 Ysbyt Cooky, fel Llifon antiwion Robert Lawsson o Dimhau, accessory popeth, gyda girmoch Nôl gym, Llywydd, ac tyfu yn wrtheddfa. Mae rhaglen i mwy etcwm iaith i gael iaithiau. Dech chi'n gwneud i gael ia速, ddigonwch i dribeoli mwy lleid, ac yn llag i ganlŷnnau gennym arenau of March in private, our members agree. I now continue our next agenda item is to continue our scrutiny of the patient safety commissioner Scotland Bill, and we've got two evidence sessions this morning. The first session involves representatives from industry bodies and professional organisations relating to patient safety. Then the committee, after a short break, will hear from the the Patient Safety Commissioner for England, a number of members thought that that would be useful. For the first panel, I welcome to the meeting Dr Amit Agawal, the Executive Director of Medical Affairs for the Association of the British Pharmaceutical Industry. We have Sean Galhar, the director of strategy and policy for the general medical council, or the GMC's, we'll call you. Matthew McClelland, the director of nursing in Medoferty Council, and Dr Chris Williams, the joint chair of the Royal College of General Partitions in Scotland. Joining us online, I welcome Richard Phillips, the director of strategy for the Association of British Health Tech Industries. Good morning to all, and I will do my usual and with the caveat that not every member will be able to go round the entire panel for every question, or else we would be here all day. I tend to like to start with that opening question and allow everyone to state their case. On your general views on the establishment of a patient safety commissioner, and would you think that the patient safety commissioner would add in value in terms of the existing scrutiny mechanisms that there already is for patient safety? So, I will start with Dr Agawal. Thank you very much. Thanks for the opportunity to contribute today. I'm here on behalf of the ABPI, which is the UK trade association for the innovative poverty-based pharmaceutical industry. I myself, I'm a physician by backgrounds being an industry for 15 years, the first one and a half years, which was in fact in farm provision and sort of drug safety. So, I have a good impression first hand of how important, how importantly the industry takes the issue of patient safety. To answer your question more directly in terms of the value of the patient safety commissioner for Scotland, when we say this really as an opportunity for a sort of uniquely patient-centric wider systems-based approach to signal detection, what do I mean by that? Industry and regulators are really good at collecting, collating information from a wide range of sources from patients, from healthcare professionals, and looking for signals that affect the safety profile of the medicine, that affect the benefit-risk balance. But traditionally, that signal detection has been very much geared towards looking at the medicine, the chemical, the compound itself. And we know that there are many other factors that affect the benefit-risk balance of the medicine when using an individual or group of individuals, for example, pregnant women being one such example. And while I would say the system is now better at taking some of those other prescribing factors into account when assessing the benefit-risk balance, but it's still not perfect. And I think that's where a patient safety commissioner can add real value by taking that wider patient-centric systems-based approach to signal detection and in so doing investigate accordingly and make recommendations. It's also an opportunity for the patient safety commissioner to give sufficient weight to anecdote that was cited in Baroness Cumberlidge's report as quite often being dismissed as mere anecdote. But the patient safety commissioner can give weight to that anecdote, again in a systematic, evidence-based and objective way, and therefore set priorities, which are important to patients, important to the public. And that's fundamentally where I believe the value of the role is. And I think it's a real opportunity to fundamentally alter the landscape of patient safety for the better. Thank you very much. Mr Gallacher. Okay. Thank you, convener, and good morning to everybody. It's good for us to be able to give evidence to the work of this committee. So I'm Sean Gallacher. I'm from the General Medical Council. We are the statutory regulator for doctors, and we operate UK-wide. And our fundamental purpose is to protect patient safety through the regulation of doctors' education and practice. Like Dr Agarwal, we very much support the establishment of the patient safety commissioner through this bill. And that's mainly because of the evidence that we've seen from plenty of inquiries and reviews and instances of healthcare concern, not just from Baroness Cumberlidge's review, that the voice of patients is still often underrepresented in the way in which the health and care system operates. So we think a commissioner can bring a very useful role in amplifying that voice and strengthening the voice of the patient throughout the system. We do have some suggestions or views about where the bill could be strengthened. I'm sure we'll come on to those during the course of the discussion. Okay, but we will. I mean, you're mostly welcome to do it now, but if you want to wait, then that's fine. If I could just give you very quickly three things. Yes. One is we think there are further steps in relation to the principles that the bill requires the commissioner to have that there could be an open and full consultation on those, mainly to address the concerns that I know many have had about cluttered patient safety landscape and duplication or ensuring that the role fits in the most effective way and adds value. So that's the first one. The second, probably the key one for us is powers of data sharing and just checking that the commissioners powers are set in the right way to enable sharing of data, particularly with us as a professional regulator. We think it's a bit constraining at the moment compared with other organisations of a similar kind. And then the third one is a relatively small point, but the powers in relation to asking organisations to report on how they have implemented recommendations that have been made seem like a one-off, one chance rather than the opportunity for the commissioner to revisit and review on an ongoing basis. So those are the key things. Thank you. Very helpful. I'm glad I asked you to continue. Matthew McClelland. Thank you, convener, and good morning, colleagues. Thank you very much for the opportunity to talk this morning. My name is Matthew McClelland. I'm director of strategy and insight at the Nursing Midwifery Council, where the statutory regulator of nurses and midwives across the UK, and we regulate around 72,000 nurses and midwives in Scotland. Like colleagues who've already spoken, we very much welcome the bill and the establishment of the patient safety commissioner. It's a real opportunity to amplify the voices of patients and to take a system-wide approach to improvement, which we very much welcome. I think I absolutely endorse the points that Sean has made about areas for potential improvements to the bill, and I would just add one to those, which is making sure that the commissioner is able also to take account of social care landscape and how that might evolve in the future. We think that's very important for people who use services to have that wider view across social care as well. But yes, very much welcome the opportunity to talk with you this morning. Good morning. The RCGP Scotland has consulted with our Scottish patient forum around this. We are, along with our patient forum, very supportive of the proposals to have a patient safety commissioner. We do think that this allows an opportunity to create a more open, just transparent environment for staff to be able to, for health workers to be able to to help to progress issues that are sometimes difficult to progress in the current landscape of patient safety support, so that there are multiple organisations and frameworks that are involved. Currently, I suppose, what this affords and allows and enables is some further advocacy that doesn't exist at present, and to, again, I think, picking up on earlier comments, to put weight behind individual and collective patient voices. I think that with patient safety issues can often be complex. There can often be multiple things that are happening simultaneously that combine to create real harm, genuine harm, and to be able to understand what is happening, that, again, data will be a key part of being able to tap into different sources of data. So the ability to open to commission investigations, the ability to compel people to provide information is very interesting and, I think, an opportunity that we haven't seen before. So, again, RCGP Scotland is very supportive of the scope and the broad scope of what is being proposed here. Just to pick up on what you were saying about the investigations, but individual voices, do you support the rationale of it not being about taking on an individual case as such, but having it being, we'd be prompting a wider investigation? So, I suppose, the way that I and RCGP Scotland would view this is about the patient safety landscape rather than the complaints landscape. There are methods for individual cases to be raised for questions to be asked of different healthcare organisations. I think that establishing this office then allows a broader approach to be taken across different organisations to be able to scan the horizon, to be able to spot emerging problems or issues that people can describe, but that might not be at the surface in terms of what's being looked at. I'm going to bring in Richard Phillips and then Sandesh, which is why I want to pick up on what some of the points you're saying, but I think it's important to get Richard Phillips, so don't feel left out, particularly when you're online. I haven't forgotten about you. My first question, your general views on the Patient Safety Commissioner, Mr Phillips. Yes, thank you, convener, and, like everyone else, I'm very grateful to be with you this morning, and I'm trying to assist you in your work in this inquiry. Please accept my sincere apologies. I'm not there in person. I have a school-aged daughter, one-half to him, a 17-week-old puppy, and my wife is away on a course this week. We have no family, so it just wasn't practical. I'm Richard Phillips, director of strategy from the Association of British Health and Care Industries. We represent the manufacturers and suppliers of medical devices, diagnostic and digital health technologies. We have about 350 members out of the sector, which has about another three and a half thousand companies in the space. Many of those are small and medium-sized enterprises, but the vast majority of small innovative companies develop in solutions often in close working partnerships with clinicians. We are essentially an engineering industry. I don't disagree with what anyone has said so far. I'll try and perhaps give a slightly different slant on it and maybe give you some thoughts about how some of the bill might be strengthened from what some of my colleagues have said. If you read Cumballage, what is the essence of Cumballage? I think that this came up when the transcripts of your last session were that the heart of it is about people not being taken seriously and women not being taken seriously. That chimed me very personally from my own life experiences with the experience of my mother up to the point of the death. My wife feels like a lot of women are experiencing a lot of inflammatory-based conditions as a result of childbirth. She hasn't been taken seriously. Reading Cumballage really chimed, although that is tragic in itself. It is also a problem because it causes people to lose confidence in the use of medical technologies and the use of systems that are in place to protect them and keep them safe. I think that voice is really important. We are welcome and delighted that we have a patient safety commissioner now in England. We look forward to working with the commissioner in Scotland once that has gone through an injured course and following an injured process. The other role that a patient safety commissioner can play is to encourage a growing up conversation about the risks and benefits of medical interventions. No effective medical intervention is completely without risk. We have to recognise that that is a difficult conversation that many of us have when we are in front of a doctor and we want to be helped quickly, pain-free and risk-free. We are also recognising that the balance of the appetite for risk may shift depending on your own personal circumstances, your age, the condition that you have, et cetera. We saw that in the pandemic with people who were willing, including myself, to be vaccinated very early on. There is also something there about innovation being incremental. There is not often a big bang explosion that changes clinical practice overnight, but there are particularly medical devices. There are small steps that, over a period of time, add up to a big change in clinical practice and on patient care. We will give some examples if that is helpful. However, there will be a conflict to that. If you look at the Government's response to the MHRA's consultation on medicine and healthcare products regulatory agency's consultation on their new programme of work, it talks about five pillars. The first two might illustrate that potential conflict. The first one is quite rightly strengthening MHRA's power to act to keep patients safe. The second one is to make the UK a focus for innovation to be the best place to develop and introduce innovative medical devices, and that is writ large in our life sciences strategy. I am very conscious of time and I have members wanting to ask questions. Apologies, Mr Phillips. Can I bring Sandesh? She wanted to pick up on something. It was just what the convener was saying, Dr Williams, about individual cases. I appreciate that there are lots of different ways, but do you think that maybe hearing and logging individual cases to maybe find the golden thread that runs through them might be a useful thing for the commissioner to be able to do? There are some systems that we have already that attempt to do that, but I do not think that that extends globally across our healthcare system. I do not think that it extends well across the primary, secondary care boundary, for example. In general practice, we put a lot of information together. We record a lot of information across a patient's lifetime, but being able to tap into what is happening in individual episodes of care or how different conditions might overlap or cause an unintended outcome is important, as you say, to be able to have some sort of logging process or ability to keep track of things that are potentially incidents, potentially harm. Within individual practices, we have significant event analysis, so when we know that something adverse has occurred, we can look into that and try to unpick what has happened on an individual basis, but sharing that learning and being able to pick up on the possibles, the probables and the maybes also has value. The speed of response and being able to intervene at an earlier point to raise the profile of something that is causing harm and to be able to strip that out would seem a large benefit that is waiting to be realised. I will move on to, specifically, to medicines and medical devices. Gillian Mackay. Can I come to Dr Williams first? How can the Scottish Patient Safety Commissioner complement the work of the patient safety commissioner in England and the MHRA, and how does that interact with the work of clinicians up here? As technology progresses, we have different materials used, different devices and different ways of using drugs and medicines that were used for different purposes previously. So there are all sorts of small changes in practice that can overlap, that can accumulate. These different organisations provide different forms of oversight or can bring different bits of information together. It has already been mentioned the importance of the data that might be collected for one purpose, also being used for other legitimate purposes. I have a slight fear about the length of time it might take to develop a level of expertise around what data is being collected, what information sharing agreements are in place, what memoranda of understanding exists between a new organisation and multiple other organisations that they will need to interact with, to interface with. I think that there are different places where expertise will be held. I think specifically with the patient safety commissioner that advocating for patients I think that there will be an ability to focus on a specific issue or area and go from topic to topic and highlight instances and work between agencies to raise an issue and allow somebody with the relevant expertise to look into that. Do you think that there is any potential for conflict in that relationship and potentially overlap in some of that oversight between the two commissioners in that interaction with the MHRA? I think that there is a potential for crowding. I think that conflict will be avoidable. Again, a memorandum of understanding can help two organisations to know what complementary roles they might have. That does not mean that they will not be working in the same space, but my thoughts would be that this sort of office would very quickly mature and very quickly find where the boundaries naturally sit. Just on the topic of overlap with MHRA, I think just being really clear, the regulator and the powers regulator have is very much tailored around the licensing of the medicine. There are many facets that go with licensing in terms of how it is described and restrictions and all that kind of thing, but the patient safety commissioner, in terms of their role, the licensing is one aspect of it, and there are so many other parts of the story that make up a good prescribing decision and an appropriate prescribing decision. Education of healthcare professionals, education of the public, how that education interfaces. I think that the patient safety commissioner can again have that overview. Yes, the interaction with MHRA and how they govern the licensing is a really, really fundamental important part of it, but it's only one part. If there is a bit of overlap, that's okay, because I think in terms of the powers that patient safety commissioner has in terms of powers of sanction, they are distinct from the powers that the regulator has, so I think that in terms of the danger of further overlap, I'd be possibly less concerned about that. Are there any areas that any of the panel would like to see, including in terms of medicines and medical devices in the remit of the patient safety commissioner that are not already covered by the bill? Maybe to take silence is no, convener. I suppose that I might just highlight the area of software and the advances in technology where we're seeing that once there's decision support being enabled by devices, by systems, once information is being not only manipulated and presented, but when there's a system that helps produce or prompt a specific course of action, that's a more recent, more modern area of focus that we've had to grapple with both ethically and professionally. I think that's certainly an area that the patient safety commissioner will need to give thought to. Lovely, thank you very much. Dr Williams, I seem to be picking on you, sorry, but one of the things the RCGP said in your submission was the interface between primary secondary care is where half of all errors and problems occur, and certainly something you touched on in my opening question to you. Just as an example, when I was in GP last week, I had a patient come to me telling me all the things that the hospital had said and done to them, but I didn't have a discharge letter to tell me anything. I knew less than the patient did about their care. Could you give us some further examples of the problem between primary and secondary care interface and also exactly what you feel the patient safety commissioner can do around this area? Yes, so I think you're exactly right to highlight that the communication between primary care and secondary care often has deficits, and some of that can be around the format that that communication takes, that somebody might spend several days going through an emergency admission to a hospital. There might be all sorts of different professionals involved, all sorts of different discussions, scans and other tests. The information that is then relayed at the end of that might have been carefully summarised or distilled down, but we often have a sense that more has happened during that period of time than gets handed over. We're also not yet at the stage where patients can check what their summary medical information contains, for example, or even what their up-to-date contact details are in terms of the different organisations that are looking after them. We're still in a place where people who are receiving care and who are carers for those who are in our health system don't have that level of assuredness or ability to check things that are being done on their behalf or being done for them. That's something that the Patient Safety Commissioner might want to pick up on in multiple instances across the board and to improve the use of information, the communication that happens between different parts across those interfaces where we know that, if you're looking for error or harm, that's where it may occur. Thank you, convener. Just a quick question and good morning to everybody. I'm thinking about the remit of the Patient Safety Commissioner. Sometimes the impact of care or unsafe care is not directly or overtly evident. In the remit of the Patient Safety Commissioner, Dr Williams talked about advocating for patients. I'm thinking about advocating for a group or a population where harm has occurred related to caring and maybe lack of compassion. It's not really directly safety-orientated. Would you expect the Patient Safety Commissioner to have a wider remit where harm might not be overtly caused in a certain patient population? I can think of lots of instances where someone has received poor care where there isn't a patient safety issue or where they have been let down, disappointed, where they haven't had a good experience. I suppose that, with patient safety being something that, as a medical profession, in terms of the broad range of clinicians that have enthused about patient safety, that have tried to bring in improvements and yet still here we are with patient safety issues still occurring regularly. I would think that the work ahead of a patient safety commissioner is so substantial that I would hope that they would be able to focus on the patient safety elements, although I appreciate that there are all sorts of poor healthcare experiences that we want to eradicate and improve upon. I would take a slightly different view from Dr Williams in the sense that there is a very close link between compassion and safety. In particular, we are listening to patients and to people who use services. I absolutely think that there is scope for the patient safety commissioner to take a slightly broader look at things. I do accept and absolutely agree that there are some things about service delivery that might be better dealt with through a complaints mechanism, but where there is a systemic lack of listening and lack of compassion, there is a really strong link to patient safety. Therefore, I think that it is absolutely crucial that the patient safety commissioner is able to take those issues on and look at them and make recommendations for improvement across the system where necessary. Can we then move on to talking about the voices of staff in this and questions led by Paul Cain? Thank you very much, convener, and good morning to the panel. I think that in the evidence we have seen a large degree of support for that patient voice, but I think that it is important to explore the idea of staff voice in this as well. Particularly in terms of whistleblowing processes, providing a safe space for staff to communicate their concerns, and also to add to the intelligence perhaps of what a patient is saying in this process. My initial question would be, do you feel that there is a place for that in terms of the role of the commissioner and engaging with staff in that way? I would perhaps ask Matthew first to comment, if possible. Thank you very much. I think that there certainly is a place for the views of staff in this because, of course, many staff, nurses and midwives, in particular, from our perspective, are dealing with patients, people who use services all the time, and are really well placed and trained to advocate for patients and people who use services. There absolutely is a place within what the patient safety commissioner does to hear those views. I come back to the sort of wrong seal approach. It is the patient safety commissioner, and therefore I think it is really, really important that the primary voices that the commissioner hears are the voices of patients and people who use services. There are routes that exist already for staff, and we are very clear as a regulator, as are others, that openness and learning are absolutely key to patient safety. Colleagues have a duty to speak up when something goes wrong. We have developed joint guidance with the General Medical Council on that point. We also acknowledge that it is not always easy for people to raise concerns. We have guidance that we provide for colleagues to assist them in doing that. Then, as I say, there are various routes where a prescribed person under the whistleblowing legislation says that people have a measure of protection when they come to us, as they would to the Healthcare Improvement Scotland and other organisations. I think that it is quite important, as it will be in all of the commissioners' work, to look at the whole landscape, to work out what the right routes for people to raise issues are, and for the commissioner to be able to listen to a range of views and really focus in on the things that are important to patient safety. That may include voices of staff, but I would not see that necessarily as becoming a primary route for colleagues to raise concerns, because I think there are existing routes that might be might be usefully continued and exploited. Thank you. I wonder if Sean might want to comment. I do not want to repeat things that Matthew has already said, so an awful lot of what he has just said, I would say, absolutely reinforce that. I suppose one of the things that I believe your hearing evidence from Henrietta Hughes later today, and that may be a worthwhile question to pursue. I know that one of the things that she has set herself as an objective is thinking about the culture in healthcare organisations that supports patient safety and what that means that she can press and encourage in healthcare organisations to think about the voice of the patient. That may well include organisations' ability to create safe environments where staff feel able to speak up. That is a really critical indicator for safety and effective care for patients. Certainly, if you look back at inquiries and reviews and instances that have happened far too often, it is clear that people did know that there was something wrong among the staff, the professionals working in the service itself, but they did not feel safe enough to speak up. That is a critical issue. As Matthew has said, it is absolutely central to patient safety. However, how much of the time and energy that the patient safety commissioner can give to that, rather than trying to pull out the voices of patients that are less heard, is a tricky balance to pull off. If I can, I think to perhaps expand that to Amit in terms of, I suppose, should we explicitly include hearing from people from the pharmaceutical and healthcare industries? Should the commissioner be looking to engage with those industries in terms of trying to understand the bigger picture of often what can go wrong and how essentially we can make moves to prevent that? I think the patient safety commissioner, I think it is a really good opportunity to engage with industry. I mean, there are obviously many people working in with an industry, working with an R&D, with an drug safety from the provision itself. So there is a rich resource with an industry that the patient safety commissioner can draw on and learn from where necessary and industry stands very much ready to work with the patient safety commissioner. Also very mindful of the independence of the role of the patient safety commissioner and so very happy to engage on his or her terms as they deem appropriate. But I think just to reinforce the points already made, the scope absolutely has to be, focus absolutely has to be the patient voice. Yes, where there are, if there were concerns raised by individuals within the industry, they have the regulator, another internal whistle blowing procedures, the regulator who they could escalate things to. The industry itself has a very strong self-regulatory system and there are those means to escalate concerns within the industry. So I would not see this as a means for industry individuals proactively to go to the patient safety commissioner to raise concerns because there are many well-established mechanisms already, but certainly ready to work with the patient safety commissioner. Thank you. I'm going to bring in Mitch Phillips. We're just waiting for your microphone to be made live. I think that might be you unmuted, Mr Phillips. Okay, can you hear it? Oh, yeah, yeah. There it is now, yes. Yes, we can hear you, yes. Yeah, Paul, I think that was a fantastic question. I think you've actually nailed what would be a really, really valuable role of the independent patient safety commissioner. Someone mentioned before about patient safety being a rather cluttered landscape and I think that role is that the independence that the commissioner can bring as a convener and advocate. So as it happens, we have a discussion in a couple of weeks' time between the healthcare safety investigations branch, CQC, MHRA and the Ombudsman and the patient safety commissioner to see just how can you bring all those various elements together. That includes ourselves because patient safety is the absolute forefront of what we do as an industry. So yeah, I think your point is very well made, Paul. I think you're absolutely right. Can I bring in Tess White? Thank you, convener. My questions to Matthew, please, from Nursing and Midwifery Council. So Matthew, you talk about whistleblowing, but what other mechanisms are in place for staff to raise safety concerns? So within organisations, there should be opportunities for people to raise concerns within their teams and to raise concerns beyond that, if necessary. I know the national whistleblowing officer has issued guidance on how whistleblowing concerns should be handled by organisations. Of course, there'll be wide varieties of practices within teams from stand-up huddles, ward rounds, all of those sorts of mechanisms that exist within organisations and within teams for people to discuss the issues that are of concern to them, the issues which are coming up to them from patients and people who use services and make sure those issues are explored and resolved. So I think that there are a wide range of mechanisms in place within organisations where those are not working effectively are where some of the problems occur and that's where the lines out of the organisations into regulators like the NMC regulators of professions or Health Improvement Scotland or the national whistleblowing officer operate, but normally those mechanisms should operate as close as possible to the environments in which the care is delivered. And just a quick one. Do you think, Matthew, that having a PSC will actually add value to the processes that are in place? I think it has the potential to do that. I think that it will all depend on the approach that the commissioner takes, but I absolutely think it can and it should add value, both in terms of identifying opportunities for systemic improvement and driving those across different organisations, bringing a measure of consistency. And as Sean said, potentially looking at the culture within organisations to get that open and supportive and learning culture really embedded within organisations, which is in a way the absolute heart of patient safety. We now go on to questions from Evelyn Tweed on blame culture. Thanks, convener. My first question is to Richard Phillips. Richard, you talked about growing up conversations and you also mentioned the issues that particularly women have in raising problems with services, et cetera. Do you think that a patient safety commissioner will open up avenues for women to be heard and taken seriously? I can only hope so. I think that the independence of the role, which I think is going to be important in that case, you can see people who maybe feel they've been let down by technology, they've been let down by the system and they don't feel they've got anywhere to go. That turns out to be my own personal experience and I'm sorry to share that with you, but I think that an independent place to go is vital that people think they've got somewhere they can go that will listen and take them seriously. I think that that will be a huge step forward and I think that everyone would wish to get behind that. Again, it's that independence removed from the service, removed from the current structures that are already there, but it's a different place where people can go to feel they've got a strong advocate. Richard, do you think that there is a blame culture and why is that? If there is a blame culture, how do we move on? It would be pretty obvious on the panel from the profession that people have answered that. I do sit on the board of a hospital, but I think we try to move away from that. We know that we need to be framed as a learning experience rather than actually blaming people. People will do make mistakes, so what you have to do is create a culture where people are prepared to admit those mistakes and learn from them. If sanctions are so extreme and everybody is absolutely terrified, things will just get covered up and hidden away. We need to be able to come forward and say, if in the case of this particular device there was a problem, was it the device, was it the way it was implanted, how can we learn from that? That's actually how we improve technologies and how we make those iterative gains that I talked about in my opening remarks. Yes, so we absolutely want to be moving away from a blame culture. The duty of Canada, both at an individual clinician level and at an organisational level, has helped transparency. However, we do want to create and foster an environment where people can raise issues going back to what we were saying earlier, where we suspect that harm is being caused. Before we were even certain that harm is being caused, there are, especially when you've got a large organisation, there are often people there who can see things that need to be escalated. Matthew mentioned several different structures that exist or ways of working where people are encouraged to speak up or we try to create conditions for people to speak up so that quieter voices are heard. However, having a just culture in terms of people being able to say here is a problem and describe a problem without blame being apportioned to an individual. I'm not saying that there aren't situations where people make errors where that needs to be dealt with, but generally if we're looking to improve patient safety we need an environment where things can be brought forward, brought into the light and shared. Again, I'm mentioning the systemic improvement or systematic approach and the patient safety commissioner brings an opportunity for that to be out with these multiple organisations in healthcare. I have a couple of questions. The first is just going a little bit back to the voice of staff as well and Sean is really directed at you, so Matthew certainly spoke of whistleblowing legislation, but my understanding that people who sit on health boards are not covered by this legislation and does that not create a little bit of an issue especially when we're talking about blame culture and do you think that we should be doing something to try to include members of health boards? I'm afraid I can't speak to whether that's correct, but I'm sure that that's true that the whistleblowing legislation may not encompass everybody that it should, but more generally it is absolutely critical that there is the right framework in place to encourage people to feel able to speak up. Healthcare is not an area where perfection of outcomes is possible and it can be easy for a culture to develop where any concerns will become adversarial and therefore people feel I'm not going to say something because it will turn into a problem and I may myself suffer from this and we know this from inquiries and other areas where it's established after the event that people didn't feel able to raise concerns. There are, as Matthew has already talked about, a lot of ways in which people have the opportunity to raise their concerns within organisations and through the legislation that protects them in whistleblowing and so on and there are, you know, we ourselves have a confidential helpline for doctors in particular to speak and sort of understand what they may be feeling and to support them in their concerns for how they speak up and we also issue a lot of guidance through our good medical practice guidance for how doctors should consider these questions. In a sense, the opportunities to raise concerns all need to be there but it's the culture and the environment that people feel that they're within that influences whether they're able to do it. Just on your point of culture, do you feel, and I suppose Matthew, I'd like to include you in the follow-up, but do you feel that the culture that we currently have, possibly the patient safety commission might be able to help with, but do you feel the culture that we have is one where there is blame, where people are a bit right? So we've heard in previous committees about cover-ups and people being very worried and using datex forms as threats or I'm going to complain about you as a threat to get what you want so do you feel that the culture really is one of blame and that we need to move away from? Absolutely, we know that if you just listen to what people tell us they say they feel that there is a culture of blame that they therefore can encourage them to cover up their concerns rather than speak out. One of the useful things to keep track of in any organisation is the sort of staff survey material about do you feel able to speak up? Do you feel confident if you raised a concern that it would be listened to and that you would be supported in doing that? So I think we always need to do more to encourage a culture of learning rather than blame. Adversarial processes can easily kick in whenever there are concerns and understandable in some ways when we think of the harm that patients may feel that they've suffered, but we know from all of the evidence that actually best outcomes come from a culture where those sorts of concerns can be raised earlier, addressed and without turning it into a punitive process for the professionals involved where there is just learning that can be taken from that. The patient safety commissioner again comes back to what is that person's role in encouraging the broader culture of safety, perhaps rather than specific mechanisms or legislation that they can take forward. I would hope that that could be a contribution to it. I'm going to move on to talk about the powers of the patient safety commissioner led by Emma Harper. Thank you, convener. I'm interested to know what your thoughts are about the patient safety commissioner regarding having sufficient powers to bring about improvements in patient safety. We've got the Scottish patient safety programme already that's widened to look at maternity and neonatal primary care, paediatrics, medicines. I was part of the surgical safety stuff when I worked in the operating theatre, when I worked in California implementing that surgical safety checklist and things like that. I'm interested to know about whether you think that this patient safety commissioner will have enough powers to actually make safety improvements. I don't have anybody in particular in mind. Please indicate to me if you want to come in. There's certainly a lot to be getting on with that the powers that are currently proposed will enable. It seems that the powers being described in the bill here go beyond what is being set up in England currently. I guess that the next witnesses might give you a better sense of where that extra space, where those extra powers take us all. I'm quite comfortable with what's currently described as being able to advance things, as being proportionate to some of the challenges that we currently face. I guess that, even with those powers, there may be questions about, as I mentioned earlier, about how quickly you develop an expertise around the data and about handling the many conversations that will need to occur or will occur and again the financing of things. I think that the powers that are currently described will move things on enough and enable a patient safety commissioner to find their place suitably in the landscape. I'm especially pleased that the powers to be able to compel evidence to be produced, because I think that, in particular, will make a big difference. Sean Gallar? I'll just very quickly reflect a couple of points that I've mentioned already. One, the scope of the powers I think is sufficient. The key thing will be how the patient safety commissioner uses those powers alongside all of the other organisations and making sure that that's a really early priority is critical. The other point is I think there is a need to strengthen the powers in relation to information sharing, where, for understandable reasons, in section 15 of the bill, there is a barring of sharing information that is confidential, but that bar is very strong and names a couple of organisations that the commissioner is able to nevertheless share information with that doesn't include professional regulators. We think that there is a need to have something that allows, maybe not all the time, but certainly where it's appropriate information to be shared with professional regulators, where there could be a concern that would be suitable for us to follow through and investigate. In our previous evidence session, one of our panellists spoke about the health and safety executive and enforcement orders and fines and the ability to, for potentially the patient safety commissioner to be able to have those sorts of powers. Do you have any thoughts or opinion on whether that would be something that the patient safety commissioner should be able to act upon? I have to confess that I don't know enough about how the health and safety executive works to draw a direct comparison. My initial reaction comes back to the cultural point and how we design a system that supports openness and learning culturally. My instinct is that giving the patient safety commissioner a set of powers to find and directly issue sanctions of that kind might take us more into an adversarial place and you might find that organisations and others named in and participating in patient safety commissioner investigations were more likely to adopt a defensive pose if there were outcomes like that that might result. I think that that would be the trade-off. I can see why it was raised. I can see why it was suggested. It may operate quite effectively in other sectors. I don't know that but I would be quite thoughtful about whether having those sanctions would actually drive us into a defensive place rather than one that promotes openness and learning. Dr Ago, I want to comment. Just to add to that, one of the powers is the ability to publicly name organisations that don't cooperate. I wouldn't underestimate the power of publicly naming and shaming. For example, in the pharmaceutical industry we operate a self-regulatory system. One of the sanctions within that is for breaches of our code of practice that bring the industry into disrepute a full-page advert that is taken out in various medical journals. That has a very powerful effect on companies involved and therefore I think the powers that the commissioner has to publicly name and shaming are actually pretty strong. I don't see a common scenario where an organisation would choose to ignore that completely. I don't like the idea of creating a patient safety commissioner that would produce an adversarial kind of environment and defensiveness. I think that I'm in agreement about the way in which we would agree to promote and produce a patient safety commissioner to help to promote patient safety. Are there any things that might need to be included that are not included regarding additional powers, such as naming a health board, a company or a business? Is there anything that you think that's missing from the bill? I absolutely agree with Sean's points about information sharing. The other area that I think it's just worth understanding is whether the patient safety commissioner would be able to operate across social care as that evolves in Scotland. People don't experience primary care or secondary care or social care or nursing care or medical care, they experience care. I think that the boundaries and divisions that we impose over the top of that are constructs of management and the way we operate, rather than the way in which people experience care. I think just making sure that the powers of the commissioner are broad enough that where there are issues occurring in care, wherever those might be, they are able to deal with them effectively and make recommendations and investigate where necessary. I think that that would be quite important. I move on to some questions from Evelyn Tweed. Thanks, convener. Issues have been highlighted to the committee around agencies not being joined up. Patients have to give the same feedback to numerous agencies. Could the patient safety commissioner have a role in joining up those issues that we've heard about and make this sacrifice a level of independence in your view? I'd like to ask Dr Williams. I don't think that it would jeopardise the independent position that the commissioner would have. I think that I'm referring back to the systematic improvement approach that we're looking for and the ability to highlight topics or areas that are relevant across multiple organisations. I think that there's very much opportunity there that we haven't managed to sort out with the current frameworks, with the current organisations that we have. I'd say that we mentioned earlier the Scottish patient safety programme as an example of where you can look at things topic by topic or where you can gather people together. That works to the extent of coming back to how much you've funded or how much time that people have available within their professional role. I think that the ability to work across organisations, across primary and secondary care, I think that some of the patient's safety aspects are more—or the higher stakes events can be more—linked to the healthcare side of things than the social care aspects. Although, broadly, in health and social care, we're looking to get rid of those divisions to stop artificial constructs. I think that this role can be across multiple organisations. It can be effective across multiple organisations. It can work for specific topics, for specific patient groups. I don't think that the nature of that will jeopardise the independence. Thank you. It's an absolutely key question. One of the things that we hear from people who have suffered harm is exactly what you described, which is that they may be engaged with multiple regulators, the system regulators, multiple profession regulators. They may have engaged with the police, they may be taking legal action. All of those bits of engagement require them to relive the issues and to produce witness statements for all of the bodies. It'll be an absolutely key role for the patient safety commissioner to try and support people to understand and navigate those various different routes as effectively as possible, and indeed to help guide and direct organisations to do what they can to make those pathways as easy as possible. There are really good examples of where organisations collaborate already, but nonetheless we hear those stories of individual patients and their battles and their difficulties with multiple organisations too often. I think it's really important that the patient safety commissioner does bring that co-ordination. We're an independent organisation, we hold that independence very dear. We think it's incredibly important, but we wouldn't see the role of the patient safety commissioner in impinging on that in this regard at all. I think there's one related area that is just worth mentioning that touches on this, which is the actual provision of advocacy services for patients who are going through that type of journey, I think is really key. There are organisations that provide those services, we provide some advocacy for people who are involved in our processes, we work with other regulators including the GMC to make sure we can provide those advocacy services on a multi-regulator basis, but there isn't anywhere where patients can go to really understand currently what the landscape looks like and how to navigate that and how they can get somebody to help advocate on their behalf through that. I think that that might be an area that the commissioner could look at and support with. On the issue of the patient safety commissioner, it's proposed that there will be a parliamentary commissioner rather than an appointment by Government, so do you believe that this line of accountability, where its accountability to Parliament rather than Government or the National Health Service as an institution, is preferable? I'd probably want to bring in the front line representative, so maybe Mr McClelland, if you want to start. Yes, thank you. The independence is going to be absolutely key, I think that the line to Parliament rather than through to Government will certainly help with that. I think that the commissioner will need to guard their independence jealously and make sure that they do everything they can to work with patients to make sure that people understand their independence and feel and experience that independence in the way that commissioner operates. I think that the line of accountability to Parliament is crucial and will be really helpful underpinning, but the way that commissioner operates will need to reinforce that. I'm comfortable with the line to Parliament for the reasons that Matthews articulated. I would certainly agree with that, and as Matthew referred to before, as professional regulators we are statutory independent of Government and independent of the professions that we regulate. That independence is fundamental to the confidence in the regulatory framework and the judgments and assessments that it undertakes, so we hold that to be fundamental in the way in which we operate and the confidence that we hope people will have in it, and that I think would be true of the commissioner. Therefore independence from the Scottish Government and from the health service itself is an important aspect of confidence of patients and the public in the work that it does. There has been a sort of argument from the English Department for Health and Social Care that the commissioner would be, as an appointment from Government, we give it a powerful role within the system, and that the commissioner, which is entirely removed from the policy department, can be more easily overlooked by Government. Do you agree with that view? It's potentially a risk, has anyone got a particular response to that? I understand that the structure of the set-up of the commissioner in England is different, and I expect that you will be told by Henrietta Hughes when you speak to her that she does feel she would exercise her independence and jealously guard it, so it's not as if it removes the possibility of acting independently, and I've worked myself in organisations that had more of a direct responsibility to government but still absolutely acted independently. So it is possible, I think it just provides an additional safeguard and confidence that's visible to the public that there is a degree of separation from the system, and I think that's therefore an entirely positive thing. Thank you. Any other points? Thank you, Paul. We now move on to talk about the resourcing of this post in this office. Questions led by Sandesh Gauhani. I think that everyone on the panel has spoken about other areas and other places that they would like the patient safety commissioner to have under their wing, and so I suppose with four members of staff, which is currently allocated, knowing that there is also a lot of other commissioners, so it's very expensive, do you feel that the patient safety commissioner is adequately resourced now in the future? Seeing as Sean and Matthew, you both first spoke about extra areas, wondering if I could direct my questions to you to start with. I'm happy to start. I don't think I suggested additional scope of powers. I think I would like to see additional provision for information sharing, which I hope would be something that could be simply done within the way in which the commissioner would be operating anyway. I think in a sense it's not for the GMC to take a view about the resourcing of the commissioner. It will be what the Parliament and the Scottish Government is able to resource, but what will be really critical is that the commissioner works with the resources that she or he has to focus their efforts on where they will make the most difference and at the most value. As a number of organisations I think have commented to you, there are a lot of organisations with some remit of patient safety already in Scotland and the healthcare system, and I think one of the first priorities of the commissioner should be to work out where to use the resource that they do have in the most effective way. One of the things that we've talked about a little bit is being able to take that strategic view of information across the system. Actually, as Dr Algarwell talked about, the analogy with signal detection, spotting those areas of risk, analysing data, working with other organisations who also may be able to share data and hear those signals of risk and concern that might otherwise be missed. That doesn't necessarily have to mean a lot of work dealing with individual cases and complaints, as we've talked about before, but it does require a certain amount of capacity to assess and analyse and understand that broad range of information. For me, that would be the key thing. Can you do that with that sort of staffing structure and with the collaboration that you can have with other organisations? No, I think I agree with what Shorda said. It's not really for the NMC to have a position on what the resourcing of the commissioner should be. That collaboration with other organisations, in order to make the most of the information that is already there and pick out the important themes, I think, will be absolutely key. On the point about checking that the commissioner's powers would extend to social care, that from my perspective was about making Shorda Bill as future proof has everything in it that it requires. It doesn't necessarily mean that the scope of the work immediately needs to expand significantly in the first instance. It's very much about focusing on the important areas. Thank you. My final question. The NMC, GMC, you both undertake investigations and that's a very different skill to analysis and is, I think, quite resource heavy and difficult to do. Do you feel that knowing how difficult it is to do investigations that maybe the patient safety commissioner uses other agencies to do the investigations whilst highlighting areas of concern and thus making the resource go further? So, certainly that sort of approach may well be possible and I wouldn't want to impose on the commissioner the right approach to take. I think understanding the functions and the priorities of what the commissioner should do and then the skills and capacity and capabilities that they will need to draw upon is a really important first test. I would just again reinforce the importance of working with other organisations who will have some of those skills and capacities and who, therefore, I mean we certainly would want to be able to work closely with this commissioner and offer contributions to how they may undertake their work. We gather and collect a lot of data in our work just as a matter of routine and we certainly see part of our responsibility as offering that to the wider system to support understanding of risk and patient safety across a range of areas, so we would want to offer that as part of our work with the commissioner. Nothing to add to what Sean has said. Thank you, Sandesh. Final questions from Paul Sweeney. Thank you, convener. I think that issues have been raised about the budget, obviously, and they're described as a bit like this half million pound per annum budget. I suppose also the discussion about the heaviness of the data and the sheer volume of data. We know that most data is useless because it's just that it's not necessarily reliable, it's not necessarily being collected in the same way or in a rational way. It may be biased. Is there any competences that you would like to see within this office that are critical in terms of both process, technology or skills that you think would be critical for it to be meaningful and give it best effect? I hope to open that up to anyone who might have a view. Dr Williams? Yes. I suppose that I've previously picked up on the data aspects in our general practice clinical information systems, our patient record. We're generally collecting information for direct patient care. I think that there is a wider piece of work needed if we're going to change some of the practices involved in inputting and maintaining the information that goes into that record. But, specifically, turning to how the patient safety commissioner office might work, I think that there's some degree of set-up needed to make sure that they are informed by our data experts within the health service. We have lots of them. We have lots of information analysts and people who have that expertise. I'm sure that we have multiple health boards that can donate some of that expertise that can help things to be set up. In terms of data issues, are we collecting the right things, especially when there's lots of sensitive information there? How things can be collected and curated and appropriate focus can be be had without simply hoovering up information that, as you've highlighted, may have been collected for a different purpose? Having the feedback loop for the commissioner to be able to feedback organisations to say that we would have spotted this if you had collected things slightly differently or if there was an extra bit of information that was collected within a certain data set. I think that the intelligence aspect of that, so moving from information to data sets to being able to draw useful conclusions beyond just the direct patient care, that's one aspect that the commissioner is going to have to deal with across multiple different organisations. As we're talking about this, one of the things that's in my mind is if we go back to the cases that led to the introduction of this commissioner and that led to Baroness Cumpallage's review, what would it have taken for a commissioner to highlight the concerns and bring it more into the public debate? In a sense, that wouldn't have required super sophisticated data analysis and mining. It would have just been hearing the voices, joining the dots and ensuring that there is a profile and a championing given to that set of concerns, which I expect then probably would have led to more intensive investigation that might well have been undertaken by somebody other than the commissioner in order to examine actually what do we think we've got here. I suppose there's something about, we don't want to overcomplicate quite how much we're asking of commissioner themselves to do on this, but it's the patient voice and bringing it more to the surface that's, I suppose, the key thing. Dr Agarwal. I guess once your question is slightly different where I quickly agree with everything Sean's just said, one of the parts of our submission was around the role profile for the patient safety commissioner and the importance of that, whether it's a clinician and what sort of background they have, their ability to look at things from an individual aspect, but also a public health aspect as well. I suppose something to be mindful of is that this role is very intended to be by a very public facing and where the patient safety commissioner may become aware and highlight issues have a broader public health concern. I think there needs to be someone who is aware of the impact of the role and very mindful of the public health impact to take a few examples. You know, 1995, the pill scare, where an increased risk was highlighted, lots of women came off the pill, ended up having terminations instead, the MMR scare of the early 2000s. So, the profile of the role holder is really important here and they being able to navigate not only their role itself, but the impact their role, the potential that their role has to impact wider public health. Thank you. I don't think there are any more questions, sir. No? I want to thank our five panellists for the time this morning. We're going to suspend for a 10 minute break. Thank you. Welcome back. We continue our scrutiny of the Patient Safety Commissioner Bill with evidence from the Patient Safety Commissioner for England, so I welcome Dr Henrietta Hughes to the committee who is the Patient Safety Commissioner for England and Dr Gary Duncan, chief staff to the commissioner. I want to thank you for coming at relatively short notice because we weren't originally going to take evidence from you, but following discussion from the patient groups, we felt it was maybe important to hear how things were going in England in the first 100 days. I'm going to hand over to my colleague Tess Waite to start questions. Great. Thank you. Thank you, Dr Henrietta. Could you just share with us initially your views of your first 100 days? Any surprises, anything you'd like to you think would be helpful to us? Yeah, absolutely. I'd first like to say thank you so much for inviting us to come and give evidence. We really appreciate it and I think that working in partnership and learning from each other is going to be the way forward on this. My first 100 days, I started at a time of quite a lot of political turmoil and I think that was really important in terms of being able to make the right connections and also the time when a lot of distraction was going on. I don't think we can underestimate the task of setting up something entirely from scratch. The first time that the Department of Health and Social Care in England has had an independent commissioner role and so we've been really learning together with the officials the best way to do this and setting up some of the structures, recruiting staff, procuring a website, finding office space, you know some really basic things which I think have taken quite a long time to establish and that's partly because of some of the changes that were happening at the time that I was appointed into the role but I have to say that I think it's all been done with a huge amount of work from everyone involved, a huge amount of professionalism and really excellent partnership working so that we're looking for the win-win, looking for the solutions and trying to get things up and running as quickly as possible to meet the needs of patients who've had such a terrible experience leading to the compilage review itself. And just in terms of any difficulties, any hurdles that you face that you didn't envisage? So if I just take them in order, I think getting the appropriate domain for our website and for our email so having a .org.uk rather than a .gov.uk that was a really important one from the beginning. I think that inevitably it takes time to do everything and I'm probably a bit impatient for change so setting up the recruitment of staff. As I said, we haven't got an office yet but we're working on getting a lease signed and then the procurement processes following all the appropriate DHSC procurement processes does take time so it's just about thinking about this as a very long-term project rather than a short-term project so it's thinking about setting things up for the long term. I think the other thing I would say is that having a small setup team is really important to be able to be agile and to be able to design and develop the functions of the office but also it's important to have a longer term plan for the scope of the role and also for the expansion of the team to meet the needs of patients because otherwise it can potentially be a bit of a distraction when setting up the functions to then also be going in and saying this is the types of roles that I need in the team and being able to begin with the end in mind I think it would be a really good step in that situation. I'm interested in the remit in your role and how that compares to the proposed remit of the patient safety commissioner in Scotland which seems to be a bit wider for instance so I'm wondering if you have any opinions or on any benefits or drawbacks that having the remit in Scotland it might be a bit different but and whether you find that your remit has given you enough to to work on at the moment without accepting any wider issues at the moment? Absolutely so my remit is to promote the safety of patients in relation to medicines and medical devices and to promote the importance of listening to the views and voices of patients in the public that's already a very wide remit because there are an awful lot of different problems that people are experiencing or have experienced with medicines and medical devices and so I think it's about looking at the context in terms of patient safety and the patient safety organisations that already are operating in England and there's a large number of patient safety organisations so the way that my team is working is to be working in partnership with a whole range of different organisations and that includes the regulators, the professional regulators but also representative organisations, membership bodies and professional organisations as well as the providers and I think the reason why that's so important is because otherwise it could be confusing you know for the system and I've read the bill and I can see that the the scope in Scotland is wider and I don't think it's for me to say how you should be organising your scope but I would just say that putting it into context of what you already have and how the commissioner in Scotland would work effectively in partnership with the other bodies not only in Scotland but I would hope also to have a really good relationship with the patient safety commissioner in Scotland so that we can continuously be learning and improving by watching and speaking to each other and seeing where the successes and the difficult areas are as well. In the previous panel I asked a question about not just focusing on safety because care and compassion in how we help support a patient's journey in whatever care they are in receipt of and whether harm has occurred or not. Caden compassion is at the heart of that as well. Would you have any comment about whether I mean whether we just focus on safety aspects or the whole patient's journey as far as Caden compassion as well? I think that's a really good point because it's not just about being safe it's also about feeling safe and I'm a GP myself and so when I look at the experiences that some patients have had it's not so much about it's not just about the safety of the procedure or the medicine that they're taking it's also about their experience as well so I think that having that as part of the ethos of the role is really welcome and when I think about the priorities that my office has for the year ahead the culture and having a speak up listen up follow-up culture which is a compassionate culture I think is a really important part of that too. Just a final question convener it also people have intimated that the patient safety commissioner is about healthcare not health and social care and so again if we are moving towards a national care service for the whole encompassing of a patient's you know care journey or would you expect that the remit would even encroach wider to include social care down the line? I mean what I would be saying on that is that if it were to include social care it's important that the commissioner would have people in the team with the right experience and expertise to be able to support with that and I think that you know what I've seen in you know the work that I've been doing listening to patients and patient groups is that they want to make sure that everyone involved in their care you know is able to be knowledgeable about their condition share information with them ensure that they're consenting to the treatment that they have and also listening and acting when they raise a concern so if that was going to extend into social care those are the elements that I think that I've heard from patients that really matter to them. Okay okay thank you. Thank you Emma and then we've wanted questions from Evelyn Tweed. Thanks convener and good morning panel and good morning Dr Hughes. Obviously you're quite new to your role and we're hearing in evidence that those most at risk find it really difficult to have a voice and to be believed and particularly from women. What are you doing to engage with those most at risk to make sure that their voices are heard? So most of the patients who were involved in the convalage review were women, a woman who'd taken sodium valproate during pregnancy, who'd been given hormone pregnancy tests and who had been treated with pelvic mash and I've been meeting a wide range of patients not only those who were involved in the convalage review but others as well but I absolutely agree that it's the voices of those that are seldom heard which we need to really focus on because if we get it right for those that are most vulnerable we get it better for everybody and so when it comes to the advisory group which I'm establishing that's been a real focus of mine to ensure that we've really got reach into groups of patients in the public who wouldn't often have a voice and I've been engaging with other organisations such as the Patients Association and being really interested in the networks of patients that already exist in different parts of the system. I'm also really interested in the patient safety partner roles which have been established in NHS trusts in some of the regions as well because I think that's another way that we can get the patient voice included in the design and the delivery of healthcare so although I've only been in the post for a few months I've been visiting different parts of the country meeting people, patients and staff who are looking after them and really listening to what their concerns are and how this role can be forward thinking not just backward looking as well and hoping to you know horizon scan and identify concerns you know before they actually become harm and that's the goal of this role in the future to be a forward looking role. Thank you. Now you are sponsored by the Department of Health and Social Care and appointed by the Secretary of State. Now in our proposed bill there will be a parliamentary commissioner who is independent of government. What's your view on the pros and cons of each of these approaches? So my role is independent of government and my office although staff by civil servants we're able to I'm not a civil servant so we can meet with different people I don't have to I don't speak for the government and my reporting line financially is to the Department of Health and Social Care because that's where my funding comes from but for my operational side it's through the the Health and Social Care Select Committee. I think that what that does is it gives me independence I'm going to have an independent website, I have members of the public contacting me and the responses that I give are independent of government. I also think that it's really important that I have good close connections not only into the Department of Health and Social Care but also into the ministers as well as well as to the regulators the providers and others because it's the small changes that are going to be happening across the whole system that will add up to the major changes so I feel very lucky that I have the arrangement that I have because I think there's something about being independent without being isolated and so it's really important to be able to build good relationships into all different parts of the system and I don't think that that hampers independence. Thank you everyone. No move on to questions from Sandesh Gohani. Thank you and thank you for coming to the Scottish Parliament. My question is about individual cases and I know that you are not responsible for individual cases but does that lead to frustration with people who are contacting you? I think that for people who are getting in touch it can be sometimes a hard message that they're sharing information and it's not something that I'm then able to take forward as individual case work and I think that that's really important in terms of communicating with the public and with patients and patient groups about what the remit of my office is there to do. I think the other thing I would say having done a previous role where I was doing investigations and I was doing case work is that the risk of that is that you can't investigate every single person's experience and there will be others in the system that would be able to maybe do those investigations as well and so there is the risk that you either end up with a huge backlog on a waiting list or you're selecting the cases that you can investigate and I think all of those lead to unhappiness in some people so I don't think there's any perfect solution in this but we do make it really clear when people get in touch that I don't have an individual case work role we can't investigate their cases but what we can do is help to signpost them to parts of the system who can and so I'm really keen that patients who have been often bounced around the system in quite a difficult way in this very complex and baffling system that we have have a warm hand over to the right part of the system and I know that you heard earlier from General Medical Council and that's the examples where people have come to my office where we've been able to support them to the appropriate part of the system and I think that's also about treating people with you know care and respect as well. So just on to it I mean you're not able to take on individual cases but I go back to this this idea of a golden thread so if you have multiple people coming to you from different say parts of the country or from different areas giving you a similar thread how will you unfortunately miss it because you give them the I'm sorry I can't do that or do you log the information and see if there is that golden thread that you're able to pick up? So we're in early days but we have been logging information with the themes that people are contacting us about and I've been able to speak to senior officials for example at the MHRA about particular concerns and we've often had patient groups contacting us about multiple cases that have got similarities to them so what I would say is that it's not necessarily going to be you know for my office to look into these details because there are other organisations who do have that remit and I think from my perspective it's about us understanding a really good understanding of the health system so that it's really clear as to where would be the appropriate part of the system that would be investigating those aspects so if it's about professional practice it would be the professional regulators if it's about concerns about a particular device or a particular medicine it would be to the MHRA and if there are broader patient safety themes then that would go to the national director of patient safety if it's about an individual national investigation that would go to HDB and I think it just shows the complexity of the system that we have multiple different organisations who've each got their own part to play but what I think is really important is that we do actually speak to each other we meet regularly and that we're able to understand the remit of each other's organisations and roles so that we can then you know be effective and supporting patients who've got concerns. I suppose that that's quite reassuring to hear that you you're all speaking I mean more than to expect you to but it's still reassuring to hear that you are speaking and I suppose that the question is about investigation so you said that you had previously done a lot of investigation or been in areas where you do investigate and that takes a certain skill time and resource to do so do you feel that your role at bearing in mind that I appreciate it's only been a hundred days but do you feel your role is to find these themes and maybe pass that on to the relevant organisation or do you feel that your role is to actually then go on to the ones that you want to investigate further? So I would slightly shy away from the word investigate because I won't have an investigation function but what I am hoping to do is to have a function in my team to do research to actually be able to horizon scan and see you know where the concerns are at an early stage because I think one of the features that I see not only from first you know harm but from other reports is that it takes sometimes years or even decades for the patient's voices to get to the point where they're heard and then acted upon and what I'm keen is that we get to a situation where it's business as usual to have patient voices included in the design of services and when people are raising concerns whether that's into their trust or into other parts of the system that they are then listened to acted on shared and that we get learning from that across the whole system so um there are multiple different strands of information that are coming through for example the yellow card reporting system into the mhra and I'm really keen that we use and and really maximise the opportunities through those learning systems through the national patient safety strategy through the care quality commission and the data that they have so that we're able to spot things earlier believe and I think that's a really important word in this listen and then follow up thank you and my my last question if I if I may is hearing from dr Williams in the last panel um with the rcgp about the primary and secondary care interface this is a gap I think that exists within all health services it's not exclusive to scotland it's it's in england and in wales and northern island um and how is that somewhere that you would you'd be able to focus on uh contribute to or is it as you say finding the relevant person to pass those concerns on to so um I mean as a gp I'm fully aware of the you know the the gaps that can happen between providers of care um and I think one of the things I would say is that part of it is having an understanding of the entire patient pathway so it's really clear you know that the information is shared in a way across and I'm seeing development of digital systems for example which are really enhancing that so if you look at medication errors there are 297 million medication errors a year in the NHS and part of that is to do with the the digital systems that that you know mean that you're having to transcribe information again and again um so where there was examples of good practice what I'm really looking forward to doing is on the website is having a an area where we're able to share that so that organisations who are looking for innovation looking for inspiration will actually be able to find out what's happening in different parts of the country or in different countries and then be able to then take that on board and incorporate that good practice into their care that they're providing to their patients so I am seeing examples of really innovative practice in this area where the the patient record is visible across the whole patient pathway and I think that's the sort of thing with the right you know safeguards in place would really help to remove some of those gaps in in knowledge as a GP myself I'm able to log in and have a look in the hospital system and it's that sort of thing which can really help to reduce the the pressure and also the stress on the patients and keep people safer as well thank you Gillian Mackay thanks convener you mentioned communication earlier on and I think there's an interesting line that you may have already had to walk or me me in the future between where people come forward with an individual case that they believe may have indications of of wider patient safety issues but whatever investigative body believes believes it doesn't and those patient groups that you were talking about that do have multiple stories happening over and over again in different places how do you see your office and yourself as the commissioner communicating to those people who have often been traumatised as a result of their as a result of their treatment how do you see communicating where that line is between individual cases that have an individual feeling and individual cases that may have wider wider implications for patient safety yes that's a really good question because it is very difficult and I think the other area that I think is a really interesting one that I've just kind of come across from the patients who've contacted me is where it's not a failing in the treatment in the sense that it's being used according to all of the license it's not there's no recklessness the indication was correct but it's a known and recognised side effect which can be really catastrophic so I think this is about having those good relationships into the regulators understanding what's already been known what steps have already been taken but also to to open the mindsets so that we're able to look at things in a way which is really patient centred because I think that the more that we're able to get the patient voice into all the different aspects of care whether that's in terms of the provision whether that's in terms of the regulation and also you know that all of the areas and what I've been really pleased about is that when I've been speaking to officials in different organisations and healthcare leaders and asking you know how they're listening to patients people have been really open to the idea of incorporating patient voice and I think that's the sort of movement that I'm looking for in the system that we do get patient safety as a higher focus in terms of our priorities that we do see the patients as partners that we do see shared decision making or supported decision making as the destination that we're aiming for and and for some organisations they're already there and for others they're not quite but they're really open to looking at things differently and I think it's that by doing that and making it so that the patient voice is a really significant and contributing part to the way that we design and deliver the services the more that it will be easier for organisations to attend to early signals when there are concerns that are being brought to their attention. That's great. Thanks, convener. Emma, you wanted to ask a quick question. Yeah, thank you, convener. It's just a quick question. I'm looking at your first hundred days report and there's a couple issues have been raised about concerns about electroconvulsive therapy and also Covid vaccine concerns and I know that I'm the co-convener of the mental health cross-party group and so that's something that ECT thing has come up with us as well and also Covid vaccine concerns there's a lot of fake news out there. Will your role help combat some of the issues that really need to address evidence and combat fake news for instance? So I think that the word believe I think is a really important word in this because people have concerns and need to be listened to but at the same time we've got to be clear about where the evidence base is but people can still have concerns so for example in terms of the Covid vaccine damage the concerns that were brought to my attention were about the reverse system and about delays and about problems that people had encountered with that so I think it's really important to keep a really open mind so that it's possible to hear what people's concerns are and to ensure that people get the opportunity to express what it is that they're looking for help with and I think that's where also the value of working with parliamentarians is in this because people will come to their their NP or to their APPG and then it's when there's a body of patients who have a particular concern rather than looking at an individual one and similarly when it came to electroconvulsive therapy it was around the regulation of this and so I'm of the view that I don't want to be in a situation where I'm missing what is the next pelvic match or the next sodium vial proate or the next primados and that's about and and that's about also within my team having you know supportive and challenging conversations so that we're continuously keeping a really open mindset because when you look back in the history of you know where patients haven't been listened to um there are so many examples not just in terms of medicines and medical devices but going back over the decades and so it's um I was going to say easy to shut people down but actually the hard thing is to keep a really open mindset and that's where the position that I meant. Earlier you talked about the value of being independent and your independence and and the fact that you're talking about listening to people and hearing concerns. Are you already finding that people are just really engaged in and trusting the role that has been created for patient safety commissioner of England? I mean my experience is that the patients that I've been speaking to and I've met a lot of patients and been listening hard to their experiences is that they have been let down so badly by different parts of the system that to build trust in a brand new role you know is it is a really I would say quite a difficult thing to do and I've been overwhelmed by the incredible generosity of the patients who have been helping me providing information wanting to meet share their experiences um and you know really looking for that listening and supportive role. I think what I would say is that the volume of people who've been contacting us is out with the size of the team that I have to be able to then follow up as much as we would like to be doing to support all the different patients and patient groups who've been getting in touch and that's really tough because when somebody's been to lots of different organisations already and they've been told nothing to see here and then they come to the patient safety commissioner and we're saying we would love to help but with such a small team we're not able to do it. To be able to still maintain the good relationship with those patients I think is really challenging and it's only because of the incredible kind of generosity that I could describe of the patients who've been contacting us that you know we've been able to do that and I'm just you know keen that we're able to help many more patients and patient groups. I'm looking forward over the next year to going out and doing public engagement events where we can meet even a wider group but I do also think that there are a lot of concerns that have been you know sort of put on ice over the years which are still unresolved and they're coming to me in my office about that. Okay thank you. Thank you Emma. Paul O'Kane. Thank you very much and good morning to Dr Duncan and indeed Dr Hughes. I suppose I'm interested in the particular powers that you have in your role and indeed the powers that we might seek to provide to our commissioner here in Scotland. I think everyone is keen when we talk about the establishment of commissioners that commissioners have teeth I think we use that expression quite a lot so I suppose maybe just to begin currently what powers do you have and other powers you would like to see expanded in your role? I know that's quite an open-ended question but. So thank you. The powers that I have are to request information and also to make recommendations and I think that the requesting information is a really important one but I would also say that I would hope not to have to deploy that power if that's the right expression because I would hope that organisations would be keen to work in partnership, keen to set the shared objective of keeping patients safe and to see sharing information as a really important part of that and when it comes to making recommendations I'm really aware that the health service for example but the health sector as a whole is under enormous pressure and as I mentioned earlier there are multiple different organisations who are all making recommendations and so there's a risk that this could be confusing, contradictory or burdensome. So my hope and expectation is that recommendations will if I'm making recommendations that they will be not burdensome but more inspirational in the sense that these would be for organisations to accept gladly and see the value of them and to do this in you know understanding the context of other aspects of what's happening in the service at the moment but also in terms of the other recommendations that might be being made into the system I think for organisations where they've got 95 recommendations to prioritise it's really difficult and then they might say well we'll pick one so it's really just understanding where into the system I might make the recommendation and also what the read across would be for the rest of the system as well. Thank you for that overview I suppose in your experience so far and your sort of initial assessment of the role we had an interesting discussion this morning with representatives of people who work in health and social care around whether or not the recommendations that are made to organisations and to staff have to be more binding perhaps and more cognisant of the whistleblowing nature of or you know trying to make improvement that will be whole system and lasting so I wonder do you think it would be useful to you and do you think in terms of our Scottish context there should be you know an ability to make binding recommendations or indeed to issue kind of enforcement orders? I mean that when you speak to people in the health service or across the wider sector and there's always a risk of whether it should be a should or a must and that people have only got time to do the musts so what are you going to do with the shoulds and I think that's about that speaks volumes about the pressure on the service but what I would say on the converse of that is that there are huge numbers of allies in the system already who are doing fantastic work and part of this is about ensuring that they have got the support and that they've got the information and that they've got the resources to be able to get on and do that good work and so part of the role that I see for myself is actually adding to that support adding that information through the information on the website and encouraging leaders to see safety as a really high priority in their organisation not as a sort of add-on and we've got a lot of pressures on leaders at the moment but I'm really keen that if we have safety seen as something which is a really core part of our business so that we're in the preventative space rather than dealing with mitigating the consequences then using powers and using fines or using enforcement just feels like quite a punitive thing to do and I'm more keen to really encourage and support and you know suggesting influence and you know in that much more positive space clearly if I find that there are parts of the system where I'm not receiving the information that I'm asking for or that a recommendation is not followed then that would be about looking at where the other powers in the system are and working really collaboratively with the other regulators in the health system so that's the sort of take I would say because I think having a just culture and having a positive and a encouraging way of doing things in my experience is more effective than deploying powers at the first instance. Would it be your sense that patients have responded well to that approach in terms of feeling that they are getting to the answers and results that they need through that kind of more collaborative and encouraging approach or do you think that there's a sense that they want to see a kind of option of last resort almost in terms of being able to enforce things? Well I say that it's still early days for me and so the organisations that I have approached for information have responded and so I'm hoping that we're going to be in that space very much most of the time. I think there will be times when the powers will need to be used but I haven't got to that point yet. Thank you very much, convener, and thank you to both for attending today. I think what you've said so far in this area is interesting and you mentioned earlier for example you would publish best practice for example where health authorities could benchmark against and perhaps implement recommendations. Do you feel that there should be some sort of mechanism for escalation if there is something so egregious or some area of injustice that you feel needs to be urgently addressed that can't merely be left to collegiate discussion or collegiate recommendation? Perhaps that wouldn't necessarily be yourself issuing an enforcement order like the health and safety executive. Perhaps it might be a recommendation to minister in your case that they use statutory instrument to implement changes or in the instance of this, commissioner has proposed, it would be a recommendation to Parliament that they advise this. Do you feel that that potential mechanism for escalation if necessary is important whilst bearing in mind that there is a need to foster openness and inclusivity because then people just kind of shut down and feel that they're going to be attacked if they're there to express openly issues. Do you feel there's a balance to be struck there in terms of escalation? Absolutely and there is as I said there are existing powers that already exist in the system and so there's the early emerging concerns protocol which is where the regulators can get together and you know share their understanding of a particular concern. But there's also the opportunity to encourage other organisations to use the powers that they have and the instruments that they have as well and I think that's where the role of the commissioner is really important because it's about having a deep understanding of the powers that exist in the system already and then encouraging those organisations to move forward with that. As I said it's still quite early days so it's hard to say whether if I was going to get a knock back on encouraging another organisation to use an instrument that they had where the next step of escalation would be but my reporting line is into the select committee and so I think that's a really important aspect of this as well and then also I have the annual report which is where I'm able to you know share all the detail of that as well. So I think that there's multiple paths that already exist in the system. It's partly about understanding the powers that others have but also for others to understand the powers that exist in the system and then for people to work collaboratively understanding what the shared goal is and then working towards that. That's helpful, it's also up to know the line to the select committee because I think that's something we can reflect on as well so thank you. Thank you. The final theme that we want to ask you about is about resources and so led by Sandesh and I know Paul wants to ask some questions as well. Thank you. My first question, it's a very straightforward one, did you feel you have enough resources? At this point I think I'm going to bring in Gary Duncan who's my chief of staff if that's okay. Thank goodness I'm here. So I think Henry I touched on it earlier on at start. I think one of the things that's really important set up in your office and you'll have other commissioners here but it is important to start with a relatively agile team so I think if you put 20 people in our office on day one, I don't know what they'd have done, they'd have probably ran around like headless chickens although not really because we wouldn't have had an office space. I think you need to start with something that's relatively agile to set up the initial process which is what we've done so Henry I mentioned. Looking for office space, setting up a website, we've recruited an advisory group, we will do a public consultation on principles which will underpin the role, that's another statutory requirement. Moving on from that though, I think there is a question to be had about what is the office need to be successful and I think there's a continuum there from that point about how much work you want the office to do. So the more people you have, the more structure you put around it, I would say the more things you can achieve. That doesn't mean a smaller team can still achieve really impactful results and I think that's what any patient safety commission in Scotland would need to consider and they need to consider the structure around how they want to do that as well. So you've mentioned investigations, we've said that we don't see ourselves doing investigations, what Henrietta and I have discussed is a policy unit, a strategy unit, a business management unit which is about looking after the functions and the processes and data protection and also a data and analytics function. Those four functions are what we think we would need to be successful. The size of those is how we'll manage to assess whether or not we're able to take on all the tasks that have been asked or all the issues that have been raised by patients and the ones we can't, we need to consider how we most effectively signpost them to the right part of the system and we've mentioned that already. There are parts where we can do that quite clearly. There are other ones where actually just shining a bit of light on a subject can be really, really impactful. One of the things I've noticed from the patients we've heard from, a lot of them are very pleased that someone's listening and actually dying itself and directing a lot of their attention to it can still have quite a big impact on itself. So we've started small, I think we'll be looking to expand in the coming months and years but yeah, I think that's for me the most effective way of setting up agile it for us but with an expansion plan of growth. With that, do you have enough resource to expand in the way you want to? So I think we would need an expansion of our resource if we wanted to take on further work. And looking at the Scottish commissioner, the remit's already a bit bigger than your remit and there's lots of people who have come to the committee and have asked for other things to be included within the remit and thus the role seems to be expanding as the ask goes. So do you feel that the current budget and resource that we have is enough or do you feel that it's okay in the initial phase for the agile team but we would need scope for expansion in the future? For your budget for the Scottish? I would say that's a question for your new commissioner depending on how they want to focus their priorities. I think that's one of the great things about the role. There's a lot of different ways to do this. I think one of the things that's beneficial about the way in which we've operated is Henry has had the chance to come in and set our own priorities and think about how she wants to serve the role. I think what you have from what I've heard, really hard for me to say but I would say certainly at the starting point of setting up a team, the new commissioner can decide where they want to take that and what they feel they need. I think that's the most effective way of doing that. And just my very very last question, when you have your budget set and you're reporting in your particular way, which is the health select committee, do you feel that that is where you would be able to say look this is what we found out so far but actually we need these things to be able to go that a little bit further or because your funding comes from the Department of Health, is that the route that you have to take or would you do both? Well I would say we would do both but I'd also pass on to Henrietta to see. Yeah so I think it's clear to everybody that the role is already very visible that we've had a lot of people getting in touch and that you know in terms of activity we've been doing a lot, I mean you might have read the report it's plenty going on and I think what's really important is that a new role has that opportunity to thrive and I'm not just talking about the people in the team it's about the concept of the system welcoming a new way of doing things, a better way which includes patients and hopes to get us away from that always looking back to the problems that have happened in the past but more looking forward so that we can get into that preventative space so what I'm in you know we're in conversations with the Department of Health and Social Care around funding they're really aware of what it is that we're asking for and so it's really important that you know the the that when you know I'm raising to them what the needs are that I'm hearing from patients that that is then listened to and we get that expansion that Gary was describing but I think it's also really important in that the last select committee hearing on first do no harm the witnesses were also very clear to the health and social care committee that the resources that exist in the setup phase of the commissioner's office are too small to continue with you know the ambitions for the future so I see that both routes are important but it's not what's important for the office it's important for the patients that we want to support thank you and final question from Paul Sweeney I was just really to pick up on the point but resourcing I suppose a budget and headcount is one thing but actually understanding the competencies that you're looking to achieve within the team is critical as well obviously huge amounts of risk around data and inundation trying to make sense of large volumes of information have you given much thought as to how you're able to build a process that's resilient enough to draw meaningful conclusions from what you're going to have feeding into your office and how you're able to process that it's just a major concern we've got about how that's managed with such a small team in the first instance yeah absolutely well I can start and then hand over to Gary so it's not um just about the data that we have there's also huge amount of data that exists in the system so for example in the care quality commission in the mhra in in other parts of the system and people have been incredibly generous to say that they would like us to be able to work with their data and I think that's where we get the real value of the partnership working so having um a data and digital function in my team to be able to you know use and manipulate that data in a way which brings fresh insights that will then help the system to be able to attend and listen to things that maybe we weren't aware of in the past is really key but there's also something about the you know the data protection and also ensuring that we're able to respond in a timely way you know under our statutory obligations in terms of requests as well so just to follow and turn over to Gary in terms of how we do that with the department of health the support that we get and responding as well so we we are independent of the department of health health and social care but we do make use of some of their expertise to receive advice on how we should handle and follow the best we can some of their processes there's no reason why being independent should deter us from following robust processes that exist within the department so we do that and they're very supportive and we're extremely appreciative of that I think on Henry as point she's right if you want to use it without a data analytics function you're going to be limited in the novel insights which a commissioner can pull apart so there are things which good quality policy and strategy professionals can do with the data that already exists I think what we would be very keen on is being able to do something slightly more sophisticated and that requires having that sort of high level strategic function within our team having the data analytics capability identify gather and then analyse data to produce novel insights just to kind of combine the point with powers and that capacity to gather meaningful insights say for example the transversial mess scandal where felt that patient voice was ignored not collected not heard by the data collecting mechanisms within the Scottish national system and therefore they were patients found themselves completely at loss as to how to progress their concerns beyond coming to the parliament to actually have a petition to the parliament and only then was an inquiry sort of pursued would you see potentially the need to instruct or to advise changes to how data is collected and managed within the national system that say there's a recommendation you're hearing qualitative insights from patients but you don't have the quantitative information to necessarily verify or understand if this is a wider national issue would you be able to say look we really need to start collecting this at a certain point within the system of the patient journey in order for us to then over time understand if this is a wider concern and is that maybe a mechanism you feel is necessary well I'm already having conversations with the team at NHS England who are leading on the registries and I think that's a really substantial you know step forward as recommended in the review first you know harm but it's not just about saying what device is going into which patient on which day it's also about establishing patient outcome and experience measures as well and and they take time to develop so I think it's about the culture shift that we're looking for which is to say we're as interested in what patients are saying as other types of evidence that already exist in the system and if we're not getting the feedback and we're not we're not gathering that and we're not bringing that into the way that we are looking at an outcome of a procedure or of a treatment then we're missing a really substantial part of that evidence so I don't think there's quick fixes around that but I think a really substantial part of this is about a mindset shift and about how as a health system we're able to incorporate information that's coming from incident data from complaints information from other types of feedback but also that you know in terms of research that there are really robust ways of measuring and assessing the patient reported outcome and experience measures as well thank you thank you very much I want to thank Dr Gary Duncan and Dr Henry at a huge third time this morning and we now move on to our next item on our agenda and I won't pause about guess can just leave or stay it's up to you but I'm not going to take a pause we're just going to move straight on the next item on our agenda is consideration of three public petitions the committee took evidence from the cabinet secretary and social care the 17th of january in relation to these petitions and I will go through them one by one members let me know if you want to come in and make comment in any petition so let's take the first one that is PE01845 which was petitioning for an agency to advocate for the healthcare needs of rural Scotland so let's take that one first and I believe Emma you wanted to come in first of all and then I'll go to others thanks thanks very much convener I am well aware of this petition I was at petitions committee when it was presented as well when the petitioners sat in front of petitions committee and I know there are members in the room also that were there so I know the history behind it and I'm keen that we don't lose sight of what rural health and social care needs are and having the voice of people for instance in this example that I have in front of me is the people in Strunrar you know one of the key issues that the petitioner has been trying to raise for 20 years is the the Dumfru NHS in Friesengalwy is part of the south east cancer network that means patients in the south west of Scotland which isn't in the east of Scotland end up having cancer treatment in Edinburgh for instance instead of the closest cancer centre for radiotherapy which would be Glasgow so it's either just up the road to Glasgow or this distance travelled which is pretty hefty if you're undergoing radiotherapy or other cancer treatment so for 20 years my understanding is that Dr Gordon Baird who's a retired GP but former chief medical officer at the Galloway community hospital he's been trying to look at ways where we can have the voice of the people who live in remote and rural parts of Scotland but particularly Dumfriesengalwy for instance but it has become wider in looking at the other petitions with Cathness as well it's how to support what is best for the patients and it isn't just about you know you'll get your treatment where we tell you it's about giving people the best opportunity to have the best care where they choose but also to help reduce issues of travel for instance then so that's one aspect of it and currently people are means tested for their travel whereas in other parts of Scotland they're not they get their care without having to cough up from their own finances now that's an issue when it comes to health inequalities as well so means testing people for their care shouldn't be happening and then there's other issues regarding maternity services and I know there's a review happening right now of the midwifery led service in in Galloway because babies haven't been born in Strenar for four years so that's similar to Dr Gray's issue which has been raised in Parliament in chamber on a number of occasions so my concerns are that for 20 years there's been very little progress made to hear the voices of the people who live remote and rural in the NHS of reason galloway but also wider areas and I'm concerned that we are not able to I suppose I'm concerned that if we if we don't keep the petition open if we don't hear from the witnesses in this committee that we might lose sight of what the real issues are for people in remote and rural areas but with regard to the substance of the of the petition if I can press you about an agency because it is very targeted and that's effectively what we need to decide on whether this petition could take issue evidence on the idea of an agency or are you are you talking about taking evidence on the wider aspects that are surrounding the call for the agency so I know that cabinet secretary said that he didn't want to clutter the landscape from the official report and that there's already a fair bit of bureaucracy around the organisations the agencies and the institutions that we have so so yes I'm aware that the establishment of an agency is not the route that the cabinet secretary wants to take so I suppose that the the big issue then is how do we get the rural voices heard either in in we've raised it in chamber we've raised it in in debates and questions but how do we get the rural voices heard unless we continue to pursue taking evidence so I know in regards to the actual petition it's calling for an agency so I suppose I need to understand do we need the petitioner to resubmit a new petition addressing the specific issues rather than calling for an agency okay I'll go to Sandesh I think you wanted to come in on this one yes thank you I think I want to make a wider point to start with before focusing in on the actual petition itself and the first thing I want to say is the dedication of our staff that work in rural and remote areas is without exception and they are extremely dedicated and work very hard and despite their hard work I feel that our patients who live in remote and rural areas get a far worse service than those who live in urban communities do and that is due to a number of reasons and Emma Harper has certainly spoken about a few of them about the travel and about not having the expertise we also know that there is a lack of staff in rural and remote areas in comparison to those in rural and urban areas we're looking at nurses we're looking at doctors and GPs and retention is also important in those areas and working having done a GP shift in Dumfries and Galloway one of the other issues is travel looking at how I drove to my shift the fact the road was flooded and at one point I thought I was genuinely going to drown admittedly there was a storm but that's what people face patients face day in and day out in rural areas and what we offer is not good enough and so I would advocate us looking generally at an inquiry into into rural health which incorporates a lot of what we've spoken about a lot of what our petitions come with specifically on this petition I'm not sure a specific agency is the way forwards but I do think that that needs to be folded it into our potential work going forward on rural health care okay does anyone else want to speak in this poll thank you convener I recall as a former member of the public petitions committee sitting on the evidence session on the 8th of June last year in which Dr Bayard and others it was a combination of four relevant petitions covering this area and I think it very quickly developed into a much more effective and quality discussion not just simply honing in on this idea of an agency but broader agency of patients to advocate and for clinicians to advocate on their behalf and particularly focused on the power imbalance between health boards and other stakeholders in the system so I think in that respect the petition does remain relevant and in that regard I think there is scope for this committee to consider how we take those legitimate and sincere concerns forward because I think whilst it's inevitable inequalities will exist by virtue of geography in any health system because you know you can't have a fully functioning neurosurgical department in that town of 100 people you know but but nonetheless you know we need to look at ways in which we can effectively mitigate those issues where changes to service provisions are occurring are we effectively ensuring that there's ambulance provision there is allowances to allow people to travel there are protocols in place to reduce the risks of perhaps you know going into labour in a way in which you're dangerously far from a maternity department for example these are all things we should perhaps give cognisance to and I don't think they're necessarily being fed back into the healthcare decision making system through health boards and that's maybe something with this committee we'd have a locus and helping to further the petitioners concerns that would be my suggestion and in terms of the actual substance of the petition with the agency our use of the view that Sandesh has just expressed about well maybe that's the aspect of this specific aspect that we maybe close but we look at the issues that have brought them to to meet that petition I think the petitioners even when we had that discussion at the committee they weren't hard fast on the idea of the agency they were happy to kind of roll back if you like from that opening gambit and I don't think I don't know if there's technical rules for that but nonetheless I think I would be content to keep it open with an understanding that we can look beyond the simple ask of an agency and it's actually it's the question of the concept of who has agency in the system if you like but the the sort of I suppose the protocol for us as the committee is that we have to either decide to take this forward which is meaning an agency or we close the petition but we make it a different decision about further scrutiny in the more general area of rural healthcare that we brought because we can absolutely do that but it's one of those things that we can discuss when we discuss our work programme there's also other things to to with regards to do freezing galloway I believe that they're one of the health boards that will be coming in to see us in due course as well as part of our general scrutiny of health boards so a lot of the issues for example that Emma's just raised about some of the issues that that area that health board area is facing and some of the decisions that have been made there can be put directly to them as well so but in terms of the protocols with petitions it's either we take further evidence on the idea of the agency or we close it but that doesn't preclude the petitioners from coming back with a new petition based on maybe something that we have found out as a result of the further work and scrutiny that we do as part of an inquiry or whatever that might be. My view would be that we're not bound to the the ask of the petitioner specifically and it would give us a useful basis in which to roll it forward you know we don't we could retreat you know we don't have to it's not a kind of my view it's not a binary thing that we have to agree agency or no agency we can certainly but critical wise it is because we either keep it open or we close it and if we keep it open we have to go forward in the basis of what the petition's actually asked for so but be if we if we close it that doesn't mean see we forget everything that was ever in that petition we take the learnings of the petition we take the you know the evidence as as part of maybe a wider inquiry and roll it into that so we're not dismissing it we're not dismissing the things that people have said Sandesh I just thought I'd want to make it clear that I would like to take evidence from Dr bed but as part of that wider it's part of a wider inquiry so we have played what would be cognisanced in respect to the fact that this was the petition was laid but in terms of the agency and as you see if they weren't hard and fast you know they weren't really well led to this idea but they wanted the issues looked at then maybe they would be quite happy with that and of course it doesn't preclude them from thinking well actually no we haven't changed our mind we're going to bring back a new petition exactly the same and we're going to get that looked at again because as a result of the work that the committee's done we feel the same I think if the impact of the petition is it's this committee's responded by holding an inquiry that's related to it then it's done its job in a way you know so in that sense that perhaps it's not such a big deal if it's kept open or not I'd be content to rest on that anyone else want to come in Emma? Just to come back convener thanks that you know I know the work that Dr Gordon Baird and the Galloway community hospital action group have done in order to get the petition to this place I know that the locally people feel powerless I know that Sir Lewis Ritchie is interested in how the Australian commissioner for rural healthcare is working because Australia is a big rural country as well and I know there's a centre of excellence for remote and rural medicine being created but it doesn't have an advocacy role and that's what Sir Lewis Ritchie said when he gave evidence it would not be providing advocacy and I know this agency isn't about individual case work being picked up so that's absolutely not what Dr Gordon Baird was after when he was looking for an agency to be created it's about helping advocate for people given them a voice people that feel powerless people that don't know that they actually should be offered a choice for care that might be closer to home for instance and that's part of the real challenges I know that NHS and Fries and Galloway have committed to addressing cancer care pathways and then Covid came along so when NHS and Fries and Galloway come in front of us I think there will need to be specific questions around we're rather with altering cancer pathways what steps have they taken it's not just about addressing them all overnight that I know there are real challenges and you know everybody knows I was a healthcare clinician as well so I think that I'm just really keen to make sure that if whatever pathway we take forward that Dr Gordon Baird is permitted to or invited to come and give evidence about the challenges for remote and rural healthcare and advocacy for the patients I think that's a really good point as you say there's a couple of reviews on going in the health board area as well does anyone else want to come in in this petition Gillian sorry convener not specifically on this position but maybe on the next one so I'm going to move on to the next one and then well actually maybe maybe not to confuse things maybe we actually take a decision on this petition because there's too many words and letters and numbers and we'll all get confused so in terms of the PE01845 agency to advocate for the healthcare needs of rural Scotland can I have maybe a show of hands of those that we want to close the petition with the proviso that we may be looking to do in this wider review because I think that seems to be something so we may have a show of hands yep so at the moment we have a majority in favour of closing the petition but with the proviso that we actually include the issues into a wider piece of work that might do right let's move on to so we're decided to close that petition that's PE01845 the next petition in front of us is PE0189 and it is on find solutions to recruitment and training challenges for rural healthcare in Scotland so again a very similar theme and Gillian I know that you want to speak on this I think again convener this is one that we should be looking at as part of a as potentially part of a wider wider piece of work the petition is obviously quite broad and covers quite a number of areas and I think in this session we had with the cabinet secretary we maybe explored why some of these reasons are not purely healthcare recruitment issues and why they are issues to do with life in rural environments and in the first place as well so I think if we were to incorporate this into a wider a wider piece of work I think it would be interesting to hear from from other ministers as well about how issues within their portfolios could help to support that recruitment and support people to consider working in these these rural and and remote areas because I think at the moment it's it's very much based on people who maybe come from or have a connection to some of these to some of these communities to then take up recruitment and training and go back to them rather than us making it an easy choice to be able to go and work in these communities Sundayish thank you I would want to reiterate what I said the first time around but also that this is something that we should again be folding into our potential look at rural healthcare and I do agree with Gillian when when she speaks about the other issues and listening and talking to other ministers and just as I said when I was on my way down to Dumfries and Galloway the roads were terrible and that would put people off going and moving around so that is certainly a question to be asking the relevant minister in transport housing in rural and island areas is is is just not possible for people because it costs so much or there just isn't any and so these are all factors when it comes to recruitment retention and we do need to look at that as well and again you know it's fine solutions so that the fine solutions to the recruitment and training that it's almost like the petition that is actually asking for an inquiry you know in itself Emma thanks convener I didn't think I'd be talking about the roads in Dumfries and Galloway the E75 and the E77 as part of health committee but there are so many challenges with recruitment and retention we must remember we've got a scott gem programme it would be really good to hear how's that working what's the retention how where it's doing well and because I know that that's part of it there's also programmes to have general trained nurses become midwives or become general trained and that isn't happening in my part of the south scotland region in Dumfries and Galloway they weren't selected to be the dual trained approach but there is work that is being taken forward and it's not an overnight fix but I support whatever we need to do is let's look at rural health and social care and you make a good point but scott gem because I think we've just had the first cohort actually graduating so that's been up by a good time to fold that into something we might do any other comments on this petition or is everyone just more or less in agreement with the points we made so again bundle this into a wider piece of work about rural health care because that's all going to come up so let's take the decision so are we going to those in favour of closing this petition but with a view to doing a wider inquiry show your hands right we're I think it's unanimous we're all agreed to do that right the final position in front of us is PE01924 and that's complete an emergency in-depth review of women's health services in Caithness and Sutherland and I know that Tess wanted to speak on this and I know Jolene does as well Tess thank you thank you you don't need to press thank you convener I notice the words urgently and the date of the position petition is 20th of December 2021 so these are systemic issues that I think we're all in agreement with their their they need looking at and I think making sure that the women feel listened to and that services are not just centred around the central belt for example the mother and baby unit there are two mother and baby baby units in scotland and they're in the central belt and there was one that was supposedly to be planned in Grampian but that was kicked into the perinatal so I think actually having something specific on women's health in rural areas is very very important to progress as a committee so you're saying something specific on women's health not as part of this rural healthcare because I'm not I'm not sure that we have the scope and the capacity in the committee to do two separate rural healthcare I think it would have to be one larger piece of work that would encompass that if I can just make two points convener so firstly we've got now the women's health champion so that's a major step forward which wasn't factored in when the petition came forward so it'd be interesting to find out what the women's health champion is thoughts on on this and then secondly as you say convener the wider rural but making sure that we don't water down the points that have been made in this petition no I totally agree Gillianne off the back of what Tess has just said I think it's I think the wider inquiry on healthcare rural healthcare services at large are really important but I think my proposal would be to defer a decision on this specific petition because of current work that is ongoing particularly best start north review the minister Marie Todd has other pieces of that's obviously based on maternity services in particular but looking at wider things around abortion care and other women's health women's health needs I think there are other pieces of work that are ongoing as well that we have the potential to lose within a wider a wider inquiry if these things were to develop we want to take other evidence on it or there were other issues to arise so I think my proposal would be to based on those other pieces of work ongoing particularly best start north review that we defer any decision on this petition so that we can take it back up if there was other that's really good point on this well we've only just had the appointment of the women's health post so that would be something that we want to have her in anyway so that is an option as well keeping keeping the petition open with a review to with a view to see what comes back in the best start north review etc any other points that sandesh thank you I feel that the petition it is very focused it is very much about an area but we know Dr Gray's is an issue we know there are plenty of other places around rural areas that have the same issue and you know Paul was speaking about how you can't have an absolute expert in a small village but what you can do is have that expert travel if needed to different areas what you can do is make it easier for people to get the help that they need and so I would like to see an expansion of that of an inquiry where as part of our wider inquiry into rural health we have a session which looks specifically maternal health in all areas yeah okay Paul did you want to come in are we ready to nothing to add all really good good points so um i think jillian's proposal jillian's proposed that we keep this open um can i maybe see if we are in all on agreement of that we are we're all on agree we're going to defer a decision on this petition so we'll found out some some more about the on-going work so that petition that's pe 01924 is going to be kept open okay thank you colleagues that was really really helpful so we the last item on our agenda is to consideration of two negative instruments the delegated powers and law reform committee considered these instruments at its meeting on the 7th of February 2023 and made no recommendations in relations to either instrument the first instrument is the national assistance assessment of resources amendment scotland regulations 2023 the instrument reflects a routine annual rise in rates in terms of residential care charges increasing the values of savings credit disregard by 5.4 in line with average earnings and the lower capital limit from £18,500 to £20,250 and the upper capital limit from £29,750 to £32,750 in line with consumer price index forecast of 10.1%. The instrument also disregards payments from the wind rush compensation scheme from financial assessments for individuals living in residential care and no motion to a null has been received in relation to this instrument to any members have any comments to make no members have any comments so i propose therefore the committee does not make any recommendations in relation to this negative instrument does any member disagree no we're all on agreement the second instrument is the national assistance sums for personal requirements scotland regulations 2023 and this instrument reflects a routine annual rise in rates increasing the value of personal expenses allowance by 5.4 in line with average earnings and no motion to a null has been received in relation to this instrument do any members have any comments to make no comments to be made so i propose therefore the committee does not make any recommendations in relation to this negative instrument does any member disagree no we're all agreed thank you so our next meeting our next two meetings are going to be entirely in private where we're going to consider our draft stage one report for the national care service scotland bill and that concludes the public part of our meeting today thank you