whether there are airware breathing interventions, we can tell you whether the patients are pre-alerted and we can tell you how sick they are based on their early warning scores. Having got all that information, we set up a hierarchy, which is the purple, red, amber, yellow categories that are in our report. Not only did we recategorise them, however, we also changed the method of response. For example, in our highest category, which is our purple category, you won't just get the nearest ambulance, you'll get the nearest two resources, because if someone is going to require active resuscitation, you really need three pairs of hands at least. We've significantly increased the extent to which we get two resources to these patients in as timely a fashion as we ever did. Within that category, the actual cardiac arrest rate in the first year was 52 per cent, which was more than I think we expected, but it reflected the fact that we looked to other codes that had previously had a lower response and put them into that category. Essentially, for the codes that go into our highest acuity category, which is the purple category, we know that those people are sick and in immediate life threatening circumstances. What that does, if you align your response to accurately identifying those patients, is to give you the best opportunity to save lives. When we set off at this, we had no idea what would happen in terms of 24-hour or 30-day survival, but certainly what we've seen in the first year from the old system to the new system is a 43 per cent increase in 30-day survival and, for all the other codes, very stable 30-day survival outcomes. Essentially, what we've done from the old system to the new is taken an evidence base and sought to implement that on a national scale. Given the evidence that we gathered before, we were able to sense-check that as we went along. Every week, every month, every quarter, every six months, every year, we've been refining this data to check that we've got patients allocated in the right element of the response model. We have made some refinements over time, not many, probably between six and ten over the year in terms of moving codes based on what we found. Generally, this is what you would expect when you look at so many calls in your preparation, in your planning. It's good to see that that's been borne out in terms of the way that they said that the model has worked. Thank you very much. Before I bring in colleagues, I wonder if I could ask Donna Henry to perhaps provide a staff perspective in terms of attendance on scene of what difference the new model has made in practical terms in terms of your sense of getting to the right people at the right time. In two different ways, I'm often used to attend the immediate life threatening calls as a second response to the third pair of hands. In that respect, I feel as though it's been really useful because I'm able then to travel with the crews and without taking too many other resources away, we're able to give that purple or red call that immediate help and care that they need. I'm able to be utilized to help them. I find that that's happening every single time for me, or somebody's coming to back me up really rapidly. I feel that that works from my point of view. Other category of calls, such as the less life threatening, such as the yellow or amber calls, are the ones that I'm more often sent to as a specialist paramedic because they are the ones that we can hopefully treat at home or have referred to a more appropriate place rather than having them go through the doors of any. For that category of call, it's developing, it's still developing just now. It's not always right because the people who are taking the calls are basically just working on the information that they get. As Jim said, every call that comes into the ambulance service is a 999 call, so those calls have to be categorised. At the moment, we're trying to define the codes so that the calls that we're sent to as specials paramedics are more appropriate and more probably able to be left at home or be treated at home or referred on to a more appropriate place, which hopefully will be in the patient's best interests and the patient's family's best interests. I'll bring you in a moment, Sandra. Thank you very much, convener. Good morning to the panel. Can I put on record my thanks for everything that you do for us? Congratulations indeed in the demonstrable increase in saved lives under the new system. As a constituency MSP, we hear more about the cases that are left waiting as a result of the triaging system. I don't suggest that that system is wrong, but I do have some questions about the waits that sometimes people who have non-life-threatening situations can have to suffer. I had a constituent who fell in the streets in Custorfin last winter, about this time last year, and he was in his late 70s and had to wait nearly three hours for an ambulance. When you said, James Ward, that you keep those patients in mind, what do you do to monitor the situation around those individuals who are not life-threatening but may have to wait more than an hour for uplift? If I can start by saying that the prioritisation that we do—obviously we are prioritising resources, but that is by no means the singular cause of delays in response, and I can come on to more about that if you wish. In terms of the specific patient for whom we do not respond in a timely manner, the first thing that we do is that we, our dispatchers, are continually monitoring our resources in order to make sure that, on an on-going basis, every possible resource that could go to that patient is being allocated. The second thing is that we have a clinical hub within our Ambulance Control, which we have invested in significantly in the past few years. Their job is to keep in contact with patients such as this for whom we are not able to get to, and at 45 minutes our aim is to have called back every single one of those patients in order to have A checked in with them to let them know that they are in our system and we are responding, but B and probably more importantly to check that there has been no deterioration and that their condition does not need to be escalated to a higher priority. If we take my constituent, for example, if he had had a serious fracture and gone into a state of shock, possibly underlying heart condition that we do not know about, if it then became a life-threatening situation, you would pick that up in that monitoring process, is that right? That would be the absolute intention. The priority allocated to that call would then be based on the most recent information that we had. If, as you say, a patient—I can't refer to your direct constituent, but if a patient in general had deteriorated as part of our interventions, that would be a re-prioritise within the system. I wanted to add that, in terms of some of the adaptations that we have made that Jim spoke about earlier on just before winter 2018, we took the learning from previous cases, such as the one that you referred to, and we have looked to see how we can recategorise patients that are particularly vulnerable in places outside that might be fractured, so we haven't seen those types of patients waiting just as long as they had in previous winter. There has been a lot of learning, as Jim said, in terms of the implementation of the model. On the same point, Mr Cole-Hamilton, I, too, experience what you experience. I quite like to go out with crews in a fairly regular basis. The patient had, indeed, fallen this time in a bookie shop, but had been there for three hours, and that struck home very closely with me. As a result of that, the chief executive and the board were very keen to look at those vulnerable patients who, because they are in a public place and because they are outside, are subject to more clinical risk than they would be otherwise, and we have reacted to that in the way that the chief executive has said. We are going to come on to a discussion about staff morale, but can I ask, in those cases where people have had to wait hours for an ambulance, have your staff, front-line staff, noticed an uptick in aggression or abusive behaviour, people who are understandably fed up and may be distressed as well, but is that a factor that plays into the morale discussion? Perhaps, Donna, you best place to answer that. Well, yes, it does. Like I kind of alluded to earlier, the codes and things are all still developing, and we do still get a little bit wider if we do not get sent to that. You have got to bear in mind that we do not know what the big picture is, we do not know what other calls are going on, we just know what we are sent to. However, when it does work, for example, if I am sent to a patient who is a 75-year-old, that I dealt with last week, a 75-year-old at home alone suffering from difficulty in breathing, she managed to phone 999, she phoned for the ambulance. After the call was triaged, I was sent to attend to her. Her symptoms were exacerbation of our COPD, and she had a bit of a chest infection with that. I was able to do an advanced assessment of her and make a clinical decision based on her past medical history. I was able to help that lady to stay at home without the increased risk of having to take her through to the hospital. Obviously, I was able to contact an out-of-hours GP just for some professional to professional support, and I also contacted her family, who were absolutely delighted that their mother was not going to be dragged out of bed at that time in the morning and taken to the hospital. When it works like that, it makes me feel really glad to do that job. The flip side of that, if somebody has been waiting for the three hours for an elderly relative outside in the cold, do you get pushback and anger sometimes as well? It is extremely frustrating, but I guess that that is not a regular occurrence. I am thinking that that is quite a rare thing that happens. When there is a pressure of other emergency calls, it would be just a case of trying to explain it. It does make me feel sad for the patient, but I would like to think that I am able to explain it to the patient in a way that they will accept. Thank you very much, convener. Good morning. I put on record that I am so grateful for the service that we receive. I certainly downloaded the paper today that says that the clinical response model saves an extra 1,182 lives, and that is good positive news. However, what I wanted to do was go back to the original first question—excuse me, maybe I have picked up your cold—for the basics. It is not just all about the eight minute, etc. There are so many other people who have said themselves in paramedics. But when somebody calls, the operators have a great deal to do with that as well. In regard to that, even if it is longer than eight minutes, they will decide and talk to people through it. Obviously, you mentioned a paramedic. I note that the response model now is to be able to determine whether someone has a stroke, rather than go to a local hospital or whatever, is to go to the most appropriate in that respect. Unfortunately, I have had that experience in the past couple of months or a year. I am quite familiar with it, but the public itself might not be as familiar with it. I wonder whether the public's understanding of the new model understands that, if the phone, etc. How do you have a better understanding of the public? If the phone is 999, it may not necessarily get an ambulance in eight minutes. What is the procedure? It is just to put on the record that it is not just about the eight minutes, it is everyone working together. Absolutely. I will just talk you through exactly what happens when your phone is dribble nine, because I think that that is part of what you are getting at. The first thing that we need to do is establish where the patient is. We would be invested in a bit of technology so that, if the phone is from certain or from landlines, it auto-populates. That saves a bit of time. If the phone is non-mobiles, we are not quite there yet. We have to establish the location. That is really important, especially if you lose contact with the patient. The second thing that happens is that this is you, maybe 20 seconds into the call, and the caller will be asked, is the patient breathing? If the answer to that is no, that will automatically generate a purple response and we will send the two nearest resources. We are dispatching the first of those resources, usually in about 45 seconds from dribble nine. If the answer to that question is yes, then we will say is the patient awake? If the answer to that is no, then we will generate a red response. That is on the basis of evaluating thousands of calls and understanding the journey. What that means is that, even before people enter triage, which is what I am going to talk about next, we have identified a lot of our most critically ill patients just by what we call pre-entry questions. The next question is, can you tell me exactly what has happened? That is when our call-takers have to listen and often listen to a very stressed person or someone who might not know who the patient is. They might be someone who has come across in the street or whatever, so they have to get the really good listening skills, and then what they are doing is establishing what is called a chief complaint. That establishes one of our cards and there are 32 different card sets, which take you down everything from trauma to chest pain to breathing difficulties, et cetera. At the end of that process, which usually takes about two minutes, we will have established a final code, and on the basis of that final code, our dispatchers will allocate the nearest ambulance. It is probably worth stressing that all of the delays that we are talking about here are within our yellow category, which is our biggest basket of calls. It is probably worth noting that we get to 50 per cent of those calls in about 15 minutes, and we get to 90 per cent of them in less than 50 minutes. That has been data over the whole year. It is probably also worth saying that this December, due to a whole lot of improvements that we made, our response times were significantly better than last year, despite a 5 per cent increase in purple and red demand. We are learning as we go. The final bit for a relatively small proportion of our calls is that we will say that we need some more information in order to determine the right response. That further information can be gathered by our clinical advisers, or, for a certain proportion of patients, it can be gathered by NHS 24. There is a continual crossover between us and NHS 24 when people will phone 111, but they really need an ambulance or people will phone 999, but actually their acuity is such that they would get a better service. In all the time that we have been delivering these changes, and we have been working with NHS 24 for three or four years, I cannot remember a single complaint that we have had about a patient who was pushed in that direction. I think that that is all about how things are done. It is about the quality of the communication. We make a very robust attempt to understand exactly how sick that person is. If we ask permission to get additional triage from them, additional information might be passed or called over or someone called them back within 15 minutes, then, generally, people are pretty accepting of that. Just a very, very small addition to that. Thank you very much for that. I just want to know how do we get that across to the public? Obviously, as Alex Cole-Hamilton said and others have said, we have constituents that come to us that do not quite understand. How do we get that across to the public? Even though they are on the phone to somebody, and they can give them very good information, the ambulance is coming at the same time-type thing, or they are being assessed. How do we get that across to the public if they do not get it straight away? I am pleased to pick that up. The old eight minute model has been around since 1974. It is in the public psyche, but in terms of holding the organisation to account, which is the role that I have in the board, it is pretty useless, to be honest. You have heard Dr Ward explain the new structure, and all those four categories have very clear expectations that we report to Government every week on, as well as on the eight minute response. Going forward, it would be very much in our collective interest for the public to understand how we are operating this very effective new model. We are keen to publicise that, but, weekly, we do not want to do something that would, for straight and eight minutes, continue scrutiny from Government. Thank you, convener. Good morning, everybody. Before I ask my question, I would like to echo the comments that Sandra White made about the new model saving lives. It is good news to get some good news for a change. Sandra White makes a great point about the public's knowledge about the whole process. I think that it is really important that we engage them, especially when we are going down new models of care, where you have paramedic units going to people's homes and keeping them out of hospital because of a COPD exacerbation. I am going to move on to talk about the police Scotland's comments that they are spending more time in emergency rooms because of accompanying people with mental health issues or other issues. I would be interested to know what your opinions are about the police Scotland's comments of their extra time spent. I would like to see some further evidence about that, but is it possible that the new model has exacerbated the amount of time that the police are spending in A&E departments? Both ourselves and Police Scotland are working together jointly to do much better for patients that are presenting with mental health distress issues. We have a number of initiatives under way. We are involved as a Scottish Ambulance Service in the four distress brief intervention pilots that are happening in various localities across the country. As recently as three weeks ago, we made our 2019th referral to distress brief intervention pathway up in the highlands. The patient experience and the feedback from those is very, very positive indeed. There are a limited number of pathways for our paramedics and other staff to refer into for those patients that present in mental health distress but don't have any physical injuries or illnesses that would require attendance in the accident and emergency department. Ourselfs and Police Scotland are looking to see how we can better identify those patients and refer them to alternative pathways where those exist and where they might not exist at the times that patients need them. We are working through the integrated joint boards to try to present the data so that we can come up with better pathways for those patients that meet their conditions at that point of time so that we are not taking people unnecessarily to accident and emergency departments or indeed police aren't taking them to accident and emergency departments or worse still in terms of police custody as well. We have a pilot just about to go live in Lanarkshire with Police Scotland, with NHS 24 and ourselves and we would be really delighted to explain the evaluation of that to the committee in due course. Thank you very much. There was a pilot recently done that wasn't there in Glasgow of street triage and that was partly to divert people from A and E when they didn't need to go there. Is there an evaluation of that in place yet? The evaluation of that is under way. It was in a small court of postcodes within Glasgow and there is certainly an appetite between both organisations to look to see how we could extend that pilot at the appropriate times. We have also got a similar model up in the Inverness, for example, and we target that type of response at certain times of the year and on certain occasions and it seems to be very effective. One concern that this committee has had over time across the NHS is that some very good things are piloted. The pilots are evaluated to be successful but then they are not rolled out. What are your intentions in regard to the two pilots that you have mentioned today? The issue is about sustainability in terms of being able to make sure that we have the sustainability of the workforce and able to deploy those assets that we put on appropriately so that they are well utilised. Those are the types of issues that we ask to be evaluated so that we can scale up where that is appropriate. The pilot in Lanarkshire, we think, should be capable of scaling up. We have looked at the research from across the UK and the triage from police and ambulance into more appropriate and robust referral pathways seems to be one that is sustainable and evaluates well, which is why we are testing it out in the Scottish setting. Thank you very much. We have a close working relationship with the other two categories, one in responders and the fire and rescue service. On a regular basis, the three heads of service and three chairs meet and discuss issues such as this. At the last meeting in December, the mental health approach was indeed one of the items on the agenda. That was one point that I wanted to make the other point was, and perhaps Dr Ward could speak to this, but I do not believe that there is any evidence that the new model is having any impact at all on the amount of time that the police are spending in the EDs. Just to be absolutely clear, we do not change the acuity of our response to a patient based on the police being in attendance or not. I think that you mentioned the wider NHS convener, and that is at the heart of the issue. Essentially, we have to work within the ambulance service. There is a start to the journey that is before someone phones Tribal 9. You need to look at things such as anticipatory care, planning and primary care, and then there are appropriate pathways once we have triaged patients. What causes frustration for patients is where they feel that they are being delayed at any part of that journey, whether it is waiting for an ambulance or an ED, whether it is waiting to see a mental health specialist once you are in the ED. It is for all of us to work together to understand flow right across the system and make sure that the response to people is optimised in those circumstances. Just a wee quick. In NHS Timfriesengall, we have police on-site in their ED department, so I am assuming that that would allow a handover so that other police who are delivering people to any department would not have to remain around. Is that part of a model that is looked at in conjunction with other health boards across Scotland? There are different models in place, but as part of the mental health strategy, there is an ambition to get more mental health professionals into accident and emergency departments so that they can look after those patients that they are presenting with mental health conditions. Clearly, as colleagues have commented, increased lives saved is a very significant criterion. Nonetheless, it is important to note that some of the targets for immediately life-threatening responses are not being achieved and to note that the targets are not for 100 per cent of response within eight minutes. I wonder if you could explain why the targets were set for those that are immediately life-threatening circumstances and why they are being missed, given that the number of eight-minute response time calls or the proportion has reduced significantly. The eight-minute response target applied to the old category A basket, which, as I said, was 33 per cent of our call volume. We no longer have a category A response, but that eight-minute target is currently being applied to our purple and red criteria. You might be interested to know that, within the purple basket, as I have said already, the cardiac arrest rate was 52 per cent in the first year, and the cardiac arrest rate in the red category was 1.5 per cent. That tells me two things. It tells me that we are absolutely identifying the sickest people in our highest priority, but it also tells me that an assumption that we made in the planning phase that purple and red would equate to immediate life-threatening is not necessarily what is being borne out. The eight-minute target is—I can understand why it was put there, but it has lost its relevance, particularly to clinicians in the system. We get to the sickest people as quickly as we possibly can, and that is when the role of the paramedic begins. I just interrupt you there, because you are saying that the eight-minute target is now not relevant, but it remains the criterion to which the service works. Recognising that it may not be adequate for all circumstances, I think that I would be very keen to understand whether or not the Scottish Ambulance Service remains committed to the eight-minute target for immediate life-threatening calls. Absolutely. We are committed to trying our best to deliver every target that has been agreed as part of our delivery plan. In addition to that, what we have been reporting on over the past two years has been both median and 90th centile response times for purple and red publicly and more recently at our board, Amber and Yellow, because we feel that we need to put all that information out there, particularly as it has been highlighted by the concern around the times when there are longer delays. What I would say as a clinician would be that a more nuanced use of targets and indicators, particularly looking at stratification across the response criteria, is a much better way to go. For example, we look at both median and 90th centile for a purple, red, amber and yellow, and we set some indicators at the start of that, because we were looking to benchmark our performance against other services and also internally hold ourselves to account for what our expectations would be. Those internal measures have generally been achieving or very close to across the piece, particularly for the highest acuity patients, even during the times of exceedingly high demand. I guess that this is one of the issues where the transition from an established performance framework to a new performance framework that takes into account new evidence, new ways of working, the paramedic skillset that the issues such as Donna mentioned, around shifting the balance of care, looking after more people at home and moving to understanding both response times, which are important, but also outcomes for patients is the kind of suite of measures that we are looking to develop and hopefully agree with our sponsors. I understand that clinicians focus on outcomes. That is absolutely right. Nonetheless, in terms of the measurement of performance, I looked to the whole panel to confirm that the measurement of performance remains something to which the ambulance service is committed. The cardiac arrest target that you have is 80 per cent responses within eight minutes, and your achievement is 71 per cent, and therefore falls short of the target. I would be keen to understand whether you would share my concern about those numbers or simply see it as part of the process of change that Dr Ward has described. I do see it as a concern, but in context. I became chair of the ambulance service nine months ago with a background recently in healthcare on the board, NHS Lanarkshire, but before that in business. It seems to me that if you are measuring an organisation, you have got to achieve the best quality that you can within the resources that you have available and with emotivated and satisfied staff. In relation to the response times, they have got to be meaningful in that sense. While we still look at the eight minute response, it is a bit of a sledgehammer. I hope that Dr Ward has been giving the indication as to the new ones that we are now suggesting and the standards that we are using. My board is using internally every board meeting by looking at response to purple times with a mean of six minutes, and we are beating that reds with a median of seven minutes, and we are beating that. We have targets and player standards, at least for the amber categories and their yellow categories. Those are being scrutinised at every board meeting. In terms of ensuring that we are using the finances that are available to us in the most effective way, that we are person-centred, that we are safe. To me, this is a more meaningful system. One that I would commit to the committee. We are not doing this in isolation. England has moved to a similar, although not identical, systems. A very year ago Wales moved in a similar timescale. Ambulance services all over the world in Australia, for example, have also moved into that area. Perhaps that gives you some context for the old target and the new standards. It is certainly important that we understand how you understand the targets that you still adhere to. One of my colleagues mentioned earlier that quite a number of communities lie further than eight minutes from an ambulance station. Given that you still have this target for immediately life-threatening cases, how is that applied in the context of the very large areas of rural Scotland? Perhaps the chief executive could answer that and also refer to the community and the local first responders. Yes, so we have a variety of responders across the whole country, including in the very remote and rural areas. We have been significantly increasing our investment in the remote and rural parts of Scotland. The new clinical response model is part of a wider five-year programme of investment in reform. We are investing in more staff, we are investing in the skills and development of the existing staff and we are investing in new assets, equipment, processes and technology as part of that five-year strategy too. Particularly in remote and rural areas, we have a network of first responders that work very closely with our ambulance crews. They are a vital part of our response. We have a new wildcat response to cardiac arrest patients that has been going on now for over a year and it evaluates very well in terms of their ability to get to those cardiac arrest patients in support of our crews too. We have our ambulance service and members will be aware that from April this year we will be having a Scotstar north base in Aberdeen that will significantly enhance capability and capacity up in the north of Scotland to help those rural communities as well. We have been working very closely in conjunction with our staff representatives on how we can further reduce on-call working in those remote and rural areas. There has been a significant reduction in on-call working over the past few years but there is more that we want to do and that is linked to new ways of working. We have agreed to prioritise a list of locations where we want to further reduce on-call working with our staff partners. Three locations out of that list in the last year have now become full 24-7 shift working stations and we announced a few weeks ago that a fourth in Portree would be recruited to so that we can eliminate on-call in that place too. We have more to do. As I said, it is part of a five-year programme of investment and reform but we are absolutely committed to ensuring that we can improve outcomes for patients in remote and rural communities as well. That is very helpful. Just for our understanding, does the attendance of a first responder remove the obligation or the target, if you like, for a crude vehicle to attend within eight minutes? The recognised responder that works to our clinical governance standards does count against the clock but the responder is backed up by a crew. David Stewart Thank you. Good morning, panel. Can I echo the comments made by my colleagues to thank all the front-line staff that do such a great job throughout Scotland and no covering the hands and hands, how important a service that is? Can I focus on staffing and HR issues? I have looked quite carefully at the Employee Engagement Index score, which showed that the Scottish Ambulance Service is the worst or the lowest score of all boards. If you look at the 2017 Dignity at Work survey, the scores were the worst in the following domains about staff experience, unfair discrimination from managers, unfair discrimination from colleagues and bullying and harassment from managers. Is there a culture of bullying within the organisation? We are very concerned about the Dignity at Work results and we have been working very closely to understand those results. You will be aware that, as part of the NHS Scotland staff experience measures, we use the iMatter staff experience index to which you referred to. The results from that have a much greater participation, almost double the amount of people participating in our service in the iMatter than the Dignity at Work findings. Nevertheless, we are concerned about those findings and we have been working across the country to engage with staff to understand what their experience is and what more we can do, because violence, bullying and harassment is completely unacceptable for our staff and our volunteers in terms of the fantastic job that they do day in and day out. As a result of the Dignity at Work survey a couple of years ago, we set up a network of confidential harassment advisers for people so that staff feel that there are issues that they can contact them confidentially. We have very regular reporting through our governance committees, our health safety and wellbeing committee and our staff governance committee, which reports into our board about any specific cases that we are concerned about. We have been investing significantly in our leadership and management development so that we can continue to create supportive and encouraging networks for our people, given particularly the amount that we are investing in terms of their development, and we want them to feel supported to work well in what is often a very emotionally and physically demanding job right up and down the country. So, we are absolutely not complacent. We are pleased however that the participation rate continues to increase, that those teams that are taking action as a result of the feedback at a local level and throughout the whole organisation is very strong, 89 per cent which is 30 per cent higher than the whole of the rest of the NHS health and social care participants in the survey. We are pleased that people report that they get a tremendous sense of satisfaction from their job, but we have much more to do and we want to continue on that journey. On the same point, I mentioned that I have been chair for nine months and have been out and about a lot. I am concerned about some of the results, but I am also a bit conflicted by it because when I am out and about and talking to staff, I get a lot of enthusiasm for the job that they do and the role that they do. We also have a very low staff turnover of just over 4 per cent and a very low vacancy level of a few... Stop here. I am obviously subject to correction now, Mr Steele, but my understanding is that staff turnover among Ambulance personnel is the second highest of all staff groups. I was referring to the whole organisation, the chief executive. Our latest, we monitor staff turnover on a monthly basis and the latest figures as at the end of January were 4.1 per cent with 25 vacancies, which is the lowest number that has been in a long, long time. How does that compare with other boards in Scotland? I think that our turnover rate is lower than other boards. As Tom Steele mentioned, we work very closely with the other UK Ambulance services, and our vacancy rate, I know, is lower than other UK Ambulance services. I am sorry, Mr Steele. No, your point is well made. There is evidence on one side, and I have experience of working in many, many different industries and businesses. It is unusual for... It is anecdotal that I accept that, but it is unusual to get the level of enthusiasm and at least double numbers of people that have said to me of paramedics and technicians that they have got the best job in the world. I would be quite keen for Donna Henry to say a few words. I have been in the Scottish Ambulance service for almost 25 years, and I never thought that when I joined Ambulance service I would be my job for life, thankfully, hopefully it is, unless I say something wrong the day. When I first joined Ambulance service, I was like one of the only females that were in the job, and it was much different then. The culture was much different then, and it was pretty anti-females. Probably 24-25 years ago, I might have felt how I feel about my job and feeling bullied, and that might have been a lot different, but I see a massive culture change, even just in the last 10 to 15 years, and I certainly don't see any bullying or harassment, I think, compared to some of my friends and other jobs. We have policies to protect us in almost everything that we do. We have opportunities to engage in all different kinds of activities within our work now, and I am part of the Health and Wellbeing Committee. I do a lot of the healthy working life stuff, so we arrange lots of things such as activities and well-being-type things to try to improve staff well-being. As far as bullying and harassment are concerned, I certainly don't feel that or see that, and I've been around a bit. The other indicator of health of any organisation, and I would like you to say that I've been involved in a number of organisations, would be sickness rates. That's something I would look at very carefully, and you'll know that the target was 5 per cent in 17-18, but the actual rate was 7.6. Of course, I understand that, in day-to-day life, you meet very dedicated staff like Donna Hendriew, who will speak very positively with the organisation, but I would look at what the stats say. I would look at the Dignity at Work Survey, the Employment Engagement Index score, and the accounts about bullying. The sickness rate is a factual thing. It's higher than your target. What are you going to do to try and reduce the rate of sickness in the organisation? I'll ask the chief executive to respond in a second, but I absolutely agree that it is a high sickness rate. 7.6 is a high rate, and the rate at which we are still at currently. However, compared to other ambulance services elsewhere in the UK and abroad, all have significantly higher levels of sickness abstinence than the rest of their healthcare system. That reflects the physically demanding and mentally extremely stressful role that the paramedics and wider staff play. We are increasingly aware of that and responding to that in a way that raises awareness initially, and then, hopefully, it will reduce sickness abstinence. The level is of a concern, but equally, the health and wellbeing of our staff is a concern. Again, you could perhaps send us the comparative sickness rates from the other organisations that you quote, but again, if I was running an organisation, if I thought the going rate was 7.5, I would have made the target 7.5. Why did you make the target 5 if you didn't actually achieve it? I will ask the chief exec to respond to that. There are national targets for sickness abstinence in NHS Scotland, and the ambulance service tries to reduce sickness abstinence, as you would expect. The top two reasons for sickness abstinence in our service are musculoskeletal type illnesses and mental health type illnesses, anxiety, stress and depression. As I said earlier on, our staff do an outstanding job in really trying circumstances, very emotionally distressing circumstances. They see the worst and the best in any shift of life and death in people's circumstances, and it is often a very physically demanding job. We have been investing significantly in new equipment, new policies and procedures. We have an ergonomics adviser, one of the only UK ambulance services that has an ergonomics adviser to help in terms of advice on equipment, manual handling, lifting and so on. In terms of our approach to supporting staff around their mental health and wellbeing, it is an area that we pay a lot of attention to. As other industries have seen an increase in that area as well. We have a number of programmes. We have a number of employee assistance programmes that are well utilised by staff. Those people who use those programmes report an improvement in terms of their mental health and wellbeing, and access to fast track physiotherapy, for example. They report an improvement in those outcomes as well. There is more that we want to do, particularly in terms of how we support people around their mental health and wellbeing. We are working across the UK ambulance services to understand what works uniquely in our environment, because it is quite a unique environment. We are also working with the other emergency services in Scotland as well to understand what they are doing and how we can learn from each other and share where that makes sense to do so. That sounds very positive. Are you going to meet your 1819 sickness target at 5 per cent? As Tom Seale says, we are sitting at similar levels to last year, but we are absolutely not complacent. We want to do more to support people to be well and to attend in the best of health. If I can push you on that, because you did not answer that question, what is the target currently for 1819? You will have a trend from your child department. Yes, the target remains at 5 per cent. As Tom said, we are sitting at 7.6 per cent at the moment. So it is the same as it was the previous year. What you have suggested seems to be a sensible management approach, but the rate has not changed at all. What is the cost during that level of staff absence? We monitor the abstractions and we try to cover as many of those abstractions as we possibly can. There are a number of ways that we can cover. We have what we call relief members of staff that are built in for a predicted level of sickness absence, and we also can ask staff to work additional shifts to help cover. Because of the additional investment in our service, we have got over 500 more staff now in place than we had in 2015. Our shift coverage rates have significantly increased. You may not have the figure in front of you, but it is not fair to ask you in detail. What is the difference to your budget if you had a 7.6 sickness rate versus 5 per cent? Presumably, there is extra cost to your budget because you are having to cover the staff that are off long-term sick. Have you had some calculation from your finance department about the cost to your budget of having a differential and above-target sickness rate? I do not have that figure at the top of my mind at the moment, but I can certainly get back to you because we do monitor that through our finance department. I am interested in the jobs that people do. We have ambulance care assistance, specialty paramedics and technicians. I do not want people to think that technicians are just drivers because both paramedics and technicians drive and care for people. I want to get it right out there that paramedics and technicians are highly skilled when they are crewing ambulances and resource cars. There are some differences that might be given to morphine, thrombolyzing agents or tension pneumothorax treatment. I would like to hear a wee bit about the differences in the jobs and to be clear that everybody who is staffing are competent and skilled professionals. It might be a question for Donna. Perhaps, in that shift in the balance of the workforce, you are absolutely right. All of our patient-facing staff provide clinical care and that includes our ambulance care assistance on patient transport. They have a duty of care from the second. The bulk of our clinical care is provided by a combination of paramedics and technicians working as a team. You are absolutely right. They are both clinicians and there are some differences in terms of skillset, if you like. We have also recently been looking at advanced practice and Donna is a good example of that stratification of clinical within the workforce. One of the things that we did in terms of the response model was, as well as categorising in terms of a colour-based approach that relates to time. It also defines the skillset. For example, if we have a patient with a particular condition that we think will require paramedic intervention, based on the fact that patients in that code often do, then that is what we will aim to send to that patient. We are also investing a lot in guidelines, additional training and additional equipment. Major trauma is a really good example of that. We have completely transformed the kit that is on our ambulances in terms of major trauma and new medicines. As much as we possibly can, we make those medicines available to everybody and the associated training and support is then required to make that follow-through. In terms of primary care, we are becoming an ever more relevant part of the primary care system. Often that is working in partnership with GPEs and in conveying patients to definitive care, but more and more we are seeing models being developed and tested, where paramedics, including specialists, will work within a practice and see patients. That is a really interesting development. Obviously, we have to be careful to ensure that we maintain our core business, and that is always balanced in terms of those areas of thinking. The role of the ambulance service is becoming more and more apparent across both emergency care and urgent and primary care. It is a testimony to her staff that they are willing and able to step into that space. I am aware of programmes that are happening in my South Scotland region in Stranraer, Newton, Stewart and the Mackers, where testing models assess a patient instead of a GP, or triage and go to someone's home and treat a hypo, or something like that. That is what I am interested in. Now, we have different models, where we have specialty paramedics, and we are looking at training more so that more wider primary care support can be given. At the moment, as a specialist paramedic, we work in Fife and we work within the out-of-hours primary care. We also helped out for a wee while with one of the local GP surgeries that did not have enough GPs. There are certain specialists to be in a GP, so we do not profess to be a GP, but we can do quite a lot of what the calls at the GP do. We will do home visits for them, or we will do chest infections and ablopanes and that kind of thing that come into the surgeries. In out-of-hours, we do all the home visits, apart from specialist things such as pallative care or mental health, where we allow the GPs with their higher level of clinical skill to deal with that. As part of that, it is allowing us the opportunity to develop our skills, to do more injury-miner illness-type things, as opposed to the emergency setting. They are giving us a bit of mentoring as well, while we do that in most of the situations, so it is helping us to develop as specialists and move on to potentially becoming more advanced specialists. As a specialist, just to emphasise the great skills that the other crews do, we work as a fantastic team. As part of that team, I might be able to use, for example, the D2 resources that we have used instead of utility. If one of my patients still needs to go to hospital, I will be able to arrange transport for them if they cannot get transport for themselves, but we have a variety of different things that we can use rather than using one of our emergency ambulances, which we need for our immediate life-threatening calls. We can use one of our ACAs and ambulance care assistants. They provide transport vehicles. We can use a technician vehicle. Sometimes we have an urgent vehicle that has a technician and an ambulance care assistant, and they both provide the same kind of emergency care that they would get anybody else, because they have still got their ambulance full or the ambulance kit. The difference between the technician and the paramedic is that it is invasive techniques such as intravenous techniques and intravenous drugs, or, as you mentioned earlier, the more complex care that we get with the chest and intubation and things like that. Is it too early to assess whether keeping patients out of hospital has been seen to be really cost-effective? Have the models been in place long enough that we can assess the best value of keeping people out of hospital, because that is additional cost, but because that is our goal is to support people at home as much as possible? We based our evaluation on wider work that had been done through the Norfield Trust, and they reported in March 2017 about the economic value of community paramedics, as Donna has described, and we built a case around it that, for every £1 invested in community paramedics and the wider reform programme that we have spoken about this morning, there would be a £4 return to the wider health and social care economy. Certainly, our evaluation so far in terms of our model bears that out. Thank you very much. Tom Steele. Increasingly, we are able to track the journey of the patient. We have done a lot of work with ISD recently in matching records, because frequently we do not have the exact detail that they would have in the hospital. Now, using fuzzy matching techniques with ISD, we are getting much better end-to-end information, and that includes patients who have stayed at home. For me, it is very important that we start working very closely with the IJBs and the partnerships, because they are increasingly developing new pathways for patients, and we can play a significant role in that. Donna has indicated some of that, but, going forward, that will be a much greater part, as the pressures on GMS and GPs become greater. We are having early discussions with IJBs in that regard, and that is a significant development for the future. I want to pick up on a few points. I almost returned to some of the questions that David Stewart touched on, specifically around single-crew ambulances. I know that this is something that, just far back as 2008, the then health secretary, Nicola Sturgeon, said that there would only be exceptional circumstances. Over the past four years, we have seen 10,000 single-crew ambulance journeys. I wonder what the picture is today and what works are going on to end that practice. We have very detailed action plans in place to reduce single-crewing, so that it is only in exceptional circumstances. I can report that we are making improvements. We are not where we want to get to yet. We have a trajectory to get to 0.1 per cent, which we think would reflect those very exceptional circumstances by next year. It is very much linked to our recruitment and training and development strategy, and that is why we are not there yet. I can give assurance to the committee that we are making improvements on that trajectory in line with those expectations. In terms of patient transport, it is an issue that, as MSPs, we have raised regularly. I know that here in my own region, I have visited your call centre at South Queensbury and also seen Lothian's patient transport and patient flow centre, which is making a big difference. I know that other health boards are now looking to replicate that. When I was there, I met the embedded ambulance crew to see how they were playing a role in that. As we look to the future, I certainly know that in my own region there will be more going on at St John's with the regional treatment centre. I wanted to know, in terms of redesigning patient transport systems, what works being undertaken? In 2013, the committee touched on that. When we were here in 2017, we were able to update the committee. We had achieved the objective set out in that redesign at that time, which was to improve punctuality for patients to and from their appointments and to ensure that we could reduce cancellations. Since then, we have been working, as you described, with health boards to understand how services are changing in line with changes to outpatients and to renal services and to cancer services, for example. We work very closely with regional planning fora, with the health boards, and, as Tom Steele has described now, with IJBs around service changes. We try to flex our model as best we possibly can. We have also reached out to try to understand what alternative providers there might be available within communities for those patients who do not require the clinical skills of our ambulances. The Lothian flow centre is a great example where there is a database of providers that are available for patients. We also have databases within our ambulance control centres for those call handlers who are able to signpost people to alternatives where those exist. We are continuing to engage with people and expect to continue to flex the service to meet patient demand in the future for those who have a clinical need for our service. In terms of being able to put powers within ambulance drivers themselves and paramedics, what changes do you think need to be made around that? Maybe this is a question more for Donald Henry in terms of where you think you are not being given the skills to be able to actually perform duties and stop people being taken in. You have outlined some of the cases that you have been involved with where you have not, but I know certainly that in terms of the ability to discharge that has been raised with me. Whether or not that is a piece of work, the committee should undertake to see whether that would make an improvement. As part of what we already do, we already have quite a lot of seeing-treat-type things. It means that you can discharge when you have treated your patient, but most of them may refer on for their own GP to review them if they do not get any better. Bear in mind that we have only seen a snapshot in time, but we have only seen that patient for one small time. We do not know their past and we do not know how we are going to end up in the future. It is always the safest option for a patient if we discharge them after that care, for example, if they have had a hypoglycemic attack and are able to go and treat them. We are able to deal with that, no problem. That happens regularly and sometimes somebody with uncontrollable diabetes might need to be referred to a diabetic centre or their own GP, but that option is available for them, but they need to do that for themselves. Effectively, we do discharge patients after we have seen them and treated them for that kind of thing. Following up to Miles Briggs's question, PTS is an extremely important part of what we do. It provides access to healthcare that otherwise would not be available to quite a significant number of the population, but he has also touched on the hospital discharge that he was referring to. We now have quite a number of the large hospitals' ambulance liaison officers working very closely with the acute team in those hospitals to very much speed up and make more efficient the discharge activities. He might want to say a little bit more about that, but it is something that, in terms of overall flow through the acute hospitals, is making a significant difference. The hospital ambulance liaison officers are very much part of the hospital flow team, so they join the daily, sometimes more frequently than daily meetings of the wider hospital team to understand those patients who are potentially ready to be discharged and how we can make sure that we can best match their needs. That also helps in terms of the wider flow of unscheduled care across local systems. It is very valuable resources that were introduced a couple of winters ago. They value it very well, and we are keen to continue with those throughout the year. David Torrance, convener and good morning panel. The creation of a new Scottish Trauma Network, what impact has that had on the service delivery and planning? The Scottish Trauma Network is a very welcome development for us within the Scottish Ambulance Service. We are a member of the implementation team, and we work across the regions in terms of implementation of those networks. You will be aware that North and Teaside trauma centres are now live, and I mentioned earlier that the North Scotland base will be live from April this year, too. We have invested significantly in equipment and skills for our people, and triage arrangements, too. Jim Ward might want to say a bit more of that, but we have now got a dedicated call handling and dispatch desk within Ambulance Control, so we can identify those trauma patients much more accurately and make sure that we get the right resource to them first time so that we can help in terms of improving those outcomes as part of the Scottish Trauma Network. As the network matures, it is going to have a huge impact on us, especially as the four major trauma centres and the trauma units come in to be. That puts a lot of onus on our clinicians to make the right decisions around definitive care. We are testing a trauma triage tool in terms of that decision about how unwell the patient is with the decision to, if you like, drive past a trauma unit to a major trauma centre. There is a lot of learning. Pauline talked about some of the elements that have been put in place, and, in addition to that, we have our first advanced critical care practitioner cohort being set up in Edinburgh. There are opportunities right across the service in terms of ambulance control improvements, in terms of our specialist retrieval requirements and in terms of our A&E ambulance fleet. I think that the whole issue of definitive care, if I could just say something about that, because, obviously, that is at the essence of establishing major trauma centres. That does not just impact us in terms of trauma. It also has an impact that has been longstanding in terms of heart attack centres for PCI. More and more, we are seeing a centralisation of children's services for good reason, I would say, in terms of specialist provision. We also have stroke units at the moment, but, as a thrombectomy service, comes into being in the coming period. There will be ever more responsibility on SAS to understand the needs of the patients and to really be getting those pathways right. The trauma is one live, active and interesting challenge at the moment. However, as an ambulance service, we have the responsibility to glue a lot of those pathways together. It is a huge responsibility for us in terms of regional and more local planning. Thank you, convener. Of the two centres that are open to Aberdeen and Dundee, are they giving improved outcomes for patients? The data around outcomes is pulled together by STAG, the Scottish Trauma Audit Group. I think that it would be fair to say that, at this stage, we have not got enough data to support that. What we are looking at is that the outcome will be based on a number of processes, so that will be around clear understanding about bypass protocols, triage and the like. However, STAG has a long track record of publishing really good evaluations, and that will be the source of that outcome data, which will be generated in the coming period. Confirming that the major trauma centres that are in place are already affecting the way the service operates in those regions, is that it? Yes, that is correct. That is correct. Excellent. Thank you very much. Thank you very much, convener. I want to follow on about the patient transport, which I think is really, really important, and perhaps the financial aspects, although one of my colleagues is going to come in with the financial aspects after. You mentioned the fact that, I think, it was in the slothian area about the devil, and the fact that you have records of a database about patient transport, and you also mentioned working more closely with IGBs and voluntary sector, because that is really, really important, and not using the ambulances. With what is happening with the IGBs, I think that it will come to a point where every area will have a database of patient transport that will not necessarily use of ambulances or taxis or that type of thing. There is a bit more clarification on how far we can go, because I know that it is a costly exercise and, obviously, not just that, but it is a time exercise as well for people who have been transported in ambulances or whatever. Pauline Hurrie. It would be fantastic if there was such a database. The last time that we looked to try to understand what alternative provision that was out there, there was over a thousand different providers that worked to different criteria at different times of the day, at different days of the week. It is quite challenging to continue to make sure that such a database would be up-to-date, but there are certainly a range of different providers that we know that our patients or other carers can access and can do so reliably. They are certainly on our databases, and we are really keen to add to that as often as we possibly can. You are right, the integrated joint boards, community planning partners and, indeed, the transport authorities are key partners in terms of helping us to understand just what alternative provision that might be out there to support patients. It is something that we work really closely with, and we have ambulance liaison groups with each NHS board where, again, we try to share information so that we can, between us, help patients navigate the right support for their needs at that particular point in time. I think that Mr Steele wanted to come in. Yes, thank you. I spoke earlier about increasing the link, working with the IJBs and right down to locality levels. We are a national service, but increasingly we have to deliver on three different levels. One is national in regard to David Torrance's comment, for example, around trauma networks. That is a national network and we have to plan on that basis. At a health board level, we have to plan, because each health board has different numbers of hospitals and different facilities and different pathways, and then down to health and social care partnership levels. Increasingly, and this is quite new for us, I think that that is where the value of these partnerships are going to be seen in direct impact on the patient. I think that it is quite helpful to think of it in that way and it is a new way for us to start working. From discussions that I have had with IJB accountable officers, they seem to be increasingly keen to engage with us. That is a small thank you. Most of the concerns that come from constituents and patients as well is that if they get an ambulance or transport at 9 in the morning, the time they get home or even to the hospital is maybe three hours later. Unfortunately, that is sort of the norm, and that is why I was wanting to see if we could get a database as such. Certainly, in my area in Glasgow, Kelvin, it is much easier, but when you are up north on the islands, it is much more difficult and it is also much more costly. I just wonder if you have looked at that situation, if you are coming from the islands or Oben or wherever it may be, you have someone coming down sometimes in a taxi, never mind an ambulance, with perhaps a family member to accommodate and that takes an overnight stay in that respect. I wonder if you would be looking at that in particular as well for those far-reaching areas? We work closely with health boards and you might be aware of various different ways of providing outpatient consultation such as through video technology now. I know that some of the island communities are big users of those types of consultations where those are appropriate for the patient needs. We do, in very remote areas, have arrangements in place where, if we have capacity on our patient transport vehicles, we will try to help those patients that might not strictly meet the clinical criteria but, obviously, it would make sense to ensure that we could meet their needs to get to their healthcare appointments as well. We do flex it where it is possible to do so. Good morning to the panel. When we are doing those types of investigations, we tend to always be looking at the negatives. I just want to say on record that, as with everybody else, we hope that we recognise the high regard in which we hold our front-line staff. Sometimes the language that politicians and media use when we are discussing healthcare could be improved. I think that there is a recognition in here that you are being asked to deliver a really crucial service under increasing financial constraints. I know that the board was expected to be in a break-even position at the end of financial year. As of October, there was that overspend of £1.3 million. I know that there are reasons for that. Has that overspend been addressed? Will you be back on track to break even with any financial year? There has been significant investment in our service, but there remain significant cost pressures and challenges, as you alluded to. We have had a very intensive efficiency identification programme and delivery plan in place. We are on track to achieve our financial targets this year. It is of concern to the board that some of those savings are being achieved on a non-recurrent basis at the moment. We have been working very closely with our staff, their representatives and managers across the service to understand where the opportunities for better value are. We have benchmarked our performance in terms of efficiency and effectiveness with the Lord Carter review of UK of English Ambulance Services. We do compare very well there, but we are not complacent. We are working to understand where we might make more savings. We are looking forward into next financial year, given that we are at the stage of developing our three-year financial plan now. We have a best value pipeline of ideas that we are taking through and presenting into our board shortly of more than £8 million that we want to achieve in the coming year to help us to make our financial targets next year. The Audit Scotland report was suggesting that you are relying on recurrent savings to meet financial targets. The board recognised that that is not a sustainable position. I also enter the forecast that recurrent savings are required in excess of £27 million to continue to operate in a financially sustainable way. Again, Audit Scotland has said that this represents a significant challenge. I was wondering whether you consider that the level of savings is achievable, I think, most importantly while maintaining the level of service that you want to achieve. Tom Steele. Can I confirm the number? You said that it is £27 million. Well, by 2022-23, management forecasts that recurrent savings are required of over £27 million to continue to operate in a financial sustainable way. That is the figures. I personally don't recognise that number. Perhaps the chief executive doesn't, and I will let her respond in a minute. I assure the committee the importance to which the board addresses financial matters. As you rightly said, Brian Whittle, we were at halfway through the year in significant deficit, and a programme that the chief executive has referred to to find short-term savings that we have been successful in doing. More importantly, that approach is not a one-off. That approach is going to be embedded into the organisation and it is for that reason that we are, as a board, committed to reducing any reliance on in-year savings and have a return on a sustainable basis. Your question about what happens going forward, can we sustain everything that we want to do? We are funded for next year in an appropriate way. Thereafter, we are preparing our three-year plan, and we will await to come back from Government on that. Pauline Howe, do you want to comment on the three-year financial plan? I think that the figure that you referred to is probably the cumulative figure by that time. There is no doubt that that is a very challenging ask of us as a service, but, as the chairman has said, we are working very closely with staff and representatives and managers to identify opportunities for us to improve value and make savings. As I said earlier on, in terms of new ways of working, we are able to demonstrate that there is an economic value to investment in the service in terms of the wider health and social care economy. Inevitably, the opportunity to make those soft cost savings are diminishing as we identify them. Is there a concern there that the front line is going to suffer if we continue to squeeze? When the board makes its assessment of the agreement or otherwise of our savings programme, front line service provision is at the top of the priority. We do all that we can to protect front line service provision. Certainly, the savings programmes to date have not adversely impacted on front line service provision. That would be our aim to continue to do so. Are you confident of that? Is it possible to continue to bear down on costs in the way that you have described without affecting the core service that you provide? As I said, we are focused on achieving the financial targets that have been set for us. We have indicative allocations for next year. We are taking proposals to our board next month around our budget for that year and we are in the process of developing that three-year financial plan. We have to work on assumptions that we will agree with the Scottish Government in that time. A point of clarification. I had noticed in the financial sustainability an overspend of £1.3 million. That was for 2018. The reason for that is stated as the cost of diesel, travel and substance. Does the Amblin service get discounted fuel? We have a procurement process in place that gets a discount on fuel prices. We look to make sure that that is the best value in terms of opportunities for the public purse. I mentioned the benchmarking with England. We are constantly benchmarking to make sure that we can get the best through many procurement opportunities. We collaborate in terms of procurement across UK Ambulance Services, NHS Scotland and the Scottish Public sector. We take advantage of all those opportunities. I think that more than 90 per cent of our non-pay spend is through collaborative procurement opportunities. A final supplementary question from Miles Briggs. In terms of financial management, it was with regard to overtime payments. I know that in terms of the statistics that we were given, that reached over £6 million in 2017-18. I just wondered in terms of given staff shortages and the impact of overtime, where that stands today. I am keen to advise that overtime is coming down. I mentioned earlier on that we have got 500 more staff now than we had in 2015. Because we have got those additional staff who are now trained and focused on delivering those services to patients, we have been able to reduce overtime. There is also one-off reasons why we have overtime, such as those staff who are in training, for example, and also for events such as the European Championships and other types of events like that. Thank you very much. I thank all our witnesses for a very full answer to a range of questions. I know that, in the course of those questions and answers, there have been some points raised where you have offered to provide further information. Additionally, there will be points that we would like to follow up with you in correspondence, so you will hear from us shortly on those. Thank you very much for your attendance today. We will now suspend briefly and resume in private session in a couple of minutes. Thanks very much.