 Surely Good morning, and welcome to the 25th meeting, of the public audit and post-legislative scrutiny committee in 2018. Can everyone please ask everyone to switch their electronic devices to silence so that they don't affect the committee's work this morning. I have nothing of interest to declare. I welcome Mr Sarwar to the Audit Committee this morning. Item 2 is decision on taking business in private. Do members agree to take items 4 and 5 in private? Yes. Thank you. Item 3 is section 23 reports NHS in Scotland 2018. I would like to welcome our witnesses today, Caroline Gardner, Auditor General for Scotland, Claire Sweeney, Audit Director, Performance and Best Value, Lee Johnson, Senior Manager, Performance and Best Value and Kirsty White, Audit Manager of Audits Scotland. Can I please invite the Auditor General to make a short opening statement? Thank you, convener. Today's report looks at how the NHS in Scotland performed in 2017-18. I've been highlighting the increasing pressures facing the NHS for a number of years, and they've now reached the point where decisive action is needed to secure the future of this vital service. NHS staff are committed to providing high-quality care and patient satisfaction remains high, but the quality of care is under pressure. NHS boards met only one key national performance target in 2017-18 and performance against the targets declined. No NHS board met all eight targets and more people are waiting longer to be seen. The NHS is not currently in a financially sustainable position. NHS boards struggle to break even, relying on a mixture of brokerage and short-term measures to balance their books. Boards made unprecedented savings at £449 million last year, but they relied heavily on one-off savings and they are finding it harder each year. Cost pressures continue to intensify with rising spending on drugs, high levels of backlog maintenance and continuing difficulties in recruiting staff. The focus continues to be on the short term rather than on planning for the longer term. The Government's medium-term health and social care financial framework and the other measures announced recently are a welcome step. The detail of these will be important, together with the full impact of the UK Government's announcement on NHS funding. It remains essential, however, to address the underlying challenges facing the NHS in Scotland. Transforming how healthcare services are provided will bring real benefits to patients, but there needs to be an urgent focus on the things that are critical to success. Those include effective leadership, longer-term planning and ensuring that governance arrangements are clear and robust. Most important, without much more engagement with communities about new forms of care and the difference they can make to people's lives, it will continue to be difficult to build support among the public and politicians for the changes required. Convener, as always, my colleagues and I are happy to answer the committee's questions. Thank you very much indeed, Auditor General. Thank you for this morning. There seems to be a little discrepancy between what the report says and what the First Minister said on the health budgets in the chamber at First Minister's Questions on 25 October. She said that day when questioned that health boards are not facing cuts and that the health budget has increased in real terms by 7.7 per cent. I think that your report quite clearly states that there was a 0.2 per cent decrease in real terms in this last year. Auditor General, can you outline for us have they been cuts to the health board or have they not? We try to address this in part 1 of the report, particularly on pages 8 and 9. I think that the answer is it depends on the way that you define it. If I can direct your attention to paragraph 8 of the report what we set out there is that between 2016-17 and 2017-18 the overall health budget increased by 1.5 per cent in cash terms which is a decrease of 0.2 per cent in real terms when you take inflation into account that's the overall budget when you break it down into revenue in capital the picture is a bit different so revenue funding for day-to-day spending increased by 0.8 per cent in real terms which is 2.5 per cent in cash terms but the capital budget reduced quite significantly by 23.5 per cent in real terms and that reflects to a large extent the completion of the new Dumfries and Galloway Royal Infirmary and the near completion of the new Edinburgh Sick Children's Hospital and the Department of Clinical Neurosciences so in overall terms there was a slight decrease in real terms but the revenue budget went up slightly in real terms. The report also looks is dependent on how you define it and perhaps which year you're looking at as well over the piece but I think your report points quite clearly to an increasing demand on our health service can you give the committee a flavour do you think the boards individually are really feeling that financial pressure and it feels to them like they have less money and they're making cuts to bring Kirsty White in in a moment to give you a bit more of a picture of that but in summary yes we think it's harder and harder for boards to manage their budgets and break even at the year end and more and more of them are relying on short term measures to do that Kirsty could you flesh that out a little bit Yes of course as the Auditor General says boards have been relying on short term measures for a number of years now what we saw in the past year was a continuing intensification of that some examples in the reports of the ways in which boards have been trying to break even in that past year excuse me so for example things like moving capital to revenue funding and actually the reverse as well to try and make that break even later allocations from government and a lot of that is non recurring savings and as we make the point in this report and have made the point in previous reports boards have been increasingly using savings to try and break even and then that's all combined with intensifying cost pressures which we set out in exhibit 5 of the report and I'm happy to obviously go into more detail as questions come up about that Alex Neil Can I start the Auditor General because basically I think the key message of this report is as things stood the NHS in Scotland is not financially sustainable now since this work was done obviously we've had the announcement that by 2023 at a UK level spending and health will go up by 20 billion a year south of the border and there will be consequentials and that will start next year have you had a chance to look at the impact on your conclusions in this report in the light of the additional funding we should expect to get I think I should start by being clear that the conclusion in the report is the NHS isn't financially sustainable in its current form I think that there are ways of transforming it to make it financially sustainable and you're right we have also seen a number of announcements including the UK budget and the consequentials that will come to Scotland from the funding announcement there and the Cabinet Secretary for Finances medium term financial framework for health and care and some other announcements around brokerage and removing the requirement for services and we are still waiting for the detail of some of that and will continue to look at it I think our clear conclusion though is that those things will provide a bit of welcome breathing space but they won't address the underlying challenges which are really two fold first of all as Kirsty has said healthcare costs tend to increase more quickly than general inflation anyway and secondly we do have an ageing population which means we require different forms of health and social care in future from the sorts of things that the NHS was set up to do 70 years ago which were much more about treatments and cure we show in the report that the NHS budget currently accounts for about 42% of the total Scottish Government budget clearly there's a limit to the extent to which you would want or be able to continue increasing that proportion without crowding out other vital services like education in early years and the other things that are important so the announcements that we've seen at both the UK and the Scottish level will help but they're not a substitute for making the sorts of changes that we describe as being needed in this report Can I ask what would be the three most important changes that are required in order to get into a financial sustainable position I think there are three things that we have been setting out in this report and the report we published today on health and social care integration the first is very clear leadership at both national and local levels to make sure that the pockets of really good practice we see are being developed and spread more widely the second is much better longer term planning for what it will cost and what investment is needed to get from where we are now to where we need to be and the third is much better engagement with individual people with communities, with staff to build that sense of confidence that the services that we can deliver in the future are not just a response to cuts but instead are a way of meeting people's needs better than we're currently able to do Would you include in that the need to have an examination of the overheads I mean for example we now if you include the 31 integrated boards the 22 health boards and now the three regional structures we have 56 different organisations involved in the delivery of the national health service excluding the substantial resource house and in other bodies like mental welfare commission so is there not an urgent need to look at that overhead structure because I think we would all agree that one of the problems of the health service down the years is every time they create a new structure they don't replace it they just add additional structures on to what's already there It didn't make my top three which is what you asked for but we do say in the report that the governance arrangements for health and care are increasingly complex now there is clearly a cost associated with that but beyond that I think it makes it more difficult in some ways to achieve the changes that are required Claire do you want to talk a little bit about our concerns in that area There's no doubt about it that it has become far harder to recruit to those senior positions and part of the story must be that we are looking for a grid a number of top teams than has been the case before on page 26 of the report we just give a few examples of more recent instances where it's been hard to fill posts at a senior level it absolutely is an increasing concern The other key part of all of this is the exponential increase in demand which we can expect to continue to see happening in the years ahead as well as looking overheads is there not the need for a robust demand management strategy as well obviously integration is key but one of the things that struck me as health secretary was we're not actually managing demand very well for example if we spent more on prevention that should over time reduce demand on day to day services I think I'd go back a step from demand management we say in the report on pages 17 and 18 that actually trends in demand and that type of activity aren't currently very well understood Exhibit 6 on page 17 shows that the number of elective admissions fell last year the number of new outpatient appointments fell the number of repeat outpatient appointments fell nobody's very sure whether that's because those people are being treated better in a different setting or because boards don't have the capacity to provide the services that are demanded and without having that really clear picture it's very difficult to manage the flow in hospital and obviously to plan alternative primary and community based services might be that could provide a better service to those people they're really important questions and asked Sarwar Alex Neil touched upon the and you also mentioned the leadership aspect I'll maybe try to touch upon that later on if I get a chance but I just wanted to ask a couple of questions just around the savings elements so the report makes clear there's been almost £450 million of savings made by health boards and then to running costs and service cuts Kirsty I think probably knows more about that £450 million than anybody else at the table so I'll ask her to talk you through the big messages around it I suppose savings are split into two elements recurring, non-recurring recurring is essentially what we would see as typically efficiency savings those are the savings we'll make that you would see savings year on year through say service redesign the main issue we've seen in recent years is the quite significant increase in the non-recurring savings element so the one-offs for example selling buildings for example that is a sign of the cost pressures the boards are under and the difficulties they're facing in terms of finding savings and also that's reflected in the increase in unidentified savings that we've seen at the start of the years while that's also been increasing where boards are unable to identify at the start of the financial year exactly what savings they're trying to make so the key element of all of this is that increased level of non-recurring savings and we've said this year and we've said for previous years that that level's not sustainable is this all the finances okay and then I'll come to Colin you also mentioned about the challenges around it being made clear to boards that they didn't need to break even at the end of the year there's also been the writing off of the brokerage do you think there's a risk of first of all appearance of rewarding bad behaviour for those boards that did manage to manage their finances compared to those that didn't and having their brokerage signed off and also whether there's a risk of further chaos in future years given that boards no longer need to worry about breaking even at the end of the year I've been recommending since I took up this job that the health service should move away from a very sharp focus on annual financial balance which I think makes it harder to achieve long term financial sustainability so I welcome the move in that sense we are still looking to understand fully how the new requirement to break even across a three year period will work in practice and while for the boards who currently have outstanding brokerage the write off will be welcome for boards like Tayside and Aetrin who have significant brokerage they currently have no plans to repay the money anyway so it's not making an immediate difference to their financial standing as I said in response to an earlier question I think all of those moves are welcoming that they give a breathing space to boards that are facing real financial pressures but they actually don't help to address the underlying challenges and it's important that that space is used to get the underlying sustainability back in order thank you I'd like to ask a few questions on governance and leadership but first just a general one page 23 key message 3 says that the healthcare system needs to become more open and people need to take part in an honest debate about the future then it's just who are these people who do you envisage being the people I think it needs to take place at a number of levels we if you talk to any doctors and nurses across Scotland I think they will absolutely recognise that the health service needs to change to meet the needs of an ageing population fewer people need to go into hospital to be treated and cured for something many more people need support for long-term conditions like diabetes or pulmonary diseases or simply the diseases of getting older and more frail there's wide consensus that the government's vision but changing health services is difficult people are very attached to their local hospitals the services that they know and it's much harder to see the flexible community based services that don't have a building attached to them and don't have that history so I think we're looking for people to be involved from the national level with government and the national clinical organisations talking about the sorts of changes that need to happen and that can improve services they need to happen at health board and at national authority level and they need to happen at the very local level around individual GP practices and individual communities now that's not something which is a quick fix, it doesn't take time but it also needs much more openness about why change is needed and about the way that it will be funded and managed over a period of time to help to build that confidence that it's not just about cuts I think your scope of what the people is is probably fairly challenging to actually achieve it's all of us and I think this is a very challenging transformation that's required but there's no substitute for it it's all in relation to that in paragraph 77 you say there continue to be many examples of public and political opposition to attempts by NHS boards to change how services are delivered now I don't know what your definition of public is in relation to that but I appreciate some sort of definition you say political oppositions I mean local councils, local councillors are intervening to prevent it I think again it's politicians at both local and national level we can all think of examples across Scotland of proposals coming forward from health boards to transform the way services are being provided we very often see grassroots campaigns against those perhaps in some instances because the engagement has been done well and people don't understand either why change is needed or what's being proposed in it's stead and we often see those campaigns attracting support from local and national politicians and I think we all understand why that might be the case but it also can be a really significant block to being able to make the sorts of changes that would not only help with financial sustainability but that I think clinically are seen to be better services for the longer term this is something that goes back to Scotland and more widely but I think because of the intensity of the pressures that the health service is facing it's becoming more and more important that we start to open up those conversations and look at ways in which services can be changed to make them sustainable for the future Just looking at governance and governance to me is the board of the local organisations you've been fairly harsh in commenting about the difficulties in filling those positions and certainly this committee in the past has discussed with some concern some of the quality of members of the boards of these various organisations you're talking about delays and appointments you're talking about how effective they are how do we change this there's a huge demand for non-executive directors across Scotland and it seems to me that what you're saying is there is not sufficient supply to meet that demand if that is the case how do we change the model to compensate I'll ask Lee to come in a moment around executive recruitment cos that's also a challenge I think probably we need to look at both the demand and the supply side Alec Neill asked about the number of bodies that we have involved in this it is obviously the case that the more bodies we have the more difficult it becomes to recruit people of the right calibre and experience jobs that are needed and at the same time the jobs themselves I think are getting more difficult both in terms of the scale of the challenge and the political with a small p climate in which people are working and the extent to which they're seen to be very difficult jobs to achieve in practice none of that's helped by continuing pressure on public sector pay and the sorts of changes to pension taxation that we've talked about in this committee before Lee can you add a bit of colour to that yes I think in terms of leadership and we do say in our report I think there is work to be done to better understand why some of the particularly chief executive positions are difficult to fill I wouldn't like to speculate about that but I know that the Government are also undertaking work around their lift programme which is about developing leadership and talent for the future and they are progressing that they have a number of people currently in various courses who will leadership side as opposed to the governance side yes that's to become executive directors within the health and care system thank you convener good morning I'd actually just like to follow on from a couple of the lines from earlier first of all so Alec Neill talked about the number of bodies just a very blunt question for my Auditor General have we got too many acute hospitals for the population size and geography in Scotland there are people better equipped than I am to answer that question for you but I think the Government strategy again over a long period of time not just the current Government has recognised that the things that acute hospitals need to do are an increasingly small proportion of the overall demand on health and care as the population ages that as technology increases the need for specialisation increases with that and that's one of the drivers for regionalisation in the health service that we're seeing at the moment and there's then a really important job to do of understanding what demand looks like in each area of Scotland and how that plays out into the balance between acute hospitals and much better community based services that can avoid unnecessary admissions treat people close to home and get them home from hospital more quickly when they do need to be admitted I wouldn't say we can answer the question about acute hospitals we can say we need fewer people being treated in acute hospitals when they could be treated as well or better in their own homes and if I may move on from Colin's governance point so there are quite clearly huge challenges ahead for the service as you've laid out in your report and so the boards are going to need to be very high quality it would appear consistently the case and I'm looking at paragraph 71 of your report which says that there's no consistent approach across the NHS to ensuring that the board is going to be of that level of quality and that you also reference at paragraph 72 that the health and sport committee did some work which suggested that even the boards themselves don't generally think that they have all sets required so what more needs to be done and by whom? In the report at paragraph 71 we do set out some of the issues that we found through this piece of work about the ability of boards to take on to tackle all of those challenges that we've set out in the report and we set out a number of issues in there that need to be addressed so things like understanding the skills that are around the board table identifying where people do have additional needs that need additional support training and development assessment for board members to help them to do a good job so some of that needs to be done centrally there's absolutely a job there for government we've also indicated at paragraph 73 some of the other factors that might get in the way of board members doing a good job so we've seen examples of things such as board papers which are incredibly lengthy 600 pages of reports the time board members have to go through some of those reports non executives being asked to review all of that to help inform decision making very very challenging particularly given the context that they're operating within so we see real scope there for additional support to make sure that boards do have the skills experience time and the information they need to help inform good decision making Additional support from whom? Grant here Absolutely there's a role for government around that I think there is also potentially scope around support across the non executive group for example to support each other we know that they come together to get training and support for new non executive members on all public bodies in Scotland and there may be scope for some more joint work between the kind of as a peer support group but yes there's definitely scope for government to support more And just talking about that I think Claire Sweeney you're getting a kind of collaborative approach across the non-exec field we in this committee tends to see examples where boards have not perhaps performed quite so well just as a function of what we're here for presumably there are a number of boards who are you would say in your investigations of them that are performing well do you have quality members and would be exemplar as a good practice are you able to highlight any of those and are they being able to share that knowledge across the estate So yes there are examples of particular issues that certain boards deal with very effectively I would say that differs from board to board there's absolutely a place for government to think about sharing that good practice more effectively what a good board looks like how that operates, lessons learnt particularly linked to some of the issues that we've drawn out in this report where there are challenging decisions that need to be made So for example a degree of openness from boards in terms of showing how their board is performing how they engage with their local communities to help make some of those difficult decisions about the future that is variable across Scotland so absolutely there's scope to do more to share that good practice Clare Sweeney is government doing enough to facilitate that there's more to be done I wanted to turn to the workforce issues I think it's often easy to focus on the financial issues but actually in terms of day-to-day running of the NHS workforce challenges are a massive issue we often hear every time workforce challenges are raised a response from government that we have more staff than ever before is that the right measure we've done a range of work on the NHS workforce and particularly workforce planning given how critical that is to the NHS's ability to provide the care and support we all depend on it is true that there are more staff working in the NHS than ever before and that's not surprising given we're spending more on the health service and activity levels in general arising I think the real challenge is making sure that we are thinking not just about how we feel the vacancies are likely to arise but what the workforce is that the NHS and care services will need in future as these sorts of changes come through and the work that we've published so far has found that that workforce planning tends to be much more focused on the supply side than the demand side of the equation and really isn't taking that step back to say if we're reducing our reliance on acute hospitals and providing much more care near people's homes what does that mean for the roles of doctors and nurses allied healthcare professionals and so on So would you accept that the current workforce planning hasn't allowed for a staff base to meet demand and that the workforce planning that has happened today in terms of three separate publications of different parts of workforce plan haven't led yet to a comprehensive workforce plan that one looks at all parts of the national health service and secondly is an integrated plan that goes across all health boards and national strategy rather than individual health board strategies We published a report a couple of years ago on workforce planning in the acute sector and we've got a follow up report which looks at the rest of it and I think the finding of our work so far has been exactly that that so far it's focused more on the processes by which vacancies will be filled rather than stepping back and saying what's the overall demand likely to be and how do we best meet that So far we've seen consultant vacancies GP vacancies are up nursing and midwifery vacancies are up long term vacancies unfilled vacancies are up You mentioned quite rightly the risk of Brexit in your report Would it be fair to say that we have severe workforce challenges before Brexit but there's a risk that will be amplified by Brexit, is that a fair assessment? I think that's very much what the report says that you can see in exhibit 8 some of the workforce pressures in the NHS and they are all increasing we set out on page 21 before that the possible impact of EU withdrawal depending on what the terms of the deal finally are and we're not alone in that we see that again across the UK real pressures on NHS and care workforce partly a result again of the ageing population there are fewer young people coming out of schools and universities to fill the training places available and I think that just adds to the need to think much more creatively about what the demands of the future are and how we can provide the services that are required I'm not sure if Claire or Lee want to add to that The NHS is full of people who are doing a good job they're dedicated to making sure that patients receive the care that they need in a timely fashion I think that some of the challenges in the future are related to EU withdrawal related to difficulties in filling posts but there's also a slightly different question to ask there the extent to which there's a recognition services need to change that will inevitably need to change in terms of the workforce that are needed to do that so the jobs will be different the roles will be different there's always been a question about flexibility about generalists and I think some of those are really starting to gather pace now people are starting to think through what does it look like if we've got a different model of caring for people in our local communities what staffing, what support do we need what does that mean for social care services so I think all of those challenges are things that locally the IJBs and the NHS boards and the local authorities are starting to try and think through there is absolutely more work to be done around workforce planning to make bigger challenges I think The report also outlines an increase in sickness absence an increase in turnover and that looks specifically at the NHS if you looked at social care it would be significantly higher in terms of the sickness absence rate and the turnover rate where do you put that down to is that a connection between the financial pressures, the staffing pressures and then the impact that has on individual staff, clearly when he quite rightly says our staff go above and beyond and that's not a question of the individuals working in our NHS but what do you put that increase in turnover as sickness absence down to so it's very difficult to answer because it will be different in different areas of Scotland absolutely there'll be different things going on there we know that there's work underway to try and understand how happy staff are in their roles, what support they need to support them in doing quite often very difficult difficult jobs we also know that one of the other factors that can have an impact here is rural issues so in areas where there are very small populations the model has to be different the expectations on workforce is very different we know that it can be hard to fill key posts in some of those more rural areas across Scotland so there's a whole range of factors happening there and we know that boards have different activities under way to try and support their staff around that so the answer is yes there's still things to do there but the answers are very different depending on which parts of Scotland you're working in would be my sense of it I just want a quick question representative bodies have highlighted a concern that now when people leave posts there isn't advertising of that vacancy have you come across that at all and how that would impact on the vacancy rate you were talking earlier with Kirsty White about non-recurring savings that's one of the common ways that to delay filling a post when it becomes vacant now that helps the financial position it obviously doesn't help in terms of either providing services to the people who need them or managing the pressures on the remaining staff so does that mask the vacancy rate does that impact on the vacancy rate? they're included within the vacancy rate but it does affect the vacancies that have been empty for longer periods and you'll see in the report there are some quite high levels of long-term vacancies for doctors, for nurses as well Clare Sweeney, you talked about rural staffing and when we were taking evidence on section 22 report we discovered that there were two locoms in Caithness being paid £400,000 each locom doctors is that a financially sustainable way to fund to fund our NHS? so what we've seen certainly through this piece of work is some of the more innovative approaches that have been taken in some island, some very rural communities and I think the message is that the model needs to be different there so there's a job to do to think about what services are needed to support the local community how you can build that in a sustainable way the mix of staffing the focus of the way that those staff work might be very different and rural areas but yes it absolutely needs to be planned on a sustainable basis but that £400,000 being paid to one doctor are there any Scottish Government guidelines on this? how far can we go in terms of clearly there was a need to get a doctor into place there and the board felt it had to pay more is £400,000 a reasonable salary in the view of Audit Scotland so there's an issue about making sure that the needs of the local community are being met so whatever the service might be whatever the context people are working with there's a decision there to be made about whether the services are provided in that local area or whether there's a need to have more specialist services delivered in different boards and we do see quite a lot of movement across Scotland where people will go to a different centre a more tertiary centre a specialised centre to get care so I think again those are things that local organisations need to be thinking through very carefully how do they work with neighbouring boards what services are they able to provide on a sustainable basis in their local area on which parts need to be addressed through regionalisation which we know is starting to happen but there is more to do there Auditor General it's our job in this committee to follow the public pound is it reasonable that we pay one doctor £400,000 to fill a rural vacancy? There is no doubt that £400,000 is an awful lot of money for any board and for any individual to be receiving I do have some sympathy that our remote boards have to keep delivering services and if they can't recruit staff in any other way they have to pay the going rate to be able to fill vacancies in the short term in the longer term as Claire said it's imperative that they're looking at the way they provide services to make sure that it's making the best use of taxpayers money at the same time as meeting the needs of the local population Is £400,000 the going rate? I think what we see in these very remote areas where there is no alternative but an individual sometimes working through an agency who is being paid shift by shift across the year in ways that add up to a very significant amount of money across the piece we see that the amount spent on agency staff and agency locums came down in 2017-18 compared to the previous year I've got no doubt that health boards are trying to manage that down as far as they can and we see these instances where they end up with no alternative to providing the service than to pay the rate that the market is demanding None of us want to be in that position but at the moment without the longer term planning the alternative is not to provide that service The overall message of your report is that the NHS is struggling to be financially sustainable Is this £400,000 salary to one doctor not a very good example of that pressure? It's an extremely good example of that pressure and it's one of the pressures that we pull out in the report as a whole The challenge for the board, which I recognise is that if they aren't willing to pay that amount of money they have to pull back a service from a community in an already fragile part of Scotland That's why this approach to much longer term workforce planning and to planning how the service can be provided is essential to stop that isolated example being more common across the country Have you seen any Scottish Government guidelines on how high boards should go in terms of salary to get a doctor into post? I don't know if there are guidelines on what a cap might be Should there be? I don't know. I think that there definitely are initiatives to try and reduce the reliance on agency staff in general and agency medical locums in particular and we see the impact of that in a reduction of 10% on medical locums last year I think the solution is probably less about having a cap on the figure because that does run up the risk of not being able to provide the service and instead on making sure that workforce planning is sustainable in future but it has been in the just finished Willie Coffey I just start by looking at the relationship between the money that goes into the health service and the sustainability of it in the long term Your report in page 10 paragraph 10 shows quite clearly that there has been a real terms increase of 7.7% in the last decade in spending on inter-NHS Only last week the cabinet secretary announced an additional £3 billion would go in by 2023 and that exceeds even the Fraser of Allander's estimate to stand still but from what I think you're saying in your report it's not really all about money Do you think initially that that kind of level of investment to get financial sustainability or is it much more than that that we need to do? There's no doubt that the recent announcements from the cabinet secretary for health and in the UK budget are helpful The immediate financial pressures have tightened in the last year again and the announcements we've seen will build in a bit of breathing space to deal with them At the same time we know that the population will continue to age that brings its own pressures and we already spend 42% of the Scottish budget on the NHS, we can't keep on increasing that indefinitely so I think what's critical now is to use the breathing space that that extra investment has bought to really give a boost to the speed at which the government's policy of providing much more care in people's homes or in community settings is delivered that has to be the right way to go but to meet the needs of a population which is ageing and which expects different things from what our parents and grandparents expected but the pace at which it's happening isn't fast enough to meet the pace of the pressures as they ramp up I was going to ask about that in terms of when do you think it's reasonable to expect to see the fruits of the transformation process beginning to help us is it too soon at the moment to see the urgent action and leadership and all the correct topics that you've identified but when do you think it's reasonable for us to expect to see that transformation really having an effect? The government's policy, the 2020 vision has been in place since 2011 as the title suggests the aim at that point was that it would be in effect by 2020 now that's clearly not going to be the case we're now very close to 2019 and there's a long way still to go I think we're seeing the pressures on the NHS and on social care that we are we've published a report today on health and social care integration which is a key part of how government intends to deliver those changes and we say in that that there are some indications of improvements things like reductions in delayed discharges more people at the end of their lives spending time at home rather than in hospital which are very welcome more importantly I think they show that the changes can work now is for government, COSLA and the bodies involved to get behind that and start being much more systematic about how they learn from good practice and spread it providing that leadership for making change happen across the country and again engaging people in why the change is important why it's needed and why it's not just about cuts We mentioned that I think again convener at a previous meeting that the NHS can't do this on its own there are various partnership arrangements not least with various councils for example in Ersin and Arran there are three councils that are key players in that transformation strategy Do you get the sense that that's working as effectively as it should be in terms of this delivery you might actually say so in your report that you're talking about there but does that let me ask it another way does the pace of that change need to accelerate and be much more quicker to deliver those benefits that we seek The report version of today's report is that it varies there are some really good examples and it's not nearly widespread or fast enough and many of the things that we think are needed are the same things that I described in response to Mr Neil's question earlier it can be done it's not happening nearly fast enough to relieve the pressures that we're seeing in the report before you today Last question then your report says at the moment that the NHS is not in a financially sustainable position as complete as we can get get close to that do you think ultimately that strategy will make the NHS in Scotland financially sustainable because if it doesn't we need to think of something else don't we We think it can do we've said in this report and in today's report that we do need that longer term planning including financial planning it may be that there's some pump priming investment needed in some areas of Scotland to get from the current model to where we need to be the indications are that for the Scottish Health Service and much more widely across developing countries that's the way of squaring the circle of increasing demand and changing expectations we need to make it happen more quickly than it currently is Bill Bowman Thank you, convener In paragraph 67 of your report you discussed the dual role of the director general of health and social care and the chief executive of NHS Scotland in particular it points out that as chief executive that person will be responsible for the day-to-day performance of the NHS and for implementing Scottish Government health policies however as director general they will be responsible for holding the NHS to account for its performance and how well it has implemented Scottish Government policies now whether or not there's a real conflict there seems to be a perceived conflict there how should that be handled and the scale of how it's resolved is a matter for for government, for the cabinet secretary to think through I do think that A, it's a very big job given the scale of the challenge and B, there is this tension between running the health service as it currently stands and being accountable for its performance and thinking about how it changes in the context of integration working with councils and a range of other partners there are clearly different ways in which it can be done but I think combining the two roles in the one person makes it a very big a conflicted job to be carrying out in practice So I would take from that that maybe they should be separated I think that's one of the options but I think that's very much for the cabinet secretary to be considering how she wants to deliver this What other options would you suggest might be there Well we've talked in response to Mr Neil's questions about the way in which governance of the NHS and care has changed over recent periods we now have formal statutory roles for the integration authorities alongside the health boards and councils there is no question about where that accountability sits in other places there is a separation instead between policy and delivery that's an option there are options that could be considered here which I think are all about thinking more seriously about the health and care system as a whole rather than the NHS as one part of that Coming back to these roles and you've spoken about the need for good leadership are we getting good leadership from these roles at the moment? I think they are very difficult roles to carry out given the scale of the job and the scrutiny under which they come it's made more difficult by the number of jobs we need to fill and we know they're increasingly difficult to fill all of that's making it harder Claire would you like to add a bit to that based on the work you've done in this area So I think partly the answer as to why they're difficult to fill is exactly those points all of the issues we've talked about It's not to fill the role but how it's being executed at the moment those roles are being fulfilled at the moment for sure and it is very difficult to build all of those very good senior teams given the number that I need to be So there's one person at the moment who's doing both roles Sorry, you're asking about the Clarity here I think Ms Sweeney's talking about chief executives and health boards and I think you're talking about the chief executive of the NHS in Scotland Mr Bowman can you rephrase your question Do you have these two roles you've had comments about leadership and the need for good leadership So I was asking whether these two roles and perhaps the one individual is giving good leadership at the moment So the messages in the report and in the report around integration which highlight the challenges and the things that are working and not working in the system more generally apply equally to government as they do to the rest of the system and the team in the Scottish Government around this policy area the messages in the report about the need for the need for clarity about what is trying to be delivered and the difficulty in recruiting to some of those top leadership so I'm not answering the question about that post particularly I'm talking about that top team government some of those challenges equally apply there as they do to the rest of the boards that we've been looking at through this report today I was just trying to get a view as to whether the top leadership here is working It's entirely fair to ask what it's got that question but I think we've had a good go at answering that I'm going to move to Alec Neill I just want to quickly come back to the questions asked by the convener because we touched on this the last time we discussed the national health service about in this case the two individuals in the Highlands getting £400,000 can I just clarify include the agency fee because I think you were going to send us a letter We are drafting a letter we are still in the process of trying working with the board to understand they have sent us some figures but we didn't feel it was clear enough so we are just seeking further clarification and we will get a letter to the committee It's a fairly simple question how much did the doctors get and how much did the agency get because these private sector agencies that I tried to do away with when I was the cabinet secretary they are a bunch of rip-off merchants of the first order and it's ridiculous the fees that they are getting so I think that's quite important I mean it's bad enough that we're paying £400,000 for jobs that are not worth anything like £400,000 and I think we also maybe need a better understanding of why the Highland board felt the need to pay that level of funding for locums Having been the health secretary I fully understand the challenges and I'm not suggesting it's easy but I think can audit Scotland's supply us with more details fairly soon both in the agency fee and any other costs associated with that as well as more detail of the circumstances in what the health board tried before they reached the decision they needed to employ two people at £400,000 plus agency fees presumably We can seek that additional information and put that in the letter that we have agreed to get back to you What's the timescale for getting that information to us? Clearly you've started that work but... Yes we have We're just waiting on a response from the board the agency fees are on top of the salary that's clear what we're just trying to clarify is exactly how much that agency fee was I think your response will be very helpful but of course the committee can go straight to the board as well which is something that we'll want to consider. Ms Johnson in the information you have received so far you must know which agency this is can you tell us that? I can't off the top of my head recall what the agency's called Okay so can you give us a timeline by the time we'll get this information? We're just as I said waiting on a response from the board so I will try and hurry that along when I get back and get back to you within the next couple of weeks Well two weeks I mean it shouldn't take two weeks I mean all it requires is somebody to look this up it's basic information I would have thought we should have that information by the start of next week two weeks is a ridiculous time to wait for basic information I mean the must of the information ready to hand let us hear what the information is and let us see how much money has been wasted on agency fees We will convey the committee's urgency to Highland to NHS Highland obviously it's their information rather than ours and we'll come back to you as quickly as we can I would remind the committee that we're still undertaking scrutiny of the NHS Highland section 22 report and this could be something that we've raised in that scrutiny Liam Kerr Very briefly if I may or just general on that point just a bit of a dafflady question if you don't mind Do doctors, do nurses do healthcare professionals ever come out of practice and set up their own locum agencies to supply themselves back in to the NHS I think some of the agencies which provide healthcare workers were set up by former nurses I'm aware of some former nurses and I suspect former doctors but they tend to be larger organisations now because of the extent to which they can generate revenue from the health service we've reported on this as an issue in its own right in the past that one of the risks of poor workforce planning is that there are incentives for people to work for agencies rather than for the health service in ways that are not in the public interest it's why good workforce planning is so important Indeed, thank you Anas Sarwar I want to turn our general to the targets or you could call them patient treatment standards the report makes clear that only one of the 28 key performance standards has been met across Scotland not a single health board has met all their standards the cabinet secretary in response to the report in the chamber said that the report didn't take into account the new waiting times improvement plan I presume that is the case because you're not making an assessment on the future you're making an assessment on the past and the here and now but we've heard after previous reports that there is a plan in place from government to get to grips with the treatment waiting times but still year on year it's not happened, it's not worked is it safe to say that previous years planning has failed? There's no doubt that it's become harder and harder for NHS boards to hit the eight key national standards over recent years for all the reasons we've been discussing and achieving that will remain difficult while we're seeing this sort of combination of financial pressures, demographic pressures and a focus on the quality of care which we all understand we have also in our work reported though a concern that the national standards only look at one part of the health and care system they focus very much on acute care and don't look at what's happening within primary and community health services let alone social care and one of the messages that I've been trying to convey through our work is the need to look at the system as a whole to understand not just whether the national standards are achievable but what the impact of those standards are is on waiting for other parts of the system which can often be the answer to prevention and to reducing the pressure on the acute system I agree on measures in terms of holistic care across all sections of the NHS but just focusing purely on the acute sector this includes targets for example around cancer waiting times and we know the earlier you diagnose, the earlier you treat you have of survival so they're very crucial standards and targets they've got worse year on year for how many years and secondly do you accept that the actions that have been taken by the Government to improve those treatment standards have failed the information on performance over a number of years isn't captured in this report directly we have reported on it previously and Kirsty may be able to help you with it I think what we're seeing though is another example of the pressures on the health service and there is no quick answer to that which doesn't involve looking at the system as a whole these obviously matter to patients you talk about the cancer waiting time standard is very important to the people affected A and E waiting time matters to people for all sorts of reasons but if we are simply looking at the acute system we're not looking at the opportunities for treating people at home rather than admitting them to hospital which may not be the best place for them to break down their support systems and we're not looking at the investment that's needed to avoid unnecessary admissions or to treat people in more community-based ways which would be better for them and meet their own needs better so you can't answer the question without looking at the whole system which the national standards don't do and just on the treatment improvement plan there is a three-year plan to get to the targets where they are set now in future reports will the report measure against the interim target set by the cabinet secretary or will it be measuring against the actual target the actual standard what we have tended to do in the past is to measure against both so in the past we've had the targets and the standards we've tended to measure against both of those and provide that detailed information that gives people a sense of the direction of travel as well as the performance in the year thank you again very briefly for my auditor general just in response to Mr Sarwar's question you talked about the pressures on A&E I'm just looking at page 17 of your report emergency admissions have increased by just less than 1% in 2016-17 now given the figures here and you'll appreciate I'm working very much on my feed here but that's only about 5,000 a year and I think we've got 14 NHS boards so very basically that's about one case per day per board increase in A&E now I appreciate it's dam license statistics because it's across I'm going across the piece rather than targeted but nevertheless that's not an enormous increase in A&E and it's fairly consistent thus it can be planned for and thus when you talk to Mr Sarwar about waiting times presumably it can be addressed just to be clear the figure in the exhibit on page 17 is emergency admissions not A&E attendances so a lot of people attend A&E who are treated and return home or treated somewhere else referred somewhere else from there so there's a slight difference between the two things that you were touching on in your answer Claire, did you want to add to that the national picture for emergency admissions? I think the general point which the committee might be interested to explore a lot more in terms of the integration report about the impact that integrations have on more generally because this is one of the areas that integration was intended to improve I was just reflecting on one of the questions we've been asking ourselves when we've been looking at the data this year is the pattern of rising demand and a seemingly slower rate of increase in terms of throughput so people coming into the system being treated and coming out the other end and it's not clear why that's the case we've been asking ourselves the question does that mean that demand is continuing to increase but actually the system's got as hot as it's able to get so actually they're not able to get through some of the numbers that they were able to get through previously so I think there's a whole load of interesting questions in there and the only other thing I would mention is that we continue to find it quite difficult to get really good data around in acute hospital and we know that even for the data measuring things in acute hospital setting the definitions about what's countered what's not countered the focus there's a need to improve some of that so for example understanding when people come to hospital with an emergency how they're categorised how that compares to what's happening in other hospitals we've published reports in the past about accident and emergency activity and we've found it very very difficult to be very specific about what that activity actually looks like in practice so there's something around the data that needs to be thought about here as well and again just if I may stick on that point so going back to Gavina's question from earlier who should be leading that data capture is this again you said earlier Clarys we know that government has quite a big role here is this something where government should be stepping in and saying we need better data so there's absolutely a role centrally to think about how all of the boards just captured that information what categories they use what the priorities might be but again it's not just for the boards to do increasingly we see that the system so interconnected IJBs have a really important role you really need to understand to a much greater degree social care related issues so yes there's a job centrally to be done but it's actually all of the agencies that need to work together ISD who are responsible for a lot of these statistics to be involved in that conversation as well so yes there's a role centrally in terms of consistency and agree and what the focus will be but actually it's far more a partnership ende than it's ever been before I don't think it's possible to sit centrally and say this is the answer we'll count X, Y and Z to the exclusion of anything else I think there needs to be more of a collaborative effort there Willie Coffey Was this to ask about public satisfaction in the NHS and I can remember a previous support where you touched on that and it was quite high then and I think it still remains quite high can you confirm that despite the challenges and the pressures that we all know about public satisfaction with the overall delivery of NHS services in Scotland is pretty high Yes on page 20 we try to pull together what information is available about patient satisfaction and in paragraph 43 you're right 90% of patients in the 2018 inpatient survey rated their care and treatment as good or excellent which is similar to the 2016 survey 91% of people were positive about their experience of hospital staff which again is slightly up on 2016 but there are some indicators that that's under pressure as always in this there's never a single straight forward picture the percentage of patients rating the quality of care provided by their GP declined to 83% in 2017-18 and people more generally felt they weren't getting the opportunity to involve the people close to them, their families and friends in treatment where they wanted to do that so it's a mixed picture and we also know from surveys of staff that staff increasingly feel their time to provide the sort of care they want to is under increasing pressure I think you can see that in the exhibit exhibit 8 which gives you again that sense that people are doing their absolute best but it's becoming more difficult to provide the quality of care that every healthcare professional would like to what does that tell us if people's satisfaction rates are very high but we don't meet particular targets in a range of areas what kind of messages is that giving I think it tells you it's complicated we know people really value the NHS we know that they recognise the efforts that most staff are going to to provide the best care they possibly can patient satisfaction in the NHS tends to be high almost whatever the experience of people is on a particular occasion and it's becoming more difficult it's a tribute to NHS staff that satisfaction rates are that high and I think we can't expect the levels of intensifying pressure to be maintained indefinitely something has to be done to address the underlying causes thank you thank you there are a few worrying aspects of this report, Auditor General but I was particularly interested in the estates you say there's a backlog maintenance of 900 million on page 16 but the capital budget has reduced by hopping 32% over the last 10 years is this wise given this level of needed maintenance in our hospitals one of the main messages of the report I think is that we do need to see the Government coming up with a clearer capital investment strategy to be able to make the changes that are required I'll ask Kirsty to tell you a bit more about the detail of the picture can I just clarify just what you said there you said the Government needs a clearer investment strategy but in your report you said that the Scottish Government has not planned what investment will be needed do they have any kind of planning of capital maintenance investment that's needed in hospital and community health buildings I think what's quite good in the health service is the survey of the condition of the estate and the investment that's required to maintain the estate as it stands what we're not seeing is that strategy for what the estate buildings and clinics and so on will be required for a new type of health and social care in future and Kirsty can tell you a bit more about that if that's helpful thank you Kirsty I suppose the first thing to say is that the capital budget has always ebbed and flowed depending on key investments coming forward such as big acute hospitals what's interesting is that the overall trend is a cut in 32% over the last 10 years is that correct you might need a new hospital in Dumfries, Edinburgh and Glasgow what's interesting is that every year boards produce a the survey of the estate and they have to provide a report talking about the performance of the estate and they have to provide an asset management strategy in that they set out what they think they need their capital investment to be over the next 5 years the most recent report on that boards thought they needed 3.3 billion of planned investment over the next 5 years now that's boards own assessment and that's added together to come to that figure obviously we don't know what the capital budget 3.3 billion in 2 thirds of that are acute and then the rest is very different assets obviously what we don't know is what the capital budget will look like going forward that's why we've said it's really important that the government has a national capital investment strategy Scotland's fiscal outlook published in May predicted that the capital budget may remain relatively static the NHS is obviously only one element of a number of other public sector services that won't need capital therefore it's really important that the new projects coming forward the capital budget is used strategically to continue to drive that change Auditor General If I understood you correctly I think you said that the Scottish Government is aware that investment is needed just to bring our buildings up to a standard that are acceptable now but there is no capital investment planning for what a future health service will need to be in terms of health and social care integration is that not really concerning how are we going to be able to deliver that future service if we don't have the buildings and infrastructure to do so I think it's a really good question and it's a question for the government in a sense it has to be part of this more detailed strategic planning for what the health and care services of the future will look like in terms of what it will cost what the workforce required is and what the capital investment required to get there some of the buildings we've got now may well be able to be used for a different type of healthcare in future GP surgeries and primary care health settings in other things to be able to provide healthcare differently including technology having that investment strategy is one of the really important things that are required to make progress with the 2020 vision and to get from where we are now to where we need to be in future Thank you very much Do members have any further questions that they'd like to put to the Auditor General and to her team? I mentioned how can you plan for the long term if you have such a high maintenance backlog just now a £900 million maintenance backlog 45 per cent of which is high risk or significant what's the answer to that? Auditor General what's the response to government to that? That's just a staggering statistic I think it is very much a question for government there is no doubt that choices have to be made always between different priorities within the NHS within health and care and across the Scottish Government more widely we need to be balancing the investment that we make in today's hospitals and clinics with what we need for the future and we need to be thinking about what impact prevention could have if we go further upstream so you do need to be looking at it in the round what we've done is give you a sense of the challenge that the Government's facing Can I thank the Auditor General for his evidence this morning and now close the public session of this meeting and move into private thank you