 Good morning, and welcome to the 22nd meeting of the Health, Social Care and Sport Committee in 2023. I've received apologies from Tess White and Sue Webber is joining us as a substitute. The first item on our agenda is to decide whether to take items 4, 5 and 6 in private. Our members agreed. The second item on our agenda is the continuation of our scrutiny of front-line NHS boards. For this morning's session, I welcome to the meeting Jim Miller, chief executive of NHS 24. Welcome, Mr Miller, and we will move straight to questions. I wonder if you could tell me what efficiencies you envisage will provide the £2.9 million of savings that is required by the board? Good morning, and thank you for the opportunity to speak on behalf of the organisation. The efficiencies set each year as a combination of our annual efficiency target and any balancing figures predominantly are based through a combination of what we call recurring and non-recurring items. Recurring by definition those that we are able to take out of the system year-in-year and non-recurring items that give us movement within year, which may then be different from year-to-year. In terms of our savings target with just under £3 million, we have a plan that is a mixture of recurring and non-recurring. I would say that the majority of that £3 million is on a non-recurring basis within year 1, as we continue to stabilise the organisation's position post-pandemic. Those include areas around procurement efficiencies and services that are contracted in, particularly technology services, but a significant amount relates to our on-going increase in workforce and therefore our ability to blend when we bring workforce on board, allowing us to have efficiencies in year. The board has signed off our annual accounts and are satisfied that we will make those efficiencies. That is helpful. How will you monitor your invest to save proposals? You sit touched on them a little bit there and there was some detail on that in what was submitted to the committee in advance of today's meeting. You described them as digital and workforce improvements. How are you going to ensure that they deliver the expected savings? Over what timeframe do you expect to see a return on that investment? First of all, it is important that we have that balance of investment and continuing business as usual funding, as I would describe it. The investment plot that we have set aside is designed to improve four or five areas. The first is in terms of our workforce, and probably most importantly, both in terms of our ability to recruit, to make sure that they are effectively trained and, of course, to make sure that they are retained, that they stay with the organisation for as long as possible. There are investments particularly in terms of what we call on-boarding, so the way that people access opportunities with NHS 24, making it as easy as possible, frankly, for them to join us as an organisation. That is linked to digital, which I think is the second area, and perhaps the area where there is most activity given the shape of the organisation. In relation to what we call the return on investment, all of our proposals form a standard format. They are asked what the efficiency will be, whether they are cash-releasing, whether they are time-releasing or whether they are improvements in system stability, or whether they are a completely new system that would replace older systems and therefore improve access. Those types of checklists, if you like, are against all of the investment proposals that are being touched accordingly. In terms of that, how, as an organisation, do you balance the rising costs and vacancies and plans for future expansion to meet the growing demand that we are anticipating? There will be, there certainly has been a growing demand for NHS 24 services over recent years, so projecting into the future, seeing that demand increasing. We need to do things differently and more efficiently in parallel with each other. I think that the core service is one that the public recognise and trust, and that is borne out by that demand and, indeed, by that repeated and increasing demand. However, I think that that needs to be blended with different ways of providing that service. For example, just at the end of last year, we introduced our first smartphone app. We need to be careful, I believe, in introducing what I would say front-line digital technology, that that is not seen as replacing those services that people have become accustomed to and trust, but augment that as we see different changes in our demography and our age profile, then we are seeing patients and users of our services that would prefer to access through a digital route rather than a telephony route. We need to reflect that, but I believe that it is an and and to make sure that people have choice in what way they wish to access the service. I am going to bring in Sander Cole-Honey, who has got a supplementary on this theme. Thank you, convener. Can I just start by declaring my register of interest as a practicing NHS GP, but more specifically, I have and probably will again work in the GP out of our service? Jim, thank you very much for coming. I want to say thank you for the manner with which you have given us the data, because this is much better than a lot of other boards that have given us information. I think that my question is around the £800,000 almost underspend, and in what you have said, it is because of vacancies that you have for this underspend. My question is, where has that really impacted? Which group has that underspend really impacted? Thank you. The organisation has grown significantly in the last two or three years. Probably the single biggest area, as you may well be aware, is our move from, effectively, I would say, out of ours on weekend service to a truly 24-7 service. That investment was around what was called the redesign of urgent care and the significant expansion of our mental health services through the mental health hub. So, both of those areas were given very challenging recruitment targets, and I think that with all sectors, not least health, recruiting, particularly clinical recruitment, is a challenge. Therefore, a significant part of that underspend has been in relation to us not being able to recruit as quickly as we would have liked and referenced my previous point about why that is important for us to invest in terms of how we make that easy for people. There is a relatively direct correlation between our staff availability and access of service, so I wouldn't deny that, but that's why, again, I think that it's important that we look not just in terms of increasing our staffing availability but increasing alternative channels such as digital to make sure that any shortfall in one can be offset. On the question about which group—we expand that a little bit—was there a particular area where it was harder to recruit than others? Certainly, I don't think that it's any surprise that nursing posts remain difficult. We offer a different environment for nursing colleagues, and I think that it's quite positive environment, but a lot of our colleagues who are currently in nursing posts don't recognise that. We're working hard to understand how we can make sure that they understand what the NHS 24 experience is. I'm also aware that we don't want to get into a position where we are, in effect, robbing Peter to pay Paul, if I can use that expression, where we will be taking nurses from a territorial health board to join NHS 24 and thus leaving them with the challenge. What we are introducing now is what we call blended roles, where NHS Tayside is our first test board. Colleys can work, for example, for two or three days with NHS Tayside and two or three days with NHS 24. That sounds relatively simple, but in the past it's been a little bit problematic because it involves two contracts and two employers and potentially two sets of shift patterns, et cetera. Again, we want to make that as easy as possible. We do believe that there is some mileage in this where people can do anand and working for more than one organisation, as opposed to an either or. It also makes it much more interesting for them because they get to widen their experience without having to make a single choice. Information obtained via freedom of information request shows that there has been an extreme increase in dental calls to NHS 24 in recent years, with 25,509 calls in 2018-19 and 67,189 calls in 2022-23. Your submission explains that the new urgent care model, which seeks to minimise onward referral, is in place for all but dental and some pharmacy calls. How has NHS 24 adapted and managed that particular increase in demand regarding dental-related complaints or calls? All services have seen an increase in demand. During the pandemic, we saw acute rises in demand in those services that were more difficult to access, particularly primary care services, including dental. During that time, we were fortunate enough to be able to have a number of dental colleagues join us to provide an enhancement to our core, what we call the Scottish Emergency Dental Service. That included digital remote consultation through smartphones, if people were able to uncomfortable with that, and it was a very useful service during that time. As public dentistry has opened back up, we have reverted to what we call a normal model of the emergency dental service. It does link into other out-of-house services and indeed into the redesign of urgent care, but predominantly it is where there is access to public dentistry. We continue to invest in all of our services, including dental, balancing the demand to make sure that we offer that amount of access that does not create a challenge further down the line, if I can try to describe that in a better way. In some cases, we will receive calls that are because our patients are finding difficulty in accessing all the parts of the service. However, there is an equal amount where what they are looking for is information and reassurance, so they are removing the demand from the service. I think that that is where specifically to answer your point about demand. I think that that is where we can do much more. As we increase the ability for us to enhance our digital resource, it gives people an increased level of comfort and information, so that they can make decisions to manage their own care. In light of the reported difficulties in people accessing dentistry services and increasing numbers of NHS dentists removing themselves from NHS provision, have you noticed a structural change since the pandemic in the access to dentistry? In light of that, would you consider exploring further expansion of the urgent care pathway to help to meet that increase in dental-related inquiries? I cannot say that I have noticed a structural change in access to primary care services as a whole. Some recovered at a different pace and some demand profiles were different based on public perception of availability. I would not comment on whether that was real or perceived. However, it probably goes back to that original point, but I believe that NHS 24 is in a fantastic position, I would describe it, to be upstream and downstream. In this case, upstream is as early an involvement with the patient as possible, as an early appointment as possible, providing them information and advice, which then allows them to determine whether, indeed, they actually need the provision of dental service or whether it is something that they can manage themselves at home. I wanted to ask a few questions regarding performance as we look at data that you provided and also freedom of information that we receive. Over the winter period, a large number of patients had to abandon their calls to NHS 24 due to long-wait times. What analysis has been done on the effects of those long-waiting times on patient welfare? I would first of all make the point that I wish that we had a system where everyone got the information that they received without need to abandon, so every abandoned call for me is a learning opportunity. However, the analysis also shows that, although we use the phrase abandon, for a proportion of those people, it is that they have received the information that they need within what we call the IVR, which is the automated voice message that already directs them, so whether or not they are in the right place, whether they can find information online, or indeed whether they should contact another one of the NHS services. A proportion of those people who do not stay on the call have received information that they need. I do not have that information to hand right now. Of course, it is not completely accurate, because frankly, we do not know to 100 per cent where people have gone after they abandoned. However, we carry out fairly significant studies using third parties, asking people what happened next. I am happy to provide information to the committee on that later date. A proportion of those people say that they have received the information that they needed, a proportion will say that they will contact their GP, and a significant proportion will call back at a later time. We have to reflect that information on how we provide access to the services. One of the ways that we are doing that is to recognise two things. One is what we call repeat callers, so recognising whether someone has phoned back once, twice, and in some cases five or six times, and indeed they may have been answered more than once, and trying to understand their needs to make sure that they can get the information that they need with one call, as opposed to two or three calls. The second point is where else they have gone in the system, if I can use that description, and how we can better reflect our services to make sure that they get that information at that point, rather than creating a demand elsewhere on the service. I will provide that information to the committee I have requested. I would say that it is clearly a sample in terms of that, but it is something that we do on a regular basis. During your busy periods, what is the vacancy rate for GPs that are taking calls? GPs take calls for NHS 24. What have you had in terms of vacancy percentages during the month of December, during the month of November, where things get really busy? Vacancies within our GP colleagues? I am sorry, I would not have that information, so that would be within the individual GP practice? No, sorry, so in the call centre, where GPs go to take phone calls for NHS 24? Ah, sorry, I must understand that. Clearly, we have what we regard as peak periods, and those tend to be of ours, tend to be weekends, public holidays, etc. The vacancy rate changes all of the time, I do not have a specific vacancy rate at any particular time. Of course, it can be for a number of reasons. It can be a planned vacancy for annual leave or other services, or indeed be what we call unplanned leave, which is the short-term sickness. The information that has been provided to the committee provides that overall, what we call the absence rate, or the short-term and long-term sickness absence. It does fluctuate from day to day, from shift to shift and from week to week, because I would not be able to give you a specific answer. With the length of time some people have waited, so I think the longest was over two hours that people were waiting on the phone to get help and advice, what do you feel that you could have done differently looking back at December of last year, that you will take forwards to this year's December to try to avoid the same thing from happening again? Last winter was an incredibly challenging time for all public services, including the NHS. I apologise for every wait that is longer than that individual requires. It is important to say that our average wait times are still significantly lower than those extremes, and I am not suggesting otherwise that those extremes are unfortunate. There are a few things that we do. The first and foremost, and it is really important to recognise, is that we never cut the caller off. There is no automated time where the system is so that the person will wait, and they will be constantly reassured through updates on IVR in terms of how long the likely wait times are. They will also continually suggest that they can be directed to our online resources to indicate whether that is something that people picked up. What was the learning that you have taken to... So if I take those examples of what we did during the winter, then we can say, so how can we expand of those? For example, lots of our winter learning in terms of that information, in terms of their profiling over those peak periods, we reflected in our Easter performance, and our Easter performance over those four days was actually the best Easter performance in the organisation's history of 21 years. Some of those lessons are taking in terms of managing our demanding capacity, in terms of making sure that we provide the information, and also the information that is digitally available is useful for people. I would also reference by, during that time around about December, we were also experiencing very high call volume related to people who were worried about strep A, which was a relatively short but intense period of demand, which almost came through a very short timescale. Clearly, there were lots of worried parents, so we had to reflect immediately on the information for that particular condition on our online resources. That is an important learning of understanding how quickly we can update and make topical the information that is available to patients. Thank you. My final question is again about the future. You referenced yourself how challenging and difficult the last winter period was, and my concern is the one coming might be even worse, because I think we have a bit of a mild winter, if we are being honest, when it comes to a lot of respiratory diseases. Are you confident that we will see improved performance times and performance data compared to the last time? What contingencies are you looking to put into place now, again, to mitigate any other issues that might arise? So winter will always be the most challenging part of the year for NHS and including NHS 24, and of course that is exacerbated where other services are perhaps not readily available. So I think there are a few things that we have in place. The first one is our continued focus on recruitment and retention. So the more people we have available to provide the services, then that will help incredibly. I am very pleased to say that we have recently overachieved one of our recruitment targets, where we were set a target of 200 and we were managed to achieve just over 250 in that period. But there are still vacancies to go on, as I mentioned earlier. We are looking at ways to improve those. So if we have an increased vacancy, that is point 1. The second point is changes to the system itself. One important availability is what we call the ability for people to understand where they are in the call. So there is the difference between someone having the telephone to the rear for 30 minutes or 45 minutes whereas they could also be offered the chance to still keep their place within the queue but get a call back when they are at the top of the queue. That means that they are able to go about their day-to-day business and it also means that it is more convenient for them and therefore we would hope that there is less chance that they will give up and go elsewhere. There is a challenge with that. It is important to say that one of the reasons that we are cautious about that is that sometimes that can create unintended consequences. For example, if when the caller is phoned back they are not there. What do we do in that situation? How many times do we call back and that is a resource that has been tied up trying to contact the person and potentially answering the person who would be next in line. Those are subtle changes but they can be really important. The app has proved tremendously interesting and useful for people. We were careful to provide what we call a minimum viable product, which is basically a skeleton service to begin with and then immediately get feedback from people in terms of what they would like from it. We are on our third or fourth version now. There is a healthy and continued to increase user group of that app. For example, we are now able to provide supplementary information. For example, we are working on just now that will come out in the next few weeks is where the nearest defibrillator is for example. We do not just access to where is my nearest service but where are my nearest complimentary services. The last thing in terms of preparation for winter is understanding how the technology can provide answers to people without necessarily having to speak to a member of our staff. We have embarked upon what we call a digital transformation programme that will take us towards the end of 2025. We are already working on enhancement, particularly in our mental health services, to make sure that people can pre-populate their information as far as possible, having used us in the past. That means that there is a shorter waiting when they start to speak to someone. All of those things will make incremental improvements. I hope that as a whole then it provides us, along with our internal planning, that we are in a resilience place as possible for whatever winter we may have. Emma Harper Thank you. Good morning. Thanks for coming today. You mentioned the IVR. Is that the interactive voice response? So people whose English is neither preferred language or their first language can do you monitor how many calls are made by people where English is not their first language or Scots is not their first language? I am reading here that there is ability to interpret Polish, Arabic, Mandarin, Spanish, Romanian, Serrani and Ukrainian. Do you monitor how many people make calls that English is not their first language? We do, yes. Unfortunately I do not have that data immediately to hand. I would say that we have seen a doubling of our translation service in the last 12 to 18 months through our partner that provides that service, not just a doubling of demand but a change in the profile of the demand. You mentioned some of the languages there, which reflect changes that are happening within the country. We have seen an increase. We believe that it is a useful and important equality issue to make sure that people can access the service regardless of their choice of language. Sometimes it is something that people might not be aware of, so they might go to the emergency department instead of phoning 111 because they just assume that they will not be able to communicate, but if we make people more aware of the fact that there is interpreting ability with 111, that is something that is only a good thing. Yes, absolutely. Later on this month, we will launch the organisation's revised strategy. Part of that strategy will be wider stakeholder engagement, including community engagement. It is something that has been more difficult for us to do in recent years, both in terms of the pandemic and ensuring that people understand that we are indeed a national service, whether that is in Central Belt and Scotland or whether it is in remote and rural locations. I do believe that there is an opportunity for us to reflect our strategy, which sets out the ambition, but also gives an approved understanding of where NHS 24 sits as an integral part of the NHS in Scotland. A series of community engagement and stakeholder engagement events are planned when we launch the strategy towards the end of this month. If I can just ask a short question, you mentioned the redesign of urgent care, and the aim of that was to reduce self-presentation at A and E between 15 and 20 per cent by 2026. Is that on track? It is a complex picture in the sense that from an NHS 24 perspective, we will view the demand records and whether we have been able to direct those into what we call flow navigation centres, which are areas set within health boards that act as an alternative to self-presentation at A and E. From that perspective, I think that we are absolutely on track, we would see currently between 11 per cent and sometimes as high as 15 per cent, but I would say around about 11 per cent of our reduction in self-presentation at A and E. However, I would say that if I was one of my colleagues from a territory board sitting here, they may not see that 11 per cent because there will be what we call displaced demand, so it may be that they are coming from other areas, it may be that they have tried to access services and cannot still go to A and E, so there is not a single route. However, the redesign of urgent care has been very significant. One thing that I suggest that is an interesting test of proof is that the redesign of urgent care coincidentally tied in with the restrictions during Covid, clearly was not intended to do that, but that is where the timelines began, which is where NHS 24 really began to provide that 24-7 service. We saw an immediate spike in our Monday to Friday 9 to 5 demand, simply because other services were not available, including the redesign of urgent care. We were all really interested as services opened back up, whether that demand would drop, and the demand has not dropped at all. In fact, it has remained incredibly static, which we are making that line of logic, that shows that the redesign of urgent care is working for people, because, although there are other services available, that is working for them, particularly in terms of access through NHS 24 into flow navigation centres. I am now going to move on to Gillian Mackay. What assessment has been made of the public awareness of mental health services available through NHS 24? Do patients on the whole know that they can access mental health support through NHS 24? Is the feedback that you are getting that they are comfortable using it, or is there still evidence that a lot of people are going to their GP or other areas first? I believe that the expanded suite of mental health services that NHS 24 provides really gives an insight into the future of the organisation. There are two primary mental health services that provide one called breathing space and one called the mental health hub. Breathing space has been long been established and is well recognised and understood by local communities. Mental health hub is a more recent development, again coinciding with Covid. I think that there is more to do in terms of making people aware of those services. I will reference my previous community engagement suggestion. However, the demand for those services has grown significantly and indeed continues to grow, suggesting that there is awareness and value in those services. The services themselves offer different interactions and there is a point where we are now looking to understand whether people are making a conscious decision around which service they use under that broad mental health service banner and how we more accurately signpost the variable services within breathing space, a mental health hub and indeed our online health self-guides. At the moment, people under 16 are advised to phone child-line services. Is there a plan to expand the mental health provision for children and young people? Is there a benefit in providing a dedicated mental health service, such as breathing space or some of the other interventions that you have mentioned for children and young people in particular? We have seen particularly in that, as you say, close to 16-year age group that there is a demand there. We need to be cautious in terms of how we develop services that are both safe and effective for younger people, so it is certainly something that we are looking at. The complementary services that are provided, for example, have a significant amount of information digitally available on surviving suicidal thoughts. We have seen a real demand for those digital or video-based personal stories and how people have coped with their individual circumstances. The feedback that we have received from the analysis of that is that those are picked up by younger demographics, so we are considering what that means for us in terms of development of those services. Again, it may not be that those are direct telephony services, but perhaps more digital in terms of that information. Is there a smaller proportion, do you believe, of children and young people? Given the digital literacy of children and young people, is there perhaps a smaller volume than you might expect of children and young people phoning NHS 24 versus other interventions, and does that lend itself to the variety of things that we need to provide? We look at demographic in terms of age profile and geographic profile, because we want to make sure that people are accessing their services wherever they are in Scotland and whatever age they are. However, you are absolutely right that the expectations of different age groups are different. For example, we introduced what is called a bot. I do not ask me exactly what that means, but I understand that we introduced a bot, which is an ability for people to exchange information rather than speaking to someone on the telephone. That was fantastically successful, but when we did the analysis, the largest—first of all, there were more girls than boys used it, and I say girls and boys because they were a younger demographic as well. The most used demographic of that bot was younger females. Again, that is real interesting data in terms of how people choose to access the service. We all recognise that younger age groups are much more likely to engage completely digitally than they are even to pick up the telephone, which they may feel is old-fashioned. Does that feed into some of the on-going service development of NHS 24? Is it looking at what does suit the population now and what has to continue to develop, particularly in the mental health space over the coming years? Absolutely. Again, if we reference the NHS 24 online app, that is a way where people can access the service through a digital means and then directly into a traditional telephony service, but you have that digital interaction. I still think that it is important that we keep more than one, that there is multiple access. Part of our 2025 programme is what we describe as an omni-channel, which, again, is a technology phrase that simply means instead of there being. There is no wrong door, I think, as the way to describe access into service, whichever way that you choose to access the service. Thank you, convener. I have quite a specific question about the route through the mental health hub. If you phone into the NHS 24 and you are already known to mental health services and you are looking to get directed on, is that quite a smooth flow through or do you have to go through quite a number of the assessments before being linked into your already known service? I think that, with all the access points into NHS 24, it is important that we establish some core information. The skill of our call handlers is extraordinary, because very often when people phone, they can be distressed, they can be confused and they just want help. They are unlikely to give you information from A to Z in that order. The skill of the call handle is to make sure that they bring them back to that point, so that we understand that we have established identity, that they are safe and that we have established their reason for calling. I do not believe that those are unnecessary steps. However, I think that it is important that we get through those points as quickly as effectively as possible. That also allows a trust bond between the patient and the call handler at that point, and then that discussion takes place. Wherever the access to service, those onward routes, I believe, are relatively smooth in terms of that information. However, I also think that there is more that we can do. Again, recently, we have introduced our ability to provide patient information to community pharmacy, which is a very important part of our community-based services. We can now provide information to community pharmacy and vice versa, so that that smooths that path. We have the ambition where we say that we want people to be able to tell their story once. I do not think that we are there yet, but I genuinely do not. However, I think that it is something that is really important to us, and I think that it is something that we are improving. Thank you very much. Thank you very much, convener, and thanks for being here this morning. A couple of really quite short questions. I am wondering about distress brief intervention. Do you monitor if you are getting repeat calls through, for example, in that area? My second question is about children and young people as well. If there is a child, young person, or parent, or carer that calls you, and they are in a great deal of distress, are they actually told to hang up and call another number? In answer to the first point on a DBI, or distress brief intervention, we, NHS 24, represents over a third of all referrals into the DBI service. We are the single largest referral point, and it has been really useful. DBI level 1 is contained within NHS 24, that compassionate approach, and the DBI level 2, as I am sure you are aware, is provided by a range of predominantly thought sector providers. Almost by the nature of that service, we see repeat calls into DBI, into our mental health hub, and perhaps more so into our breathing space service. For me, that is one of the beauties of that service. It does not matter whether you need us once or five times, so we are still there to help. We have an opportunity to see whether alternative methods of help have been available to people who have perhaps contacted those services on a regular basis. The DBI service is very good at providing onward referrals. For example, it may not be a direct health issue, it could be a social issue, a family issue, a justice issue that it needs to help with, so I think that DBI is a fabulous service. Apologies, do you mind repeating the second part of the question? It was around not providing direct support to children and young people. My question was whether there is a call that comes through them from a child, from a young person. They are not always bordered in the 16-aged group, they can be quite a lot younger now as well, or they are parent or carer, and that child of a young person is in real distress. Would they be told to hang up and call another number, or how would that be handled? No, I clearly let the situation depending on which service they and the nature of that distress, but if we do ask if there is someone there that would be able to provide additional information or help if they are significantly distressed, we would not tell them to hang up. Would the next step in that process be, for example, asking them to attend A&E if the situation is quite serious? Well, if it was serious enough to attend A&E or indeed warrant them to call 999, that would be the referral that we would provide. We have very small, so our 999 referral is, again, static. There are about 5.5 per cent of calls at the community NHS 24. The suggestion is that they warrant a 999 call, and then, as we move down a queue to and to A&E, those percentages change. However, on the age of the individual that contacts us, the core triage system, that patient safety system that sits underneath it, remains absolutely stable. Data has shown that the number of mental health-related calls to NHS 24 increased from 20,434 calls in 2019 to 139,08 calls in 2022, which, by my calculations, is a 580 per cent increase, an extraordinary number. Has that overwhelmed you? It seems that an incredible figure that is not necessarily proportionate to the extra resources that you have been able to put into this service. How have you been able to adapt to that significant increase in demand? The demand that absolutely has, as you say, the shape of the curve has been really quite marked. The introduction of the mental health hub has been around about 2019 as well, so that was that immediate response. Also available 24-7 breathing space currently is not available 24-7, it is predominantly still those out of ours periods. First of all, we immediately increased our capacity by genuinely being available 24-7 for mental health services. We also created a certainly new role for NHS Scotland, and it is what we call the psychological wellbeing practitioner in apologies. First of all, that is a post that people find very attractive if they are looking to further their clinical career. That has been a post that we have been quite fortunate in being able to fill quickly. However, it is also a post that gives them such rich learning experience that we have found that they tend to move on within the NHS pretty quickly. There is a positive and a negative, if you like, in that challenge. The investment that we have provided in terms of mental health services has allowed us to get to almost our target figures within those services. We have seen a commensurate increase in our ability to pick up those calls, but there is no denying that the demand is and continues to be very high. It seems clear to me that dental and mental health areas are significant parts of the overall healthcare system under serious pressure. How sustainable is it for NHS 24 to be that first point of contact, but then how effective can it be to refer on when there is not the capacity and other services where you are signposting it? Do you feel that this is sustainable as an approach of it as part of the overall model? We need to change to continue to be sustainable, but I believe that organisations such as NHS 24 are exactly what will provide the sustainability of our health services moving forward, where there are alternative methods of access, where there is information and where there are those connections. I firmly believe that, although we have a focus on—we talked about redesigning of urgent care and accident and emergency, so that is an acute setting—if the further we are able to move upstream, as I mentioned earlier, into that primary care and into that preventative space, for example providing information on healthy living, on dietary requirements and removing the need for services. There is also that downstream activity. This is an area where we are in the foothills of the potential of NHS 24, but areas such as providing people reassurance, information and advice, for example when they are discharged from hospital, when they are immediately discharged and perhaps find themselves having an on-going condition to manage. That can be very stressful, and therefore there is something about us understanding how we can work with our community-based services and augment that to provide people becoming nervous and then potentially contacting their GP or, indeed, requiring readmission into hospital. I emphasise that those upstream and downstream services—I think that they are fleshling just now, but I think that specific response in relation to mental health and digital is the view of looking upstream and downstream that will give us that sustainability. I also want to put that in context of severe budgetary pressures faced by healthcare, not just based on demand, but also the fact that, for example, the mental health budget has been frozen in cash terms this year with the cut to mental health being restored to spring it back into levels it was last year. What impact has that had on your services? Has it meant that you are being able to offer an alternative interface or is it something that you are feeling the pressure on as well? There is no part of the health service that does not have to make sure that we keep a very, very close eye on our budget, both in terms of making sure that we have a balanced budget but also that we have an effective spend of that budget. It is that last point that is important across all of our services. We need to make sure that we look at how the services have been developed, whether they will continue to be fit for purpose in the way that they are provided, and also recognise and get feedback from the users of those services on what works for them, and whether they would be willing, or indeed whether they would see it as an additional value, for those services to be provided differently, for example via digital or remote resource. Rather than changing the service and then asking people to expect to react to that, it is making sure that we take the voice of the patient first and build services around that. The only last thing that I was going to ask was the interface between the police service and NHS 24. We are doing, although there has been an increased number of call-outs for police attending mental health-related incidents in the community. Do you have a referral from NHS 24 to the police, or do you see that people are contacting NHS 24 instead of contacting the police, and that is a more appropriate presentation? Is that something that you are able to provide an analysis of? If I take the example of three partners in that, so it is Scottish Ambulance Service, NHS 24 and Police Scotland. We have done significant work there to make sure that we work together in that space. Sometimes we have recently run a programme where instead of the police attending, which can sometimes inflame a situation, the police will get the call-out, but they will refer the individual to the mental health hub. That is a judgment based on the particular circumstances at the time, and sometimes it is on-site wherever that individual is. Rather than being a police response, the police respond but then provide that information into the mental health hub. Likewise, between ourselves and Scottish Ambulance Services with Police Scotland, we are working on how we can operate those three areas. Rather than being an escalation to a requirement for an ambulance or, indeed, the requirement for the police, where can NHS 24 pick up that demand? We have talked a lot about distress, brief intervention and breathing space in the mental health hub. We know that a lot of work has been done to reduce stigma around mental health, so people then feel that it is okay to reach out. How has Covid impacted the issues around directing people to breathing space, TBI and mental health hub? I would never say that there was a positive from Covid. That would be completely the wrong thing to say. However, what it has done is heightened awareness of the public of Scotland to the services that NHS 24 can provide. Along with the additional investment to make sure that it is truly 24-7, I think that the public have responded incredibly well. There is a positive aspect to that that we have now seen increased demand, whether it is 9 to 5, Monday to Friday or whether it is those traditional times where NHS 24 would pick up at weekends and out of hours. Does NHS 24 use the ALIS system, which is the local information system, direct and folk to third sector organisations to help support, for instance, with mental health issues? Is that something that you would see as part of the upstream and downstreaming plan, using ALIS or directing to other local third sector services using whatever app is available locally? The Scottish Service Directory, which provides information on primary care services, so that GPs, pharmacists and so on, is embedded in both NHS and form and indeed the app. That allows people to go wherever they are so that they may be visiting another part of Scotland that they are not familiar with, so that they can pick up that geographically specific data. Very quickly, NHS and form is also, I believe, could be an enhanced national asset. I think that it needs some work and we have currently agreed with our colleagues in the Scottish Government that we will transform both the content and the way that people engage with NHS and form. That would pick up exactly the point that you are making in terms of access to those direct and complementary services within health. We will move on to our final theme of Llym Tweet. You had mentioned earlier about blended roles, how you were looking at recruitment and retention. Can you tell us some more about various strategies that NHS24 is using? I think that NHS24 provides a very useful alternative to that traditional idea of Monday to Friday, 9 to 5 employment. A vast majority of our staff operate on a part-time basis and operate at times that may suit their requirements at that period in time, whether that is at their students, whether it is at people with young families or other caring responsibilities, and they will fit the job around their work, which is fabulous. It means that we see a higher attrition rate than the traditional, if I can put it that way. There is something to take the learning from that, therefore, we would expect a higher turnover for those posts as people either move on or go back to university or whatever. So, how can we make sure that we can bring people in seamlessly? How can we make sure that the training is both effective and modern, so things like gamification of our training so that people start to learn before they start? There are also areas about that. Perhaps the most common question that I am asked is about home working versus being based in one of our geographic centres. That is something that we are looking at. We recognise that the workforce requirement has changed. However, it is really important for me and my colleagues, certainly for myself as an accountable officer, that whatever service we provide, first of all, is safe and effective for the patient. Just now, we have the ability for our clinical supervisors to be completely remote, so whether they may be in the centre, they may be at another centre, or indeed they may be within a hospital location or indeed within their home. That is a very recent intervention to perhaps make it easier for people if I have talked about blended roles. Does that mean, for example, that someone who perhaps works in NHS Dumfries and Galloway could then provide one or two days a week for NHS 24, knowing that they perhaps do not have to travel to Dunedinus centre? Those are questions that we are asking ourselves. We have found that the response to that remote clinical supervision is that the vast majority of our nursing colleagues still like that face-to-face contact, and whilst it is an option for them, we find that they tend to come into the centre, however, in the conscious of time. I think that, again, those are those incremental improvements, so whether it may be one shift or one instance a month where it would be more difficult for that person to attend work, if they were able to attend work remotely, I would rather they did that rather than not attend at all. For my second question, I noticed from your data that staff attendance is getting better over the months. In December 2022, it was 89.5, and in May 2023 it was 92.5 for staff attendance. What are you doing about staff wellbeing? First of all, I am really pleased to see that increase in staff availability, because, frankly, the more staff we have, the less stress it is for them to cover potential absences elsewhere within the team. That is the first point. Well-being is critical to our staff within NHS. We also need to recognise that many of our staff work in the areas where it is 2 o'clock in the morning, 3 o'clock in the morning, it is Saturdays, it is Sundays, so it is a very different working experience for those staff than many people who work in traditional 9 to 5. Resource availability in terms of those supportive resources, for example, we use and we are a significant user of the Thrive app, which is a mental health-related self-help and diagnostic app. We have a very good uptake on that. We have our mental health charter that all of our colleagues are aware of. We also make sure that the digital resources, so that the access to, so if I need help with my, I am sorry, I am making this up, if I need help with my wage slip, then if it is 2 o'clock in the afternoon, I can make the call potentially to payroll. If it is 2 o'clock in the morning, I cannot. How do we make sure that those services are equally available for people who work out of ours and in ours? We are still effectively out of our service in terms of the shape of our demand, albeit that we are now 24-7. Thank you, convener. It is just a brief supplementary, Mr Miller, just about the retention element. Again, you have mentioned some of the things that you are offering in terms of flexible working, but you also did speak of your higher attrition rate mostly because of perhaps some of the people that are coming on. What else are you doing to try and tackle that retention element, trying to keep as many of the staff in post as long as possible? A number of things. We have introduced what we call stay conversations. We find quite often when you join an organisation, there is a period where you are going through training or induction, and then you kind of left to it sometimes. We want to make sure that the individuals do not feel left to it. We have introduced those stay conversations at a 30-day, 60-day, six-month and indeed a 12-month period, just to make sure that there is a specific check-in point in terms of how it is working for them. Again, that is a relatively recent intervention, but I think that people find that, both from a manager's perspective and the individual's perspective, it is a good touch point for them to make sure that they have that protected time. Learning from exit interviews is also really important for us. Exit interviews within NHS are voluntary, but we are making it as easy for people as possible to provide that exit interview and we take that learning from it. We also have a significant amount of staff who move within the NHS, so there is again, back to my earlier question on blended roles, how can we share that wider resource across NHS Scotland and other opportunities for those individuals potentially to come back to us in NHS 24 after they have gained experience elsewhere? Rather than concentrating on the reason for leaving, I think that we are trying to concentrate on the reasons why people would want to stay, making sure that the workplace—I think that we have a very high-quality workplace—offering for people. They are bright, they are airy, they are safe, they are secure, they are easy to access. We provide lots of on-site welfare and wellbeing opportunities, but we also provide that corporate access to our HR and workforce services and those opportunities for training and development. Is there anything that everyone knows more about the package that the staff get that is not just about paying pensions? Is there anything else that they get that encourages them to stay with NHS 24 or is that all predetermined on an NHS national? I mean health facilities, gym facilities, gym facilities, all those sorts of things. I am not sure. I am maybe overreaching a little bit. It becomes a little bit more difficult in terms of making sure that we operate within that NHS Scotland parameter. However, in fact, we are actually in open conversation just now with our colleagues over in the Clydebank around accessing some council gym facilities. I hate to phrase every little help, so I think that it does in terms of that space. The one thing very quickly, I would say, is that I think that it is really important, particularly for our call handlers, when they join NHS 24, that they understand the difference between an NHS 24 contact centre environment and perhaps where they have either been or where they perceive that to be. It is a very challenging role and again it would commend the absolute skill of our call handlers is mind blowing. However, we do have people who find that very difficult within two or three weeks and they will say that this is simply too difficult. That is not good for them and it is not good for us. We are developing situations in which they can almost get an experience. What is the NHS 24 experience? We are trying to work with schools and colleges for people to come along, understand what that would be and then consider whether it would be for them, rather than making that choice and finding that it is not. That is very helpful. Thank you. I need to declare an interest as an RMN with current NHS registration, but having visited the NHS 24 mental health hub and seen the figures that you have presented to us in terms of people accessing the service and in terms of the improvements in accessing the telephone, I have just got one very brief question about breathing space. If there are plans to expand access to breathing space out with the quarters that it has just now? There are no specific plans to expand breathing space per se. What we are looking at this year is how we take that overall totality of our mental health services and treat that as a suite of services and make sure that people are accessing services in an informed manner, rather than someone who has used breathing space in the past and will use it again because they have the number. My requirement right now is probably better suited to the mental health hub. As something that we need to do more of, that would effectively increase the capacity to cross the space. Thank you very much, Mr Miller, for coming along to the committee today and we will suspend briefly. We will continue with our scrutiny of front-line NHS boards. I welcome to the committee Pauline Howey, chief executive of the Scottish Ambulance Service, and we are going to move straight to questions. I wonder if it is possible to detail exactly how the board plans to achieve the 3 per cent efficiency savings needed to achieve financial balance over the next three financial years. Yes, we have a comprehensive best value programme in place that each of our executive member teams leads an aspect of, and that reports directly into our 2030 strategy group, our audit committee and into our board, who consider the financial position of the organisation at every single board meeting. The plan looks across the whole area of our activities to try to identify those areas. For example, we might have introduced a response to Covid, whether we can respond in a different way to some of those cost pressures. It also looks to see how we can recover overtime costs, which have been significantly higher during Covid, for example, because of wider issues across the entire health and social care system. Our ambulance staff will be aware to spend longer at the front door of hospitals, which adds to the time to complete each patient's cycle and frequent results in staff being held back at the end of their shifts to, which results in more overtime too. We are working closely with other boards to try to identify ways in which we can more safely and effectively manage those patients at the front door and ensure that our staff get finished their shifts on time to reduce overtime costs. We are also looking at electric vehicles and we are about to prototype the first UK electric ambulance here in Scotland. We are working with vehicle manufacturers to try to identify more carbon-efficient ways of running our vehicle fleet. We are looking at LED lighting across our entire estate. We are looking at sharing services, where that is entirely possible to do so, so we have shared payroll services across the NHS. We are working with the other emergency services. If there is anything that we can do, for example, around emergency driver training, and we work with the other UK ambulance services around joint procurement activities to try to identify eight savings, where we can do something across the entire UK. That leads on into the other areas that I was looking to explore. I was looking at what extent can the savings be expected to be sustainable in the longer term. I am assuming from what you said that a lot of the joint working, cross-sector working and working with other parts of the NHS is part of that sustainability plan. Absolutely. All those areas that we are looking for, we are trying to get into a recurring sustainable financial position. You will see from our submission that we do not think that that will be entirely possible this year. However, that is the plan over the three years of the financial planning cycle to get into a recurring financial sustainable position. Thank you. Sondish Gohani has a supplementary question. Thank you. I just took an interest in practising NHS GEP, but I was really interested. I wanted you to expand a little bit further. Electric Ambulance. To me, that is really exciting. Can you tell us a little bit more about that and what is its range? It is very much under development at the moment. We expect it to be introduced into our fleet by the end of the year. We have not publicised that with the manufacturer yet. There is very little that I can say, because I know that the manufacturer is desperate to do a proper launch with us. However, they are content not to be named today, but for me to mention that we are the first ambulance service in the UK to bring an electric ambulance into service by the end of this year. Obviously, we need the range in Scotland to be significant because our fleet covers a significant number of miles, as you can imagine. Not just in the rural areas, but in our more urban areas, too. Typically, we might cover 10 patients a day, and the fleet can stop and start in several areas. Even across cities, it is deployed across the whole of Glasgow, for example, and the whole of Edinburgh. Our fleet covers significant miles, and that is one of the areas that we have been working with manufacturers on to get a fleet that has sufficient range to enable us to be confident that it can indeed satisfy our requirements. I am going to move now to Paul Sweeney. I have a question regarding the codes that are mentioned in the submission that you have made. Red and purple are assigned to emergency calls, as indicated. Despite those emergency markers, I understand that those patients can still wait hours to get a response. Indeed, I am familiar with one constituency case where a red-call patient was waiting six hours and 50 minutes for a response. Paramedics and your team are trying exceptionally hard on impossible circumstances. What can the Scottish Government do to support the service and improve response times to those critical calls? How can the system improve the flow of returns? I am pleased to advise the committee this morning that our response times across all categories of calls have been improving. That is principally to do with significant investment over the last three years into what we call our Accident and Emergency Demand and Capacity Reform programme. That has seen the introduction of an additional 458 ambulance posts into front-line services, an additional 52 ambulances and 10 new ambulance locations from which we deploy those ambulances. That is based on historical demand updated as we have went over the past few years. The last cohort of those additional staff are currently in training. They will finish by the end of this month, with 80 ambulance technicians. We should be up to full complement plus 458 staff, which has already had significant improvement in our response times. We have also aligned all our shift patterns to the most closely matched demand as best as we possibly can while maintaining good practice, such as reviewing with the health and safety executive our fatigue management for our staff to try to improve their health and well-being along with those new shifts. The single biggest challenge now remains those hospital turnaround times. So, while we have put additional resources in, the extra time that our staff are spending at hospitals is depleting some of that additionality, which is meaning that, for some patients, they continue to wait far too long. For those red patients, such as you mentioned, that dreadful response time, those tend to be patients who have started off on a lower acuity. Because our clinical advisers are becoming concerned that that patient might be deteriorating, they would upgrade the call to get a quicker response to them. We are working very closely with our supplier of our command and control system to be able to record those two times separately so that we can see the differences in times from those patients that are yellow and are upgraded and those patients that start off in a red or a purple higher acuity category. That certainly sounds like a promising process of improvement and hopefully it will yield significant results. It sounds promising from what you are saying and you did mention, of course, that one of the key sticking points, if you like, is that interface with the emergency departments at acute hospitals. We had heard last week of a pilot being trialled on some health boards to ease demand on emergency departments where ambulance crews phone ahead to speak to an emergency medicine consultant, make a decision on whether it is best for the patient to be presented to the A&E department or to a different facility. Do you have an insight on that particular system that is being trialled and could it be scaled up to ease demand on emergency departments on a national scale? You are talking about flow navigation. Most health systems across Scotland have got in one form or another. They have been trying them out in different ways across the country. Perhaps one of the most successful is in the NHS Grampian area, where 70 per cent of those yellow patients—the lower acuity patients—are staff will phone the flow navigation centre before they convey the patient to seek further senior clinical support and take a decision with and for the patient and with the senior clinician in the flow navigation centre to reach an outcome that all decides best for that patient at that particular point in time. That might be, for example, in and out of our GP services. It might be directly into mental health pathways. It might be into a falls and frailty pathway, for example. We are working with all boards in terms of developing the flow navigation centres. We have developed a criteria of what good looks like from an ambulance perspective in terms of being able to get quick access because, obviously, our staff are in emergency situations and they want to be confident that they can get a response as quickly as possible, preferably 24-7 access for when patients need them, particularly elderly patients who fall tend to be out of ours. We need support in terms of those clinical decisions out of ours. A range of different pathways that we have been developing with services across the country, such as community respiratory services, too. That has now been shared across all NHS boards, and we are working with them to implement that as much as possible before this winter. You mentioned that flow navigation is implemented in one form or another across all territorial boards. You are in a fairly unique position where you sit across all those boards and have that perspective. How dynamic and adaptive are the territorial boards to sharing best practice and are you able to help to indicate where things are doing well elsewhere that could be adapted across the nation as a whole and bring everyone up to a higher performance level? Yes, we are part of the urgent and unscheduled care collaborative across all boards, Scottish Ambulance Service, NHS 24, Health Care Improvement Scotland, are all involved in that. That is very much about learning together, sharing good practice and understanding what works in one system and whether it can be applied in another system. You will be aware that part of the challenge in terms of implementing exactly the same in other systems is demographics, workforce availability and geographical issues. Thank you. When you spoke earlier about how there is a difference between being categorised highly and then being upgraded, the concern is that somebody has waited so long, their condition has deteriorated, thus requiring that upgrade. Do you recognise that, even though they have waited out yellow, they have now become red? That is now a red category waiting time, so it is not a separate thing. The way that I mentioned in terms of categorising is more mainly for us to understand that upgrade or downgrade. There would be no process change whatsoever from the patient experience perspective. What we have done to try to improve our safety netting of those calls is that last winter we introduced what we call the integrated clinical hub, and that is staffed by GPs, advanced paramedic and nurse practitioners, and by paramedics, so that for those non-immediately life-threatening calls, they can safety net those patients, so that they can look to see how long they have been waiting, and they can provide callbacks to those patients and work out the best pathway for those patients at a particular point in time. Our senior clinical decision makers help us to provide that underpinning safety net. Is that tied into NHS 24, or is that separate? This is separate from NHS 24, so this will handle both 999 calls that are sitting, waiting and ambil in response that are not immediately life-threatening, but also if we get calls from healthcare professions who potentially are much lower acuity and might have been waiting too long, they will safety net those calls and try to find the best pathway for those calls. They are able also to identify that many calls that come through healthcare professionals and, indeed, from 999 callers. It is similar to the flow navigation centres. Do not require an emergency ambulance at that particular point in time. Often different pathways are better for them, such as respiratory pathways, mental health pathways, balls and free food. Absolutely. There are different options. One of the issues as a GP is when I ask for an ambulance and I give a fair reflection, so I feel that it's a four-hour ambulance. Invariably, a lot of us have to think, well, that actually means an eight-hour ambulance, so maybe we upgrade that to a two-hour or one-hour, because if we don't, this patient is not going to be getting in. So how could you reassure professionals that are calling you to say, we need an ambulance for this patient, and this is the realistic timescale, that you can actually meet the timescale that the GPs or the other professionals that are called you say? Our Demand and Capacity programme built in some of those parameters. We've also been investing in what we call low-acuity card 46 resources. Those are for GP and other healthcare referrals that are not time critical. We will understand what the acuity and the intervention levels are on route for those patients and, if possible, they can be served by our ambulance technicians and ambulance care assistants. We've invested in card 46 resources, which is part of the cost pressures that I mentioned earlier on, so that we can provide a quicker response. We're not where we want to be yet for those healthcare professional calls, but that's our plan to further develop our card 46 resource tier, so that we can service our healthcare professional calls much more quickly than at present. However, it has been improving, and we continue to remain committed to making further improvements. I want to ask about the response time definition change. I understand that, for all UK ambulance services, that has changed on 1 April 2022. What does that change mean for staff and for patients? The response time definition change was in response to significant, extensive consultation that we had carried out with the public and our staff, who were concerned that our sole focus was on response time, and we needed to broaden our horizon to focus on clinical outcomes and patient experience, as well as looking at response time now, rather than looking at an average response time within eight minutes, for example, for our immediate life-threatening calls. We monitor both our median response time and our 95th percentile, so that we're looking at those patients at the tail that might be waiting too long. By looking at both those measures, it enables us to identify whether there are opportunities for improvement and to target our improvement activity much more effectively than before. Our clinical outcome measures have been working with international organisations to make sure that we can compare and benchmark our performance with others. For example, our out-of-hospital cardiac arrest performance standards are all internationally recognised performance standards, and we continue to work to improve our survival from cardiac arrest. You'll be aware that we've also introduced the major trauma services across Scotland now, so again, we measure our performance against internationally recognised standards, likewise for stroke 2. It's a much broader, more extensive measurement framework that staff recognise that our patients feel is much more meaningful for them, but it's still maintaining that focus on response times. The immediate life-threatening calls are our purple calls, our most acutely, seriously unwell patients who are time critical and at risk of deterioration. The median response time now for them at target is six minutes, rather than the eight minutes that it was before. For our red or seriously ill patients, the median response target is seven minutes for them. Do you feel that there still needs to be more education for the public in terms of when they phone you? Do we need to keep putting that message out? I know that work has been done in the past, but do we need to keep doing that to make sure that they're going to the right place and getting the right help at the right time? We work very closely with colleagues across the Scotland, NHS Scotland and the Scottish Government in terms of right place, right care, right time messages to try to inform people about the best service for them at that particular point in time. I think that we need to continue to do that, particularly as we change services and adapt changes to make the population change in health needs. I'm interested in the response times that you were talking about and the newer model that you have around that. About just the confidence that the public should have in that, have you undertaken any evaluation of how those responses are working for patients and their families? We're constantly evaluating our practice. I mentioned some of those clinical measures in terms of the clinical outcome. We've got the best-ever clinical outcome for our purple categories, 56 per cent survival rates, which is superb, but we're never complacent in terms of the opportunities to do more for those most seriously unwell patients. We do a range of activities working with patient focus groups, public involvement groups. We also are members of care opinions, so we welcome feedback in good and less good. We view all feedback as a learning opportunity, and we take on board that feedback. We've got comprehensive systems of governance to make sure that, for all the learning that we gather—whether it's from adverse events, whether it's from thank-you notes, care opinion—we take that on board and we build that into our improvement plan. I'm sure you will know that the public hugely value the service, but there are definite problems in the system, particularly around ambulances being available for people. In terms of things that you could recommend that the committee could ask for or speak to the Scottish Scottish Government about, what would be key for you in terms of the delays that people can have, particularly around life-threatening situations? We try to absolutely minimise those life-threatening delays through the safety netting that I spoke about, and we are getting quicker all the time. Maze performance was much better than April, so we continue to focus on getting those additional staff into place at the right time and making sure that our staff are appropriately trained and developed. As I said before, the single biggest issue is the turnaround challenge, and it is complex. It's a reflection of the wider capacity challenges, not just in the EDs and in hospitals but across health and social care, and delayed discharges, too. We're working really closely with health boards and the Scottish Government and IJBs around how we can create capacity, too. One of our successes over the past few years has been the ability to recruit and retain staff. We still remain a very attractive employer, and the BSc Paramedic Science undergraduate programme is well oversubscribed. It's one of the most oversubscribed courses in Scottish universities, so we are working to see whether there are other ways that we can help people into careers, not just within the Scottish Ambulance Service, but paramedics and ambulance technicians are highly qualified members of staff that we can use in different areas of service provision. For example, we've got paramedics and advanced paramedics working in GP out of our services and in our services, doing home visits on behalf of GPs. We've got some staff working at the front door of accident emergency departments to help out in terms of staff, and we're working with boards to understand what the potential is to perhaps help in terms of some of their workforce challenges. On the clinical response model, I note that a public engagement exercise was undertaken into the new clinical response model, which found that over 90 per cent of the public supported it. That is encouraging, but what assessment has been made of the public's on-going awareness of the new clinical response model? It's been in place now for several years since 2017, so it is the clinical response model. As I mentioned to the other committee member, we constantly are looking for feedback from patients and from staff and from other stakeholders when we take on board that feedback. For example, one of the evaluations that we did a couple of years ago, we noticed that patients with breathing difficulties had a higher cardiac arrest rate than we initially thought, so we upgraded that category into our purple response category that we previously read to help improve outcomes for those patients. I mentioned falls and frailty services. We've been doing a lot of work in terms of accessibility of falls pathways and being able to make direct referrals from people's homes into rapid assessment teams from fall services and for follow-up care for those services. We often find that when we get into people's homes, particularly more elderly members of our population, they often don't want to go to hospital. They really look for us to help find alternative pathways for them so that they can maintain their independence at home. Obviously, at times when people phone the ambulance service, they're in acute distress or in acute need of help, is there on-going assessment of how those calls are handled, the experience of call handlers, and how those response times and categorisations are communicated to people who are waiting? We constantly review the call handling scripts that we call them. You'll understand that there's really strict governance around those strict scripts. There's an international academy that we feed in our experience, both in terms of our data and the experience of our staff and the experience of our patients, so that we can constantly refine those scripts and make sure that they are current best practice based on what we know and any research findings that we've been able to develop internally with Scottish universities on indeed learning from international practice. That's great. To what extent is the Scottish Ambulance Service confident that the public are supportive of the new triage system in particular? As your colleague said, the public highly, highly value the ambulance service here in Scotland, and we don't get many complaints at all about our response to our immediately life-threatening patients. As I said earlier, there's more that we want to do and more that we need to do for those patients that have been waiting too long, that are in the lower acute categories, and that's where our focus is. How can we get response times improved for those patients? The key enabler to that now is getting our ambulance crews turned around quicker at the front door of departments so that we can get back out responding to those patients, as well as doing the work in our integrated clinical hub to identify alternatives for patients at the point of call and from the scene through the flow navigation support to try again to identify alternatives. For those patients who don't want or need to go to hospital, there are alternatives that can help them in getting into the right pathway care for them at the presenting condition. That's great. Thanks, convener. Thank you. Emma Harper has a supplementary on this issue. Yes, thanks, convener. Good morning, community polling. You mentioned falls earlier, and I'm just looking at the 2030 document that said 12 per cent of ambulance call-outs are for somebody who has fallen, so there's work being done to look at that. But 10 per cent is also for patients with respiratory difficulties, like COPD, exacerbation. As a lung health cross-party group co-convener, I'm interested in what work is being done to help support the respiratory patients, for instance, because they might not necessarily need an admission, they might need a referral to an onward pathway for better management of their COPD. Indeed, so falls respiratory and mental health pathways are top three pathways that we're working with boards and IJBs to try to get direct referral and accessibility of our staff to direct referral or indeed to seek support and advice from those specialists. So respiratory patients often are known to respiratory specialists and are part of community respiratory nursing teams, but many of them might not be or might not have accessed that service before. What we've found through a whole series of different work streams is that we are often in contact with patients that might not be users of those specialist services so that we can connect them in and help them in getting a more effective treatment pathway in place. We don't have widespread coverage of respiratory pathways, but it's something that we're working with each system to try again to encourage the adoption of good practice and to have those respiratory pathways available for our staff at the times when patients present with those, which is often outwith nine to five. We're going to move on to our next theme and I'll pass to Sue Weber. You'll know that the NHS target to reduce sickness absences is to less than 5 per cent, but in the submission I think it's in the ambulance services 8.9 per cent, and that you've got a high proportion of staff with mental or physical health problems compared to other sections as well. What is your current sickness absence rate if the Covid-related absences are removed? What are the main underlying causes of those non-Covid absences? Is it still the musculoskeletal and the physical pain aspects as well? For May 23, our sickness absence rate was 7.6 per cent, and typically the Covid element of that is between 0.5 per cent in the Scottish ambulance service. Staff health and wellbeing is one of our top organisational priorities. Since it was last here at the committee, we have launched our integrated staff health and wellbeing strategy, which is about focusing on healthy body, healthy mind, healthy lifestyle, healthy culture and healthy environment for our staff. It was co-designed with our staff, and we also looked for international best practice as well as working with the other emergency services, other UK ambulance services and, indeed, other public services, including health boards here in Scotland. It's a comprehensive strategy to support staff to be well at work and when they become unwell to help them in terms of returning to work as quickly as possible. Through that strategy, we have invested in additional specialist staff. We have got additional health and wellbeing specialist staff and organisational development staff, who have a detailed action plan that they are progressing with some figure. Those actions include things such as trim management. That is where people in our service, for example, who have higher exposure to traumatic events than other healthcare professionals because of the nature of the work that they do, can get support by peers. We have recently trained 60 ambulance staff in trim practitioner training, who will support the rest of the organisation. Hugely oversubscribed. We asked for 60 volunteers. We had 250 volunteers come forward to support staff. That was work that we had done just pre-Covid. We tested out trim training and trim practice within our service in a couple of locations, and it was very successfully received, so that has now been rolled out. We have got peer supporters in place across our whole organisation as well, so that people who just want to chat can chat. We have also got financial wellbeing support for staff. We have got links to citizen advice and other services, because often we find that issues that affect the mental wellbeing of our staff are not just work-related issues, but wider societal issues as well. The top reasons remain, apart from Covid, anxiety stress, depression, back problems and musculoskeletal problems. When we were developing our strategy, it was apparent that ambulance services worldwide suffer higher rates of sickness absence than other parts of the health and social care system. Part of that is because of the psychological risks that they face. Part of that is the physicality of the work that they do, and part of that is the exposure to traumatic events. Often not individual events, but repeated exposure to, which is why we are putting so much emphasis on healthy mind activities. We have also got a series of staff-organised events, such as West Lothian Breakfast Club, which is a drop-in club. Not just for our staff, it has been extended to the other emergency services and parts of the NHS in West Lothian, which is a social event that, when people can just come together, we have got walking clubs in place. We have got discounted gym membership for our staff across most local authority areas, too. As part of the demand capacity programme that I mentioned earlier on, that has taken a bit of the pressure off of staff. When we ask staff what matters to them, they tell us that management of demand is one of the biggest stressors on their time at work, so having additional resources to help to manage the demand, having those resources on at the right time in the right place, is helping. If we can get that turnaround issue dealt with, that will help more people to get finished their shift on time and get back to their families and be fresher for the next shift. That precludes my second question, because there was so much in the answer book. Briefly, on the evaluation of all those systems that you are putting in place, have you got something to assess how they are working and what impact they are going to have? As part of our health and wellbeing strategy, we have developed evaluation models and performance data. Some of it is hard information such as the sickness absence rate, the length of absence, the type of absence. Some of it is about more surveys such as what matters to staff, the eye-matter survey, different staff engagement events, a lot of station walkabouts, an online weekly event with staff where they can ask anything and we theme up those issues. For example, two weeks ago, we did a culture week in the service where we had various external speakers about culture and an environment across the service. There is a range of different measurements that we use to evaluate the effectiveness of our health and wellbeing strategy. That ties in well with the questions that Sandesh Gohanis has for you. Absolutely. That was a very full answer that you gave to Sue Webber. My first question is, in the last 12 months, what is the attrition rate of your advanced paramedics? Advanced paramedics is higher than our base workforce. I believe that it is over 12 per cent. I have not got the figure to my head at the moment, but I can come back to you. For all the things that you are doing, I have been contacted by paramedics. One paramedic said to me that they suffered from numerous traumatic situations and suffered PTSD. They wanted to go into the triaging area because they just wanted to be away from that front-line environment, but this paramedic was forced to quit because she was told that she had to go to the front line and she had to be in ambulances. I am also being contacted by paramedics who are saying that they absolutely do not like advanced paramedics. They do not like the fact that they are only triaging and they are not getting out. What would you say to those paramedics? Obviously, I do not know the specifics of the first case that you mentioned. If you want to contact me after, I will be happy to try to understand the particular circumstances. There are a range of different opportunities for paramedics that have never been there before, not just in terms of the clinical triage arrangements, but also in terms of education and professional development. I mentioned the BSc paramedic science course that is now available. We continue to develop different opportunities for our staff. In terms of the advanced practitioners, there are 30 to 30 per cent opportunities. 30 per cent of their time will be spent in terms of remote triage, 30 per cent typically, working with GP in and out of our services and 30 per cent supporting immediate response to patients through the 999 system or through the healthcare professionals system. We continue to work with those advanced practitioners in terms of that role development. It is a really new role and it was introduced really, really quickly at the very beginning of the pandemic in terms of being able to safely respond to patients and identify those patients who are required and immediate ambulance response. We have continued to refine it over the time since we introduced this model in April 2020. The feedback from those practitioners has been essential to that. They are highly valued members of staff across the whole health and social care environment, so I am sure that you are aware of that. What if an advanced paramedic came to you and said that I do not like this 30, 30, 30? I want to be out there more. I want to be going and seeing patients more. Do you have flexibility for them? The arrangement that we have in place at the moment is the 30, 30, 30 split that I spoke about. As I said, we are continuing to refine that model. We find that some staff prefer to do the remote triage than in terms of response to it. This is very much work in progress. We are working with that team and continuing to evolve the model so that we can get the best out of people. As you know, those are very experienced and highly qualified staff. We have shown and proven that the work that they do in remote triage is very effective and that the feedback from patients is very high. If you have paramedics that enjoy the triaging and do not enjoy the triaging, surely it would make sense to allow them to do the bits that they really enjoy. In an ideal world, however, we need to make sure that we have enough people doing the triaging and that we have enough people in terms of that response. That is the work that I mentioned that is in progress at the moment. We are modelling out the numbers that we need to do both and are trying to make sure that we have the right people with the right skills in those places that can support colleagues and support patients going forward. Finally, when you do your exit interviews for your especially advanced paramedics that are leaving the service, what is the reason given that they are leaving the service? I do not know off the top of my head. I can tell you, in terms of anecdotes, that some of them tell me that there are other opportunities in other parts of the health service. Often part of that is about pay and other parts of GP practice, for example, who directly employ our advanced practitioners, and other parts of it are about the opportunities in different parts of it that are out of our services or in our services. I can certainly get that information to you. We have heard a lot of fantastic work that is going on locally and nationally. I thought that my microphone was off there. For example, the introduction of the hospital ambulance liaison officers. Very aptly, Hilo being the acronym for that. Consultant Connect is something that is really interesting, too. That direct contact between the ambulance service and senior clinicians that allows remote decisions to be made in minutes and saves going through A&E, preventing those waits there. I heard recently at the Lancashire local police plan, where it is what about 10 per cent of the demand for police forces in Scotland is, that mental health was becoming really significant and that it really was not sustainable at this point in time. I am just wondering what kind of work is going on with Police Scotland to create those kind of direct links there to give them the support to reduce the amount of time that police spend in A&E. For example, on one evening they had all five cars. We are actually at A&E, too. Are you interested in any pilots, any work that is going forward to improve things and the impact that that is making? We work really closely with Police Scotland and also the Scottish Fire and Rescue Service. Mental health is one of our top priorities among all three services. You will probably have heard from Jim Miller earlier today about the work that we do with NHS 24 and Police Scotland in terms of the mental health triage hub that is hosted by NHS 24. Both Scottish Ambulance Service staff and control room staff and Police Scotland staff can refer for those people in distress into the mental health triage hub that is hosted by NHS 24. We also have in February this year introduced a service where police officers can call ambulance control direct from scene and they can get support in terms of clinical decision making around those people that they are worried about at scene. What we have found is that the majority of those calls are in that yellow category—over 46 per cent of the calls from police officers at scene—and about 40 per cent of those patients we do not convey to hospital, so we are trying to work with Police Scotland to understand what exactly are those patients' needs and how can we develop alternative pathways that are more appropriate to their needs at that particular point in time. The feedback so far from Police Scotland has been very positive. They get a four-second average pick-up time for their calls, so it is reassuring for those police officers at scene that they are able to contact a healthcare professional and get that advice for them. If it is more serious—for example, a red call, perhaps a road traffic collision or a stabbing or a seizure—we can get our support to them as quickly as possible and, while the ambulance is on the way, we provide clinical decision support by radio to the police officers on scene. In the last session of Parliament, I was a health committee member and we heard from the Ambulance Service about how the police ended up looking after people in the emergency room and taking up their time, for instance. I would be interested to know what work has been done to support the police dealing with the NHS calls, whether the ambulance or the other NHS could do that. I mentioned the work in terms of police officers being able to contact us directly from scene, and 40 per cent of those yellow patients are not requiring conveyance to emergency departments, so we are getting very much working with Police Scotland to understand what is the best pathway for that person at that particular point in time. Last time I was here, I might have mentioned the mental health triage car, which, at that time, we were staffing with a paramedic police officer and a mental health nurse. We have taken on board the feedback, and we have three mental health cards in Scotland, one in Glasgow, one in Dindian and one in Inverness, which are staffed solely by a mental health nurse and a paramedic. We require police assistants to call, so that saves police officer time there as well. We are doing specific work with both Police Scotland officers and our staff around suicide prevention and support for people who might be contemplating suicide and providing other joint training opportunities for both police officers and paramedic and ambulance staff as well. We are constantly looking for ways in which we can support each other in dealing with more vulnerable people who might be in mental health crisis as well. We have a team within the Scottish Ambulance Service, our high-intensity users team, for those people that are regular callers to us. We often find that many of those callers have underlying mental health conditions that we can connect with other parts of the system and make sure that there are appropriate support arrangements in place. Drug harm reduction is another area that works very closely with Police Scotland on. We have both now got our oil staff trained and have kits in terms of take-home naloxone programme. We have handed out over 2,600 kits to members of family or friends of those people who have contacted us with a drug overdose to try to support people that might be in the future. We are also working to see what more we can do around community safety initiatives and connecting those people who might have overdosed into rehab services and treatment services. We found that 40 per cent of people that we were attending were not currently in treatment services, so we have been able to make contact on behalf of those patients with their permission into treatment services and support them. I hope that we can stop that cycle of repeated overdoses. I am thinking of liaising not just with the police but the fire service as well. I am sure that that is part of the work that is on-going. I am also interested in part of the work that we do to engage with people who have harmful use of drugs and alcohol, such as reducing the stigma. Is tackling stigma or addressing stigma in the language that we use, is that part of continuing professional development that would be provided for ambulance service staff? Absolutely. We have additional funding from the Scottish Government in employing specialist mental health teams in the Scottish ambulance service who have been embarking on a wholesale education and development programme for all our staff. For example, a couple of weeks ago, we were in our ambulance control centre supporting our call-handling staff in terms of mental health patients. Some of the issues that they have been dealing with are about stigma and language, but the training and education programme is for all staff within our service. Do you monitor persons who have mental health emergency or an urgent need that the police might be engaging with them instead of the ambulance service? Is that something that we track when the police escort somebody to the emergency room for his or the emergency department, rather than the ambulance crew? We do not specifically track that, but the police obviously track that. That is some of the work that we are trying to do with Police Scotland, the Scottish Fire and Rescue Service and Public Health Scotland. We share all our data with and can work to interpret and analyse the data on our behalf. We obviously need to make sure that we respect confidentiality issues in terms of data sharing, but that is work that we have as part of our work programme with the Scottish Fire and Rescue Service in Police Scotland. We have a comprehensive collaboration programme with work streams around knowledge and intelligence sharing and what is the data telling us in terms of users of our service and where we can identify different opportunities that we can be more proactive and preventative in our approach across the three emergency services, rather than constantly responding perhaps to the same people and trying to get them into more appropriate pathways that can help to treat and manage them with and for them in the future. Can I have a final question about— I have a few more to come in, so it is very brief. I will wait and bring it up later because I think it will be worth a letter. It is just about maternity services and delivering babies in ambulances in rural areas, for instance, and I can pick it up later. Thank you. I declare an interest as an RMA with current NMC registration. I am just wondering if there has been any assessment made of the impact of the mental health assessment units being established across the country in terms of ambulance waiting times at A&E? I do not have that information to hand, convener, but I can certainly get that information. As I said, it is one of our top pathways that we are trying to develop in terms of direct access to mental health assessment units for patients that present through the 999 system. Thank you. I would be really grateful if you could come to Paul Sweeney. Thank you, convener. I just wanted to pick up a frequent issue that is raised by police officers about the amount of their time that is spent dealing with cases where they do not feel qualified or are capable of addressing the situation. The number of calls made to Police Scotland citing a situation of mental health crisis or suicide risk has increased by almost 10,000 from 14,540, 2018 to 23,426 and 2022. You mentioned the pilot of triage cars, the three of which are operating in Scotland at the moment. Do you feel that there is an opportunity to look at a business case to expand that model if it is more effective and probably cost effective solution, given the huge costs that are currently incurred by response policing, attending incidents or cases where it might well be a known person who has a history of calling the police in relation to those issues or the fact that they are not qualified to deal with it when they do arrive at the scene? It may be that that is the most appropriate response. The work that we are doing with Police Scotland at the moment is trying to get behind that data to understand what those people are needing at that particular point in time, that Police Scotland is responding to them and to try to develop alternatives that are much more appropriate and are serviced by the most appropriate service or agency for that person at that particular point in time. I mentioned earlier the direct referral from Police Officers on scene now, so we are getting about 1,300 referrals each month from Police Scotland officers from scene, as well as the substantial referrals that we get direct from Police Control 2. It is very much work in progress trying to understand what the needs of people are and trying to work with Police Scotland and other agencies to put in place more effective services for those people. Stephanie Callaghan wants to come back in on one of the issues that I think that she raised earlier. Thanks for allowing me to come back in, convener. It is just kind of going back a wee bit to something that Emma said. I cannot really remember all the specifics around this. I am not sure if it is something that you will be able to answer or not, but certainly in conversations, I know that the Lancashire drugs death prevention group had raised some issues around information sharing that she touched on before. Instead, there was real fear around GDPR. One of the big things that they were concerned about was the fact that they could not get non-fatal overdose information, because, of course, usually those who died have tried before. Is that something that you are able to comment on, if there are issues around that, if it is something that has been tackled just now? Yes, so often there are challenges in terms of GDPR regulations, but we very much try to work with other agencies to understand why we are asked to share data and to understand what the potential harm avoidance is in terms of being able to share that data. So, very much we look for opportunities to share data where it is going to prevent harm and lead to service development in future. I am not specifically aware of the work going on with the Lancashire alcohol and drugs partnership, but I am happy to pick up with you out with committee if there are particular challenges. That is sure helpful. Thank you. I thank Pauline Howie for her attendance at committee today. Please feel free to leave, we are going to move on with our meeting. The next item on our agenda is consideration of two negative instruments. The first instrument is Food Scotland Act 2015, Compliance Notices Regulations 2023. The purpose of the instrument is to list offences in relation to which compliance notices are set out in the Food Scotland Act 2015 may be used as an alternative to criminal proceedings. The relevant offences relate to food information, food composition standards, novel foods, foods for specific groups and food contact materials. The Delegated Powers and Law Reform Committee considered the instrument at its meeting on 13 June 2023 and has drawn the Parliament's attention to a cross-referencing error in the paragraph 33 of the schedule should refer to Regulation 4 of the novel Food Scotland Regulations 2017 instead of Regulation 6 brackets 2. The committee noted that the Scottish Government intends to correct the error at the earliest opportunity. No motion to annul has been received in relation to the instrument. Do members have any comments? I have a comment. My interest in food standards and how we are altering and changing and engaging in things such as novel foods, I am interested in the very last paragraph 9 that it talks about monitoring. Food standard Scotland will work with local authorities where problems are suspected and infringements of the legislation arise. I am interested to know, and it might be that we write to Food Standards Scotland, how will Food Standards work with local authorities, how will we monitor that just in terms of general interest? I confirm agreement with the negative instrument. The second instrument is national health services changes to overseas visitors Scotland amendment regulations 2023. The purpose of this instrument is to ensure overseas visitors from certain British overseas territories will not be charged for certain treatment provided by health boards in Scotland in accordance with healthcare agreements. The instrument inserts a further five territories, Ascension Island, Bermuda, Cayman Islands, Pitcairn, Henderson, Ducey and Oeno islands, and Tristan Ducunat into schedule 2 of the national health service charges to overseas visitors Scotland regulations 1989. The Delegated Powers and Law Reform Committee considered the instrument at its meeting on 13 June 2023 and made no recommendations. No motion to analysis has been received in relation to this instrument. Do members have any comments? I suppose that the committee does not make any recommendations in relation to the negative instrument. Does any member disagree with that? The next meeting will be a session with the Cabinet Secretary for NHS Recovery, Health and Social Care, based on the evidence that we have gathered in our recent scrutiny of front-line NHS boards. That concludes the public part of our meeting today.