 Good morning, and welcome to the 24th meeting of the Health, Social Care and Sport Committee in 2023. I've received no apologies for today's meeting. The first item on our agenda is to decide whether to take items 4 to 6 in private. Our members agreed to that. The second item on our agenda is the first of our two sessions on winter planning. For this morning's session, I welcome to the meeting Nicky Connor, director of Fife, Health and Social Care Partnership, David Gibson, who joins us remotely, chief social work officer, Argyll and Bute Council and chair of the Workforce and Resources Standing Committee at Social Work Scotland, representing Social Work Scotland. John Paul Lockery, also remote vice president Scotland, Royal College of Emergency Medicine, representing the academy of medical royal colleges and faculties in Scotland, and Pamela Millican, chief officer, Aberdeenshire Health and Social Care Partnership. We will move straight to questions, and I'll pass to Sandish Gohani. Thank you, convener. Good morning, and thank you for coming in for our first session. My first question is directed to both of you, Nicky and Pamela, if that's okay. So, when it comes to winter planning as we saw last year, the focus is on A&E, the focus is on hospitals, the focus is on what's going on. But if you look at primary care, GPs can't call a code black. They can't say we're overwhelmed it's impossible to do what we're doing safely. I was at work this summer, and it was almost like that. And this is the summer where I'm doing things when I'm on call at a speed that really isn't overly safe, but it has to be done because that's the way we get through the patients that are needing the help. So what plans do you have in place for primary care come the winter? Thanks very much. So just to maybe outline a wee bit about Aberdeenshire. So Aberdeenshire is a large rural health and social care partnership, and so we have practices covering that whole rural area. You're correct in terms of the practices that are under significant stress already. So we have practices that we have taken over as 2C practices within the partnership. So we already know that there's a level of sustainability issues for those practices. So you're correct in the roll-up to winter that becomes more pressurised because of the need that comes through the door. So one of the things that we have certainly done throughout the year is we have a sustainability support for practices. So we have a lead RGP for sustainability who talks to practices and to look at where there are areas where we can support them with maybe the multidisciplinary team that's been put around quite a lot of it through the primary care improvement fund. So we look to see to try and maintain that sustainability going into winter. The other thing is we work very closely with the LMC and our GP SOB, and they've just brought in a method to identify when practices are at a higher level of escalation. So we used that last year, which was a sort of a homegrown version, but we're now at the G pass. We're now using the one which is the more adopted one so that we can get at a glance which practices are identifying that they're under more pressure. Last year we invested in additional funding around anticipatory care planning so as part of the late sort of just for Christmas and then over the really high pressure area trying to get that support in early with practices to try and be anticipatory about the needs coming through. And the other thing that we do is that practices through the clinical leads are on. We have a daily system connect across the whole of Grampian and primary care play into that. So they're able to identify those particular issues. We also have a local for Aberdeensio. We have a connect where our primary care leads every morning come to and practices will contact them if they're at a particular level escalation. We have good communications about what practices are struggling and then what we try and do is where we can factor in support maybe from advanced practitioners or maybe some RC tech staff to try and get a bit of support round practices when they're going through those particular difficult times. So I think that we are aware of the pressure on practices. We're trying to support them in their sustainability more generally, but then are more flexible in our support when we get a kind of quote on from a particular practice. And then hopefully things like for example the vaccination program, which we're now working to accelerate, will mean that we can try and contain some of the demand coming through. So can you give a bit more information about LTC practice, et cetera, if you're interested? Within Fife. So firstly I'd echo what you say. Firstly, how critical primary care is to supporting people. It's the first point of contact for nearly everybody in our communities and primary care includes obviously general practice, includes community pharmacy, optometry and includes our dental practice as well. There's been challenges across all of those areas. Within Fife we have in March of this year, we have launched a primary care strategy. So that is looking at 3k areas is looking at the recovery, recognising doors did not close within general practice over the pandemic period. They continue to be open and supporting people in their local communities. It's looking at quality and it's looking at sustainability. Similar to what Pam had discussed, we have got two C practices within Fife as well. And we've been going through a process to support those practices to return to independent status and how do we work along those practices to enable that to happen. One of the things that I think might be a bit unique in terms of how we've approached it is looking at how we would define our operational performance escalation levels. So every single morning we hold a primary care huddle specifically, which brings together the clinical leads and it brings together the operational services. And one of the things I did a few years ago was I redesigned the health social care partnership and we now specifically have a primary and preventative care division. So there's a head of primary and preventative care there. I think that's been critical to support the engagement and the leadership with general practice. But what then happens every morning at nine o'clock is there's a whole system huddle that takes place and that considers the pressures in acute across all of our community services but also across primary care services. And it enables us to take real time action on the day if there are particular challenges that we face, as well as the planning work that we take forward over the winter period. The other thing I would highlight was around our governance. So we have established a primary care oversight group that is co-chair by myself and the medical director. We meet roughly every six weeks. We receive feedback and reports from all of our areas and that has supported us both over the summer when it has remained pressured, as well as our planning for going into winter. Thank you very much. As Aniliki, you spoke about the real time action that you'd taken panel. You spoke about being more flexible and doing things. I wonder if, as a follow-up, you might be able to write to us with more information about what that means. But from primary care, I'd like to turn to secondary care, if I may. And I'd like to ask John from the Royal College of Emergency Medicine a question. So using your own data on people who die because they've been waiting in A&E for too long, we found that people who are dying in A&E over four hours on their way was up 164% since 2018. Are you concerned that we're going to see this escalate this winter? Hello again, thanks for having me. I think it would be fair to say that the last winter that we experienced in emergency care is the worst for a generation and the worst probably in the history of the NHS. Experienced by long delays in emergency departments, for many patients mainly the vulnerable, the elderly but in particular some groups are more prone to long waits in emergency departments. So some evidence that women have to wait longer in emergency departments, the elderly and patients with mental health problems. The winter plan of last year focused on crisis mitigation and some short term measures but without a longer term strategy to avoid further winters like we had in the last one. And we haven't really seen any abatement in the pressure in emergency departments or indeed across primary care and across all the acute specialties in the summer like we normally would. What we have seen this year is a decrease in our workforce. So we are seeing a dwindling of the workforce across all sectors in Scotland and that's evidenced by the NES Turas data that was released in June. And what we haven't seen so far is any future planning that involves more than just trying to deal with the next winter crisis. So I asked extensively of the other medical royal colleges what they thought of winter planning in general and it's unanimous that this is no longer a winter problem, this is an NHS and crisis problem. In short term winter reactions is only crisis mitigation. We know we have a workforce problem, we know we have an overall capacity problem. Partly it is a product of a tenacious number of delayed discharges in hospitals and the latest data from June of this year still shows that we're around 1700 patients delayed discharge in Scottish hospitals. And we know that over the last 10 to 15 years with a reduction in the acute and general bed base that that has probably gone too far and we now have too few beds in Scotland in order to deal with these winter surges on top of an already over capacity and overstretched system. And to finally close you raised the point of the increased mortality. There's now a wealth of data demonstrating that ED crowding is associated with mortality from our own data that was published in the EMJ which has been used extensively to try and model and estimate the numbers of additional deaths in association with long ED stays. But data from Switzerland, from Sweden, from the USA again demonstrating that ED overcrowding is associated with poor outcomes and an increased risk of death. So if we see a winter like the last one, unfortunately, as was borne out in the NRS data with the increase in mortality of 6 per cent above the average for last winter, we can expect unfortunately that we will see similar risk of increased death over this winter. My first question is to Nicky. Many responses to our inquiry highlighted the importance of social care in robust winter planning, but many said that last year we didn't sufficiently account for it. What would you like to see done differently this year? I think it is about the planning, and I'd echo what my colleague said around this being a full year effect. Planning for small bumps is not what we require. We require to be able to plan full year, and we require now to be thinking about 25-26. We're looking at what we're putting in place. When an IF resource becomes available for periods of time, we have to recruit the workforce to be able to do that. We have to bring certainty to the workforce. Some of the areas that we would be very committed to and we are is also recognising firstly the value of integration, so health and social care partnerships bring together all of the sectors, our statutory services, but also our third and independent sector. I call that out specifically important to the sustainability of social care, so I think there's more we need to do around looking at the sustainability for our independent sector colleagues. Within Fife, one of the areas or one of the examples I would share we have done is we have created a care-at-home collaborative. That brings together 27 of the providers that we have within Fife. They have came together and we have put in technology. It's called Pinpoint Care. It allows us to see where people require care across our system and to work differently with our providers in order to inform who is best to respond. That's helped us both maximise capacity within our system, but it's created that collaboration, that Team Fife approach, where we're all here together. We're not competing, we're completing in terms of how we are working together for the needs of the population. For me, twofold, I think it's the ability for the longer term planning with the resources according with that and it is about really maximising the benefits of integration to be working together in that collaborative way. Also within those responses, it was highlighted that our high levels of fuel poverty and obviously this is causing issues for people, heating their homes etc. I had read about the pilot where doctors were actually prescribing heating and this seems to be having a real impact. Is there anything, any other sort of pilots or you know service like bits that we're thinking outside the box to not just think about you know when people present but how we can help them not coming in in the first place? Last year we had within the Grampian area public health worked with one of the energy companies around looking at support around energy bills so that was for very SME, SLID areas so they were able to pinpoint that and that was something that was made available, it was tested in Aberdeen city but then there was a view to if that's something that we maybe can learn and encourage again that company to maybe do on a more widespread basis so individuals were pinpointed to get some extra support. Certainly within Aberdeen, shy, we work very closely with the council so coming up to winter they have a lot of initiatives around cost of living and support around families so there was a lot of information and support that went right out to communities to say these are the things that we can help you with around cost of living and fuel poverty. We also in Aberdeen city because of our we get affected by bad weather in terms of snow and we've had a lot of high winds so we also worked with the council and our own frontline staff to prepare families and carers so that if they are for example a power cut or if they're elements like that that we have blankets available packs that we can deliver of torches blankets etc so we can help respond in crisis and we we are part of the the powered scheme which is looking at identifying vulnerable people so specifically in Aberdeenshire we were a bit further ahead we worked with the council so taking off our management system for social care care first we are able to identify those who might be vulnerable and particularly if they're cut off from either you know floods or bad weather so that we are able from our social care and then if we need to we can then get support from wider local team response to actually go out and support individuals if we can't get in contact with them so we have that list of vulnerable people that we are able to trigger and pull off in when there's an incident around maybe weather that we can actually go out and make sure that they're made contact with that we're visiting them or we have contact details of families or neighbours so we can make sure that we know that everybody's safe so that's one of the things that we've learned through our response to resilience is actually how we're able to make sure that we are keeping people safe over winter but then also over peak periods. I'd be keen to pick up on a point that you that you made Pamela about the effect of the cost of living crisis and the how that's impacting presentations, the health of the general population. Do you see that currently impacting on presentations at perhaps ANE, to GP surgeries and exacerbating and making health deteriorate? Yes, I think one of the things we've seen particularly is around mental health so I think we've seen higher levels of need for mental health we've also seen greater complexity of care so we have a very ageing or an ageing population on Aberdeenshire so sometimes it's difficult to identify whether some of the need coming through is due to that ageing population because we've got that 28 percent increase in ageing population between 2018 and 2030 so we're on the beginning of quite an escalation of an ageing population but we've also got a lot of complexity that's coming through which is I think view that that is people who maybe didn't present so much through COVID or they presented and are now presenting at a later stage so we have higher complexity of people coming through but we also have had an increase in our adult support and protection presentations so people coming through with mental health crises so one of the areas whereby we all received winter money a couple of years ago one of the areas that we've been able to invest is in things like adult support and protection so that we can actually get round individuals and support those situations so there's definitely higher levels of need coming through the other thing is that we have in terms of social care we have 70 percent of our social care is commissioned and 30 percent is in-house and what we do is we focus our in-house re-enablement complex care and being more responsive in terms of delayed discharges and or pulling people out from acute hospitals we found that that caseload of our own team has increased so and the dependency of people coming through are higher so I think we've definitely got a more dependent needs coming through and I think that some of that will be cost of living the other thing just on cost of living I think it's affecting our staff so I think that's probably a really key area for us and earlier Nikki talked about some of the issues for social care so for me around social care is I have challenges around recruitment in social care and that is particularly in rural areas whereby the alternative work that people can get will be more attractive from a wages perspective so that's one of the issues that we had to be extremely proactive to promote opportunities in social care and we're for example going to be involved in the international recruitment hopefully so we're trying to look at every opportunities but I think that in part is the reflection on cost of living so we'll move on a bit to workforce further on in the session but I believe Emma Harper has got a supplementary here. Thanks convener and good mornings I just wanted to pick up a quick question about working with the third sector as part of winter planning because I think I'm sure David Gibson might want to come in here but Nikki you mentioned that obviously we need to plan with in a wide collaborative way and so what work is being done as part of winter planning to involve the third sector and the voluntary sector? So within Fife we have our third sector lead as part of my management team so that's about supporting open discussions so sits on extended leadership team and I've also created what is called an integration leadership team and that's bringing together up to 200 people across third sector independent sector as well as our statutory services and we're meeting on a regular basis to talk about issues that matter collectively so that feels like a change actually in progression in terms of supporting integration. What we're also doing is and I would really hugely value the role of the third sector and one of the areas we're engaging is looking at something called the well in Fife so that is looking at establishing in each of the localities that we have a point of contact for local communities where they can be signposted from other services or they can just go themselves and that's supported a lot by third sector and it is enabling us to identify using the data the priorities of local communities and then how do we best use that. We have groups in each of our localities as well which have third sector representation and as part of that work they're part of shaping and all of that is influencing the work that we are taking forward. Paul wants to come in briefly on this point. I believe I'm just checking I was unmuted. Just touching again on the impact of deprivation on utilization of services there's been much written by the group of the deep end GPs around the funding and primary care additionality that's required for looking after patients in these circumstances one to meet the healthcare needs of them and two to try and reduce their impact on other services. We know that the patients from the most deprived populations are higher users of both primary care and of emergency departments and that's not inappropriate because they have more complex and higher healthcare requirements. There was some work published recently by one of my colleagues Dr McHenry examining the association between deprivation and ultra long waits in emergency departments of more than 12 hours which found quite a clear association for the patients from most deprived backgrounds having longer and longer waits in emergency departments so this is a truly whole system problem from patients from the most deprived communities requiring more healthcare from both the GPs and an emergency departments but also receiving a poorer healthcare experience and increased risk when they do come to our doors so that really is another example of the whole system approach that's going to be required not just for this winter but for planning for the next five to ten years. We have an ageing population, yes, but we need to get to the bottom of how we address the equalities in healthcare and make sure that the patients from our most deprived communities receive equitable care from those from our greatest. And David Gibson wants to come in here. Hi, thank you chair. Apologies, I don't seem to be able to get hands up or read the messages. Exactly as my colleague just said there, this is a whole systems approach that we've got to look at the third sector are absolutely key to that. I think one of the things that has to be pointed out though is and obviously serve our rural and island communities is we're often robbing Peter to pay Paul, you know, if the third sector is successful in recruitment they've come from us more likely the public sector and NHS have taken staff from the third sector. So we have got a fundamental problem that we don't have enough people to look after the people. So how do we do it differently as we move forward and also pick up on something that John said just previously? It's fundamentally whole systems. We've got to get away from the short termism. We've got to fundamentally get away almost from the concept of winter planning. These are system pressures that are endemic. We don't have enough social workers, we don't have enough social care workers and I know you've mentioned we'll come on to workforce. That is so key. That is the key restrictive factor as we move forward as the workforce. And a point when a mother colleague said, this is not just about recruitment, this is about there are not enough people to recruit, this is about training and so forth. And I'm realising, chair, I'm drifting into workforce apologies and happy to come back to that at that point. Thank you. Paul Sweeney. Thank you, convener. Thanks to everyone for coming in today. Submissions to a call for input to the inquiry cited this proportionate focus on secondary care in the last winter plan and claimed to undermine the Government's intention to support a whole system approach. Indeed, health expenditure across the UK is similar to other OECD developed countries in total but differs in that most of the spend is allocated to hospital care as opposed to preventative care or community-based settings. So it could be argued that this disproportionate expenditure on secondary care is a year-round structural imbalance, which exacerbates the vulnerabilities and particularly in acute hospitals. So the witnesses agree with the views expressed in written evidence that primary care wasn't prioritised in the way it should have been in the winter plan. Perhaps picking up on the point that John Paul Lockery made about GPs and DPN practices. So, though we got instructions out which informed our winter planning, I think as Nikki alluded to, we work as a whole system. So as health and social care partnerships we bring to the table what is going to be important to us for winter planning. So we do that collaboratively and we're aware that the acute services would be looking at how they could maximise their capacity but we all came together and looked at our whole capacity. So we did, for example, we have community hospitals, we looked to maximise and improve a number of surge beds, we also looked at we have very sheltered housing and care homes which we run in house, we looked to increase the number of places there too and we looked at where we could commission some additional support and put in key staff, for example, into the discharge hub within acute. So we increased our staffing in the discharge hub in acute. Now some of that was done with the winter monies we got a couple of years ago but actually started to have that impact last year because it took a period to recruit. So we work as a whole system to try and maximise how can we as a community work together and that includes primary care. So I talked about anticipatory care plans. If I am aware that people spend the majority of their time in the community so absolutely the more we can do around preventative and support there will mean that we don't, people don't have to go into hospital, I think as others have commented, it's absolutely can be the wrong place for people to be, it certainly is the wrong place for people to be when they're waiting as a discharge. So we have some initiatives like, for example, virtual community ward, which is our equivalent of hospital of home but that's to try and stop people being admitted. So it's support we put around the GP practice. People we think are likely to get admitted. Can we put additional support around them? We've put a bid in, just been asked recently to put a bid in to government to look at to expand that capacity. I think there's mileage there. So I do think that there is mileage with additional support and capacity in the community that we could avoid admissions, we could support people better at home and we could do more preventative stuff. I think as I've talked about both in terms of workforce and the resources that we have, then you are trying to get the best that we have and we know that things are tight. So we're going to be tight for resources this year and we're tight across workforce. But what we do try and do is to use people to best effect and that includes third sector, for example, so very much around for us a place based locality response to make a difference and if we can build our places and our localities so we're starting to be part of place based planning, which is really about working with third sector, working with council, working with communities to try and build that resilience and that local responsiveness so that we, statutory service I guess, have to then intervene less. So that needs to be part of our response to the future. If I could just build on what Pam has said. In line with, I guess, a priority for Health and Social Care Scotland, but also our own priorities and partnerships, the sustainability of acute services is a key priority for us. I think the role we have is the alternative pathways to support people that don't need to go to hospital, to not have to go to hospital and when people do need to go to hospital to support them to be discharged as quickly as is possible. Some of the work that's going on around that, I echo what Pam said around hospital at home. We've also put in a bid to recognising that some of the causes of admission over winter is respiratory conditions and could we do more? We believe we could do more in those areas and we have put in a proposal around that. There's also the work around urgent care and flow and navigation to identify people's needs. Similarly, as all partnerships will be, we take a locality-based approach and we have identified in one of our localities where we have higher admissions to the emergency department and we're doing a whole system, I guess, a huddle looking at the needs of the people in those communities and how do we respond and we're also doing work specifically with the Scottish Ambulance Service around support for mental health. So there's a range of areas that are going on and I think prevention is the key. The other thing that is really important is that we don't just look at the discharge from hospital or prevention of admission, it's unmet need within the community. So that's an area that is absolutely critical to us and we monitor that. We provide submissions on it every week in relation to the unmet need in the community and making sure that the individuals who have assessed need in the community are also accessing their care and I think that's a critical preventative measure because these are people that have been assessed to have their needs and we've seen significant work in making sure, I guess, in health and social care partnerships that we provide that balance across a system. And that monitoring, I presume, feeds back into design of the services but then trying to prize the immediate firefighting activity in an A&E department towards building up that capacity might be a challenge. I just wondered if John Paul Lockhart had a view on the practical way in which he would pull resource out of areas where it's currently people in crisis because they've not been dealt with earlier on in their care journey, if you like. Yeah, it would be remiss of me to not talk about the experience in primary care and the experience of GPs and Mr Sweeney, I think, you've probably read directly from a submission from the Royal College of General Practice who are deeply concerned about both last year's winter plan and the on-going winter planning that seems to focus as they have described largely on secondary care. We know that around 10 per cent of GP practices have had to close their lists and we know that there is a workforce crisis in primary care. We also know that a lot of the strategies around the winter are about attendance and admission avoidance, trying to keep people at home, but a lot of that puts more pressure on to already overburdened GP surgeries. The messaging around a lot of that seems to focus on avoiding coming to emergency departments and going to see your GP or pharmacy, but a lot of that fails to recognise that those services are already experiencing huge pressure as well. When hospitals and health boards ask GPs not to send patients to hospital, again, that falls a lot of the burden of risk into the community. In terms of the strategy for funding of our healthcare service, organisations have called for a national conversation, a longer-term strategy, a review of how all this is funded and organised. Undoubtedly, patients get care better when it is as close to home as is possible, when patients are in hospital for a shorter period as is possible. But when we talk about flow in the system, we largely focus on flow from emergency departments and receiving in its into hospitals and out into the community. Rarely do we focus on the flow back into primary care of some of that complex work, which has traditionally been performed in secondary care and has increasingly landed on to GPs to perform. We know that emergency patients are becoming more complicated, so previously 10 per cent of patients presenting to EDs were considered complex. Now that's around 30 per cent, and that's an experience borne out in primary care, where our GPs and colleagues there are having to see more and more complicated problems, often for longer periods because of increased waiting times for outpatient clinics and for elective procedures. If we have a winter, like the last one, when we have swathes of elective care cancelled short-term to respond to acute pressures and acute crises in the emergency care system, that is again just delaying care, and that is leading to long-term complications for some of these patients. Really, I don't think that there's any significant strategy for this winter that would considerably increase the capacity in primary care, but we need a longer-term strategy to help our colleagues in primary care and GPs respond to the needs of our population and be resourced to respond to the needs of our population to do what they do best, which is managing complex long-term conditions and having a long-term oversight for the care of their patients. Thank you. We need to move on. Can I ask that both MSPs and the panel give us short, concise questions and give short, concise answers, because we've still got quite a bit to get through? David Torrance. Thank you, convener, and good morning, everyone. To what extent does the existence of pressures all year round now make the concept of winter planning redundant? A quick answer. I think we both said that it's all year round pressures. We have a particular thing around winter, so we will get increased flu with vaccinations, et cetera, and respiratory illnesses. We also, as I said, will have weather incidents, which will cause falls, so we will have, so we know that normally January, February will be potentially even more pressurised, but you're absolutely correct. It's all year round. I would agree. I think we need 365 planning, and within that, there are different peaks and troughs and different challenges at different times of the year. I think some of the challenges, as well, are over the public holiday period. Do you know when we have faced those challenges? They are in the middle of winter, but we also experienced those at Easter, and the planning that we've taken to both of those this year was no different in terms of how we support a system. In evidence, the committee heard 2022-23 winter period, winter planning, and associated funding came too late. If policy makers intend to continue with the creation of an annual winter planning future, how can the timings for its development be improved to accommodate the needs of different professions? The main funding that came through to us as health and social care partnerships was some interim beds funding that came through in January, so that was in terms of getting that up and running for the winter period. It was helpful, but it really only built on if we had those plans in place already for interim care beds, so it allowed us to expand capacity. We did that, and we found it very useful. We'd invested ourselves in interim care, which meant, as we could just build on it, that I think it is, as people have said, that if it is a much more planned and sustained investment, that makes a difference, because we need to be able to recruit teams, embed them, and get systems working well to be really effective. Funding is always really supportive, and we are in very challenging times at the moment, but having that much more in advance is much more effective. I would absolutely agree. I think it is about that. We need to plan in the medium to the longer term. We are talking about real diversity of need across the system. I think that knowing that funding is coming targeted for specific areas can often be helpful, but it has to also come in the local flexibility, because across Scotland there's 31 health and social care partnerships, all of which are different. When we are looking at different organisations, different needs, whether that be primary care, whether that be social work, whether that be social care, third or independent sector, bringing that forward with the requirements to focus on those areas can also be a helpful direction. I think that David Gibson has his hand up. Just as we said there, we need to get away from winter planning as a concept. The pressures are all year round. Also, when we are talking about winter planning, we are getting to short termism. We are planning for a few months ahead. Actually, it is not just planning for the next year, it is planning for the next five years, the next ten years, because we are fundamentally developing the workforce, developing services, and we can't do it with short term funding that is coming in on an almost emergency basis. If I put my Argyllun bute hat on, which is not why I am here, but if I put it on, it is almost impossible on a rural and island areas when we get short term money to actually recruit for short term posts. No one is going to move to an island or some of our most remote areas for a six month contract, a three month contract and so forth. The short term planning and the short term funding is actually damaging the system now. Money is not the main restrictive factor anymore, people are. So we have got to look at how do we get those people in place. That is a four and five year plan, not even a one year plan, never mind the next three month plan. So I would take your point very much into consideration. Harper has a supplementary here. I am interested in the national treatment centres because if we are talking about winter planning and Pamela, you mentioned that people fall on the ice so that becomes an emergency orthopedic bed space that is occupied but the national treatment centres are intended for elective approaches so that we can do keep this sequestered elective bed spaces for instance. So Golden Jubilee has the national eye centre but in Fife I think there is the orthopedic centre. So is that part of what will help plan organised approaches to beds in secondary care? I think some of the value of that as well as around the regional approach. So we are all part of regional networks and about how we plan together across the regions. So there is what you do at a locality right up to what you sort of do across Scotland and then what you do within regional units. So I think the value in being able to do that is being able to plan together. And I think it is about recognising the distinction between emergency and planned medicine as well and the different responses that are required in relation to that. One is more predictable than the other but that can also become incredibly challenged over a winter period when there are particularly if there is increased pressures on emergency medicine. Going to move now to Gillian Mackay. Thank you convener and good morning to the panel. It was highlighted in submissions to the committee that it can be difficult to recruit staff into short-term contracts to fill winter pressure particularly during a cost of living crisis and that uncertainty for on-going employment. How can workforce planning and models that we currently use be improved so that staff are given that level of security and are being recruited according to future needs given the previous comments on 365 planning rather than in response to short-term pressure periods? Across all our services recruitment is a real challenge in Aberdeenshire and I think it was picked up in terms of I think for rural areas in particular because as individuals say you probably need to come from those areas or need to have an attraction to move back. So we need to grow our own so one of the things we need going forward we need to do is grow our own so we definitely need to have longer term planning and we need to so there's some elements which I think is around our touched on social care it needs to be an attractive proposition to come into for staff but for other staff groups I think there is something about making the work it is people have had a very stressful and challenging time if we look at our levels of people off with stress that is still relatively high and so we need to make the careers something that is attractive for people to both come to and stay in so that's right across what social work nursing, allied health professionals, GPs, social you know care management the whole the whole gambit so we work very closely with schools so we have have got an extensive number of foundation apprenticeships young people's coming into our schools so actually experience that and so that they can have that work experience before they go out and hopefully take a career in health and social care. We have we've gone out recruitment fairs right across Aberdeenshire to try and bring people back into the profession but also to attract people to the profession so we also need to work with universities to look at the career pathways so for us we have a key component part of my priorities is a round workforce and the continuous development but the other thing we need to do and I think it was touched on as we maximise integration we need to look at how we can use the skills that we have got to best effect so how can we bring staff teams closer together and try and make so for example we have community treatment and care nurses we also have vaccination staff can we actually look at who's doing what to try and maximise their that the the input that they can provide for the local community similarly between our social care and our healthcare support workers so at every turn we're trying to make the best use of our staff but also we need to look at that that kind of career pipeline and make it a really attractive place for people to come work and stay. I wanted to to speak. David. You caught me off guard there. Thank you. I think that just as was put forward there we have got very significant plans that are going to help us out in four and five years time grow your own is a phrase that is often used however all of these are plans that are going to have a benefit three and four and five years time we have got a very distinct problem just now what do we what do we keep doing as we've been doing it what do we do differently and the question that no one really wants to answer is what do we stop doing because if we can't increase the size of the workforce in the shop in the short run how do we make the size of the workload fit the workforce now that is a really difficult question at a local and a national level but it's one we've got to address and not avoid thank you chair. So I think it's also about the retention of staff that we have as well and so there's a huge amount of work we're doing it's one of my passions actually this around how do we support a workforce because without them we're nothing and we need and that involves our culture that involves the work that we do to support that culture but it's also some of the practical things so one of the things we did is we've got posters up in every co-op and you can queue our code and if you want to become a carer then then you get straight through in terms of how we support interviews so how do we make it accessible for people and we established a care academy which is working with our local colleges and our local communities to develop the career pathways as well and when staff are with us how do we support that career progression not just to grow your own entry point but actually to create careers within health and care. Thanks. A very short one. Thanks convener. Submissions to the committee also have highlighted significant concerns around staff wellbeing particularly with the cumulative stress over over repeated years and the practicalities around staff sometimes not having access to to hot food and drink and obviously travel issues for for social care staff. What concerns do you have about the impacts of winter pressures and how is that being dealt with within your specific services? If we can maybe go to John Paul who's been wanting to come in and perhaps he can address that. I'll keep it brief convener. I think that's a very pressing question. We do have a problem with the way that our staff are treated and the pressure that they have to work under. We have a 6.2 percent sickness absence rate in NHS Scotland which is increasing over the last 10 years. The GMC training survey last year pointed that trainees in emergency medicine are at the highest risk of burnout and the GMC survey of GPs showed that they are increasingly at risk of burnout, increasingly unable to provide sufficient care and that around 15 percent of doctors surveyed have taken hard steps to look to leave the NHS and leave medicine. If we don't address this just now it is a generational thing to fix. It doesn't take five minutes to train a GP. It doesn't take five minutes to train specialists. This is something that we have to have a long-term and coherent plan for. Short-termism is not the answer in this. We had around 450 million spend on agency staff in the NHS in Scotland reported last year. That's money that could be invested into the people that we have in post just now. In order to do that we need to look at a parity of esteem and parity of pay so that we don't, as David said, rob Peter to pay Paul. National treatment centres will be recruiting from a finite group of staff to operate on those as well as NHS staff to move from third sector and from social care because of perhaps a difference in pay. Without a long-term workforce strategy cutting across social care, healthcare, medicine, all of this, we are going to end up taking away staff that could be providing essential care in other sectors without a long-term view of the unintended consequences of that. I've got three questions, if I may convene. The first for Pamela Millican, if I may Pamela. Aberdeenshire Health and Social Care Partnership covers remote and rural areas where the future of primary care is in jeopardy. That includes Breymar where, as we know, there have been huge difficulties recruiting a GP and it means that the practice will have to hand back its contract in December. So it'll be handing its contract back to a 2C arrangement and there are already six GP practices under a 2C arrangement in your areas and this will make it seven. So my question is do you expect this to increase so it's six to seven, will it increase over the coming year? So actually it's five at the moment but yeah because we returned one back so we were able to return one back to independent practice last year. We're out to tender for our independent 2C practice at the moment so we're going through a tender process and we have had some interest. So my question is about will it increase the number increasing? So the number hopefully the number will decrease because we're out to tender to bring in some independent contractors to hopefully take some of our 2C practices back in the independent sector so we're going through that process and we're optimistic about where that will take us. So I think that that will be helpful because and we have as I said recently been able to return one back to independent and contractor status so that's something where I would hope that we can minimise a level of 2C practices with Breymar because it is a single-handed practice primarily that having won the second GP having retired that means that we we have to we get much shorter timeline so to keep services safe for individuals we have to support that practice to withdraw within three months and given that timeline we can go out to independent go out for tendering for that practice but to make sure that we've got that continuity of care we plan to take it over and we can then can go through a tender process. We're also working very closely with the GP practice and we're working closely with the community to make sure that we can try and make it as sustainable and supportive during that period and then if if we are able to recruit either if the practice is able to recruit in the meantime that's brilliant because they will probably retain the contract or we can try and bring in a new practice and so I think we had another example earlier on this year of a very large GP practice that looked to return their contract but having got round them with a team looking at their sustainability and how we could support them they also reached out to other practices across Scotland and looked at maybe the models that they were doing and they were able to redesign themselves to feel more confident and therefore they decided to retain that contract so it's a constant close joint working with the practice with the community when we have a practice that is stable. Sorry so you the question so you don't expect it to increase it hopefully decrease so my second question because I've been asked by the convener to be Chris my second question is and you described the issues of rural practices particularly and Braemars a good example here where you talk about bad weather high winds in the winter heavy snow flooding so in terms of moving to a 2C and the cost model of sourcing and supplying the GP practice with locums that can be done in hours but out of hours it can't be done and so you've got these rural practices that are cut off isolated during the winter months so what are the cost implications of that and then also what are the considerations of leaving these remote areas without any form of GP support? So the Braemars practice is quite exceptional practice it does its own out of hours which is very unusual all the other practices across Aberdeenshire out of hours is done by our GMED service our GP out of hours service so that clicks over so we will need to do work and we're having a workshop later on this month to work with the practice we will also work with for example Scottish Ambulance Service because as you say it is very remote and they have the practice has traditionally done its own out of hours we'll also work with GMED the out of hours service to see what service to make sure that we've got an out of hours service so you're absolutely right we are we require to provide both an in hours and an out of hours service to that local population and so that will be something that we will look at what model will be effective in doing that and as you rightly say there may be cost implications but actually the important thing is to get the right care for the local community. Okay thank you my third question convener so one final question for Pamela. Miss Millican, Inch Memorial Hospital's minor injury unit and minor injury units are very very important as we know and the inpatient ward closed in 2020 to allow nurses to be redeployed to other healthcare settings and it never reopened despite the former First Minister committing to renew or upgrade the community facility more than two years ago so my question is what are the obstacles reopening this facility and what is the time frame for delivering on the commitment thank you. So I need to correct myself if I'm wrong but I don't believe I've had a minor injury unit but it had when I came it was already closed I've been in post for a couple of years but I can correct myself if I'm wrong on that so in terms of that local the physical infrastructure is not appropriate for inpatient care so both in terms of the size of the rooms etc but also some of the infrastructure. We're working very closely with the Friends of Inch in the local community and to see what alternatives can be used in terms of both that facility but also about how we can make sure that we have good community resources and support in that area so at the moment patients from that area travel to neighbouring community hospitals if they need a community hospital stay now I know every community would like to have their own local facilities but in that particular environment is not one that we're possible to run inpatient services at the moment so we need to both look at what we can do now to shore up and work closely with the community about what outreach or home-based services may be building on our virtual community wards and other ways that we work more proactively with people in their own homes and do that while we're looking at and so there was a potential for a business case being put through to Scottish Government but we all know that capital is extremely tight across Scotland as well so we need to be realistic around that. That sounds like a politician's answer to it it's not going to reopen thank you. I have been asked to go in a theme about public messaging and sometimes there's a suggestion that we need to manage the expectations of the public around the NHS and sometimes I worry about it saying that and I'm wondering from the evidence I've heard today and some of the discussion that we've had is does government need to be more honest with the population about where we are in the NHS and whether you feel that message is out there in the public because my experience is that most people are really just trying to access a service and the way in which it's been provided over many years. I think there's opportunity for us to reframe a conversation I think it's important that we do and I think that's what that means at a national level in terms of national comms but what also means at a local level because it's the national comms can only by their very nature be broad local comms can help people navigate the right place in the system there needs to be synergy between those comms because I think sometimes people can get a little bit confused to get directed someplace they go there and it can't meet their needs so we need to be clear about all of that so I think there's also communications about services that can be provided there's also stuff around our public health messaging though and the importance of vaccination the importance of some of the measures that people can also take to helping to support themselves and again I think there needs to be synergy between those nationally and locally but I do think I do think the time is now to to reframe a conversation for the future. I wonder if I could briefly ask John Paul Locrie. I was going to ask John Paul in particular I think we put a lot of pressure on people about alternative pathways which I absolutely believe in but people have access services in the same way for a long time and I feel sometimes we put too much pressure on people particularly in the deep ends that you mentioned to access things in a different way but we don't really help them you know to navigate that very well I would welcome your comments on that. I think there's a really important point to address around public messaging a lot of public messaging is around trying to get people not to access services when generally these are people, patients, our friends, our families who are just trying to access services in the best way possible. I think there's two areas to address we do have to be honest with telling people telling our service users and patients what they will expect this winter it may be that some of your assessments are done virtually over zoom over other platforms and ways that are new to patients that might take a bit of getting used to but many consultations can happen in that virtual manner especially in primary care and colleagues in primary care have wanted to address that that we need to make sure that our patients and our population know that that's the way that sometimes healthcare will be conducted at the moment that maybe that we use our flow navigation centres more to pinpoint and redirect people to the best services for them but around the measures around public health messaging last winter we saw astronomical numbers of patients presenting to pediatric emergency departments to GPs and to pediatric services with concerns around the group A epidemic. Now a lot of that was worried well patients and parents who were perhaps on treatment and weren't getting better as quickly as possible but that public health messaging never really changed and there has to be an agility around a public health messaging that can change to try and make sure that our services aren't overwhelmed by patients who could be directed to self care so one I think we need to tell people what the winter will look like and how they will be seen generally people do choose well very few patients actually that present to EDs should be seen in other services it's around 10% we're not deluged with people who should be seeing their GPs their GPs need the support to say you don't need to be seen for this you can self care or we can see you virtually or by telephone and also around about planning for spikes in activity asking people not to come to emergency departments and to see the GP instead as again just pushing more pressure on to an already overburdened area of the system where some of these patients might be better with self care or with actually being seen quickly in the place that they have first chosen to try and seek their health care it's helpful thank you thank you and Emma Harper has a brief supplementary to this point thanks thanks convener it is going to be brief just think about public messaging and this winter encouraging folk to take their Covid vaccines and their flu vaccines because of this new variant now that people are being worried about BA point 2.86 but it's interesting that I suppose does more messaging need to go out there to encourage people that Covid isn't over that we need to get the messaging out that people should take the vaccine absolutely so clearly we've had the announcement this week to bring forward the vaccination to respond to the new variant so that's something whereby we've already looked at our plans and we're able to accelerate that program particularly for people with complex needs so and we will do that for our over 75s as well so we're looking to try and accelerate that program and get people protected early but I think you're correct the more public messaging we can get out to get people protected and also we will be encouraging our staff because it's key that our staff are protected too so both in terms of their availability but but you know we want to be really cautious about you know making sure that we keep everybody safe so everything around that would be helpful. I'm now going to move to Paul Sweeney to our final thing. Thanks very much convener. I just want to touch on some of the submissions that have been made around potential waste in the healthcare system. I think the most valuable commodity in the national services time and certainly Community Pharmacy Scotland reported in their submission that they did not have read and write access to patient records so had to email or write to GPs with details of any changes. This is taking up pharmacist's time and antiquated process and creates a risk that patients may seek further treatment before their records are manually updated and that's just one example. Are there other blockages, there are blockages that came to light last winter that could be remedied with the support of technology so with the view of you know obvious waste within the system that's just one that's been highlighted. Is there any other examples that you really find difficult and would benefit from parliamentary support to to sort of address? We had a good news story last year in the sense that we were able to get our care managers across our communities on to the hospital IT system so that allowed us to reduce the time for assessment from 15 hours to one and a half hours so that was by giving live records so I think you're absolutely right the more interconnectivity that we have between records can absolutely save people's time and so we have I think there does need to be more investment in information technology both in terms of the capacity for people to be more agile in the way that they're working but also connections between the different IT systems that we have across Scotland so I think that perhaps having the unified CHI will make or the CHI replacement will make a difference because it'll be a lot of that back office linkages between records which will mean that we don't have less duplication but we are still have areas of our staff who work on paper-based records and that's something that we're working on because that's that really isn't good enough but it has been something that maybe over time it is not being prioritised for our community teams around their support around digital technology. I think building that I think without a doubt having that ability for our systems to talk together would be great I think there's the work on going around girfy in terms of the pathfinder work and what does integration look like and I understand it's not an area we're one of the pathfinders but we're looking at transitions in care but I understand that is one of the areas that has been explored which would bring forward some some learning. The other area for me would be around technology enabled care and it probably also goes back to the public messaging if we're going to deliver care differently whether that be through video consultations or whether that actually might be about sensor technology in people's homes reducing the need for individuals to be there to be responsive we need to support people to understand and feel confident in the care that they're receiving in that way so that is an area where everything all parts of our lives if you go to the supermarket we're much more digitally enabled that should be expanding much more within our care sector and that involves I guess that horizon scanning that's seeing what works in other places and being able to bring that in the one thing I'd say though around all of these changes is the product itself it's actually the confidence in staff to use it it's the confidence in the public and being able to access that information for us to be able to give assurance around safety of information for individuals as well so I think if we're going to be doing something different around this area I think we also need to invest in the rollout and how we support that to be implemented well at a local level that leads on quite well actually to another supplement I had on this which was I might have heard from GPs in Glasgow in particular that they're so busy firefighting day to day in clinics clinics that they are simply not enough time for them as a practice to consider innovating or making improvements and that's a real frustration because they note that digital solutions could help alleviate some of the pressures facing primary care indeed submissions have also referred to digital care technologies such as near me do you have a view about how we actually create the space for not just deployment of the the technology but then actually to to allow people to be trained and actually get that embedded particularly in primary care settings just wonder if any of the other seed David Gibson's got his hand up yeah and there was just the point that the two examples you've given of both been NHS based healthcare based but exactly the same frustrations and challenges are very much paralleled in social care and social work did social work Scotland did a bit of research called setting the bar which we have circulated to members of the committee where the number one frustration for social workers was paperwork and the the ever increasing pile of paperwork sometimes electronic forms sometimes paper forms and the interface between social care social work and the NHS as soon as we start on technology that there were almost two organisations sometimes divided by the technology we use so your your points are parallel very much in the whole system and not just within the NHS thank you don't know mr lochry wants to come in but yeah if i may and i'll be brief um a number of things the once for Scotland approach where we should so if we're integrating health and social care we should start to integrate our healthcare records and communications our colleagues in gp have rightly flagged up that while the centre for sustainable delivery is looking at a sway of once for Scotland pathways that they currently don't have representation on the strategy for that and given most of these patients originate from primary care and inner communities that they should be involved in shaping those pathways and in the last thing a very simple point is that protected learning and development time and primary care is something that is being called for by the royal college of gps as someone who potentially receives patients in those times that sometimes causes a little bit of caution but actually if we address the wellbeing and the sustainability of working for our staff it has myriad benefits for our patients in future the time for quality improvement the time for development of ourselves and of our services comes when we're not patient facing and that is important time that has to be valued as well but we have to plan for that for the future so that that's something that's sustainable so that patients aren't left without access to any care during those times so whether that's offsetting and cross covering whether that's patients understanding that on that particular day they will see a different GP from a different surgery i think again around the messaging and the management of that not just in primary care but in hospitals so that protected teaching and learning time to nurture our medical and nursing staff to develop their careers but also to improve things for our patients is the only way that we start to look beyond the firefighting as you correctly identified thanks thank you um so i think you know panmanic we've been talking in this exact terms for a decade um john for example will send me an email a letter from A&E saying could you please do these things for this patient who's come who doesn't necessarily need to be an A&E and they rock up to see me on the monday from the saturday and i still don't have that we don't talk but let's go more basic when our GP is going to be able to do something as simple as repeat prescriptions without having to dangerously sign them so the GP i have to sign all repeat prescriptions but i don't have time to actually read them no GP does so when can we go to something really basic and simple we've had in other countries for a long time which is repeat prescriptions that are automatically done so i think from what understand in terms of when we have we're trying to get longer so periods whereby where people get prescribed and maybe the support around pharmacotherapy but i i can understand the frustrations that you're talking about because just the scale of the of the activity that GP goes through and even with pharmacotherapy i think we're trying to support around that prescribing issue and actually have more patient reviews for example but certainly from my area getting that workforce in place has been really challenging around pharmacotherapy so that's something whereby we have not been in terms of the various levels of support that were identified as part of the new GP contract around to pharmacotherapy we've only been really able to put in the basic level so i think you're right in terms of both from the GP's perspective in terms of you know how we're actually supporting people with long term conditions but also in terms of the patients and their ability to have regular reviews i think you are highlighting i mean it is it is an area whereby if we are able to enhance the pharmacotherapy service i think that could be supportive thank you very much we now have a short break while we change to our next panel of witnesses we now continue on to our second session on winter planning and i welcome to the committee caroline lamb chief executive of nhs scotland and director general of health and social care scotland government john burns chief operating officer and director of performance and delivery nhs scotland and angi would interim director social care resilience and improvement scotland government and we are going to move straight to questions sandish gohani thank you and thank you panel for joining us today my question is exactly the same that i asked in the first panel we in primary care don't have the ability to call a code black to say that there are far too much in the way of pressure it's an unlimited workload for a gp partner so what are you doing to mitigate this to enable gps to do more than firefight to do more than just the basics and to actually do things for patients okay i'm happy to kick off with that now i'll maybe bring john in as well if he wants to add anything so clearly the question that you've raised is much broader than winter planning and winter pressures this is around how we support primary care throughout the year and support primary care to provide the best service that it possibly can so our focus has been very much on on increasing the the number of staff working in disciplinary team multi disciplinary teams around the gp to enable the gp to be that expert generalist in the community we've now grown those multi disciplinary teams to around 4700 staff across scotland which means that on average and it is on average then every gp practice has access to around five either pharmacists, phlebotomists, physiotherapists, advanced nurse practitioners so that that sits at the core of how we're trying to support primary care thank you so on that community link workers in glasgo have written to me en masse so practices in the deep end with community link worker being cut a meeting i had suggests that some a lot of community link workers are considering their job given the changes that might be coming down the road so if that's the case how are we helping primary care if if we're getting those deep cuts into into our link workers so community link workers are an absolutely integral part of the those multi disciplinary teams particularly in our deep end practices so clearly we are aware of the issues that have arisen in glasgo and the Scottish government has provided additional funding in the current year to support that those community link workers and we're continuing to look at how the primary care improvement fund is being used and how that funding is being prioritised to ensure that that really important service to people can be maintained okay thank you and my my last question um stats have come out just recently show 820 000 scots are waiting on a waiting list that leads to pressures in gp because they come back to gp but also leads to pressures to any because they can't all get the help that they need in gp and then they start going to any and this the cycle continues and make things far worse so what are you doing to ensure that our patients are getting seen in a more timely manner when it comes to referrals so i'll i'll just give you a few headlines and then hand over to john on this one so we have been as you know we've been working to try to reduce and had have had significant success in reducing the very longest wait we know that there is much further to go and much more that we need to do so we have been working with our health boards and with the centre for sustainable delivery to look at how we can take advantage of all the productive opportunities and how we can also use our our national treatment centres coming on stream but maybe ask john to add a bit more detail around that yeah thanks carline as carline said our our focus is working to support boards to reduce long waits recognizing the that as a key area of focus but also looking to discuss with them the opportunities to address waits in totality on on on our lists it is a combination of things that we are looking at because i think that firstly working with boards to find ways of improvement so for example patient initiated review to improve the experience of patients who may previously have come back for a review appointment to be able to take some of that power back but also create capacity within our outpatient clinics so these are like that's one example i think other examples are looking at the advanced clinical referral triage so ensuring when patients are being referred in that we are assessing them and ensuring we're putting them to the most appropriate professional for care and we've seen through the work that the centre for sustainable delivery has done significant impact and positive impact through that work but we are seeing quarter on quarter the number of people being treated are increasing and and that since the pandemic and and it's through the work that we are doing in funding waiting list initiatives to support boards that we're able to create some of that additional capacity but as carline said this year we've also seen our NTCs in fife and highland come on board we have capacity in the golden jubilee and the the second phase of golden jubilee will come on board and we also have NHS fourth valley later in the year as well so building capacity to be able to increase the level of care and number of treatments that we can offer thank you thank you i'm going to move now to evelyn tweet thanks convener good morning panel my question is around you know this inquiry is looking at the effectiveness of last year's winter preparedness plan i mean how does the government feel that the plan went i mean we've heard a lot today about moving away from the notion of winter planning and also moving to a whole systems approach is that something that the government is going to do absolutely i think i think we recognise that our focus needs to be on improving the systems year-round but there will always be points of surge and points of additional pressure winter has traditionally been one of those because of the increase in respiratory illnesses and also because of people having having accidents due to to to adverse weather conditions but they're not the only surges that we've seen so we've seen you know in recent in the last couple of years we've seen COVID driven surges out with the winter period as well so we recognise that we need to support the system to manage unscheduled care as effectively as possible throughout the year and have the ability to to surge so we have reflected on the planning that we did last year we have learned lessons collectively with the system engaging others in that process and the approach we have taken this year has been a i suppose to start much earlier but also to absolutely engage in that whole system planning so if i was to just give you some headline examples from that we issued our delayed discharge and hospital occupancy plan in in march and we have been building on that with local systems to develop those improvements to deliver the things that we know make a difference to improve flow through our hospitals but also work around data and the workforce as well we had our first ever winter summit involving led by COSLA and Scottish Government and bringing together leaders from across health social care local government but also third sector as well um that happened those 300 odd folk there just just in august and that has all been part of informing our approach to winter planning which is very much absolutely accepting that the system is an integrated system and we need to engage all partners um so that we can provide that um national ability to draw out good examples to to to produce the guidance around what works really well but actually then local systems need to be supported to plan collectively and to draw on the resources across those systems to deliver in an integrated fashion to to support people if any colleagues want to add to that at all the only thing i would add to that is we've also ensured that we have a whole system oversight to our planning so that is a group that's co-chaired by an NHS chief exec council chief exec and a chief officer and we're working together in terms of those actions that we think will deliver improvement or indeed where we think that there is evidence of good work that we want to spread so again another demonstration of working differently this year to to the way we had worked last year okay thank you um i had mentioned in the to the last panel about you know we're in a cost of living crisis people are dealing with a lot of issues you know heating their homes fuel poverty are we thinking outside the box in terms of initiatives that can help people with those problems to stop them presenting to the NHS i mean i had read about one initiative where doctors were actually prescribing heating to patients so we know that you know the health service does not work just as one thing so are we thinking about all those other things that will will help people not become ill not present yeah so we we absolutely recognise the additional pressures that have and that additional burden of ill health that that is driven by the the cost of living crisis that so many people have experienced so as as an NHS and social care services we absolutely seek to try and ensure that we can provide for example apprenticeships and we can bring people into into well-paid employment we've also you know i think the community link workers that we referenced earlier are really key in supporting people to access all the services that are out there but our chief officers in our health and social care partnerships have also been looking at some of the preventative work that that they can take forward and i don't know Angie whether you want to give us any examples of that i'm happy happy to do so i think you're absolutely right i think that that approach needs to be that kind of whole system approach the chief officers as Caroline says are key to that i think so are our local authority partners and you know many of these issues are very high on their agendas too so there's certainly a number of examples across the country both in terms of link workers but i think in other those multidisciplinary teams now i think traditionally we often think about those multidisciplinary teams as being purely health and social care but actually in many many areas they would involve you know other partners from the third sector who absolutely are working with families who are experiencing poverty but also things like housing providers so actually some really innovative work going on around how we can look at how we can support people in these different environments in different ways so that whole system approach is so critical to that both from that preventative agenda and also from that kind of health agenda at the other end of that scale so i know certainly colleagues in Aberdeen City for example they have really really strong links with many of those community resources particularly through the community planning groups and absolutely those chief officers and the health and social care partnerships are key and critical to that i think some of the work that we're doing around that preventative element is very much trying to get into that space so you know often we feel that we go into a kind of resilience place when we talk about winter but actually i think what we're trying to do is to get into that very much preventative space so that we can identify these really productive opportunities and often this is the way our teams are working and this is the way that primary care are often working in their local communities so it's making sure that our structures are reflective of that and i suppose from many of the chief officers experience it is not just about how can we help the pressure in the NHS but absolutely how can we help people to improve the outcomes that they're experiencing particularly in that preventative space thank you i'm going to move to David Torrance thank you good morning everyone last year's winter plan was criticized for coming too late it was published in october when will this year's winter plan be publicised our plans currently are to bring the winter plan to parliament in october however what i would say the difference from last year is the amount of work that has already gone in with systems to developing that plan so there's no no surprises for anybody in that plan as i referenced earlier i feel like we started the planning in march coming off the back of last winter with a really clear focus on the actions that were necessary to to improve flow through our hospitals we've built on that through um through as john described the system oversight group we've had responsibility for seeking assurance from local systems around that we had our winter summit which was an opportunity for everybody to engage in agreeing what were the key things that needed to be in that plan so the publication the plan is sort of the last hurdle if you like but as i said there won't be any surprises in that systems are already doing the work um and then john if you want to say a little bit more about the winter checklist and just around you yeah i can do a couple of things i would add to to what caroline has said firstly your core to winter and and you know it has been you know referenced the you know we need to be planning throughout the year so fundamental is our unscheduled care improvement work which is a continuous programme of improvement so boards are working all the time on those improvements in terms of flow through hospital discharge etc but we're also as part of our winter assurance we will be issuing a checklist for again whole system not just for the the acute sector but for boards to work with their partners on what the critical assurance points are so we can assess where each system is in terms of their winter readiness because it's important to the work and why we have been you know the importance of that engaging early is that we need our local systems to be doing their planning in detail as they lead into the winter months as well so i feel that we are that earlier work is putting us in a much better place in a much more participative place with partners thank you for that you partly answered my next question john but how does it respond to suggestions that winter planning is now redundant due to pressure is now being year-round and therefore requiring year-round planning so yeah really just building i think i think that we would all recognise that that way we as carolines referred to we get surges throughout the year we you know you can have a busy time in the summer it's just a different type of demand on the system so that's why i think the the work we do in relation to unscheduled care improvement is an essential underpinning for delivering the improvement we need on a system wide basis to meet and support the the care experience of those using services you know 12 months of the year how we ensure that winter planning accommodates the needs of different professions so i suppose we our starting point has been the level of engagement that we've undertaken with those with those different professions so as i've said this has been an absolutely whole system approach to this building very much on our learning from last winter but also the relationships that we built through last last winter so john you might want to say a bit more about the engagement from the health professions and and you can talk from the social care side yeah again the importance of having clinical involvement in our work is is central to what we take forward this year in terms of winter which is is in terms of that focus we have through the summit that we we held just a few weeks back was a wide range of participants including clinical colleagues involved but we'll also be engaging with the royal college of general practice in terms of the winter checklist in the plan and just understanding what is important to them that they would want to see and and rcgp and the royal college of emergency medicine were participants at the summit as well so we we have really been quite deliberate about broadening the and being much more inclusive and participative in this year's plan taking the learning and the challenge from the work that was done last year and clearly our work with COSLA has has just built since you know from learning from last year and and again I would say that has been a continual process I don't I haven't seen any step back from planning over over these these summer months we have continued at the same the same level of activity and including those kind of cycles of improvement as we go so really close collaboration between Scottish Government and COSLA but also with with other providers so I think you're absolutely right to to mention the professional groups that we need to engage in but there's there's obviously a huge range of providers out there as well and some of that is is led nationally others are really kind of promoting those really close collaborations at a local level and I think we are so aware that there is so much variation across the country there's so many different opportunities across the country so it's what do we need to do at that national level but also how can we promote that really close collaboration at a local level and I'm sure you would have heard from Fife this morning about some of the real innovation that they are doing around that collaboration which I think really reinforces to me how how we can do that at a local level to meet the needs of the population obviously but also that different makeup of providers and contributors aim to helping us prepare better for for whatever searches come our way Paul Sweeney I think it's clear from submissions in written submissions and in oral evidence we've already heard this morning that demand is unsustainable and it's simply inflating more capacity particularly within the acute hospitals isn't really an optimal solution to this relative to other healthcare systems in the OECD the expenditure share on acute hospitals is much higher and this expenditure share in the primary care landscape is much lower how do we pivot to that restructure fundamentally and how are you actually implementing a mechanism to monitor presentations in the acute hospitals that could have been avoided had an intervention taken place within the community earlier whether it is something as simple as providing heating for someone's house or you know some sort of pastoral support of whatever it might be how is that analysis being undertaken and how is that informing service design and how you then respond to to sort of pull the system into the place it needs to be because simply you know I think demand management is the key challenge really so I would absolutely agree that demand management is absolutely critical and is fundamental to what what we've been doing in terms of how we use NHS 24 not just the phone line system but also the online the self-help guides that are available on NHS inform increasingly the app so that people are able to support themselves and self manage their own own health so using NHS 24 investing in multidisciplinary teams in primary care and seeking increasingly to try to manage that demand and John John will be able to give you some of the the figures around where we've got to with all of that but that is absolutely key to our response is trying to ensure that only those people who need to be in our acute sector are in our acute sector and that applies both to people presenting to admissions but also critically as well to making sure that when people no longer need to be in hospital they are able to be supported to be either returned back to their own home or to a homely environment John do you want to say something about yes I can I can just just develop that a bit further so I've mentioned the unscheduled care work that we do part of that programme has an admissions avoidance work stream to it where you know we we we analyse data on length of stay and particularly those short stays in hospital to see what opportunity there is to redesign and deliver services differently and of course we've seen in in in recent years the positive impact of hospital at home pathways around community respiratory around opat and hospital at home itself so that is an area that we have seen developing grow we know it's an area that is is is we can deliver further growth in you know speaking to our clinicians about the opportunity for that redesign and of course that's taking acute care into the community and so I think that increasingly as we look to redesign and address the demand challenge it is is about looking at that almost removing the boundaries of hospital in community and ensuring that the right teams are delivering the right care in the right place and I think hospital at home is a very good example of that but I think other things that we have found to be impactful is the redesign of urgent care and the work we've taken there and particularly work around flow navigation where we're able to direct and often completely avoid in attendance hospital through clinicians working within flow navigation being able to engage with a patient perhaps through near me and determine the outcome but also we've seen with the Scottish Ambulance Service the important work that they have been doing around see and treat hear and treat and ensuring that again if an individual doesn't need to be conveyed to hospital they are given the right care at home to avoid that admission there is still work to do here and looking at that admission avoidance pathway will be a key part of that continuous redesign that we will need to develop with our clinical teams in the the months and years ahead sorry I just wanted to get given that I mean your question was around that capacity in the acute sector and and how we've shifted away so just thought might be helpful for Angie to say something about the work we're also doing at the other end of the hospital in terms of ensuring we can get people out absolutely because obviously part of that demand is when people with with complex needs with particularly frailty come into our acute settings often you know they are particularly susceptible to to deconditioning while they're in hospital which again increases that demand and also potentially increases the demand for social care obviously it's not right for the person either I mean that's the really key and critical part of this so certainly many areas across Scotland they would probably see Lanarkshire or one of our leading examples of this you know really investing heavily around their their re-enablement services and discharge assess which is really really key and critical when they would report that at times they're seeing people's care needs actually be reduced by half when they're actually taken home into their own environment and assessed and supported within that environment to make sure that the package of care that they need absolutely fits their needs but also fits that environment so you know often we see people you know they they adopt a different persona when they're in hospital and I think many times professionals can assume that they actually need a degree of support that maybe actually when they were comfortable and confident within their own environment that can can perhaps be less and obviously that's the best thing for that that person to feel that they're maintaining the absolute maximum amount of independence that they can with continual review so that that can be increased should it be required but but certainly some of the stats that are coming through from the likes of Lanarkshire who as I say have invested really heavily around their multidisciplinary teams to be able to do that assessment are really interesting so so there's definitely something at both ends of that absolutely preventing where we can but also trying to reduce that length of stay in particularly for those free and free rail and vulnerable people so that we can get them back into their own environments whether that be a care home or whether that be their own homes with support really assessing them within that environment and getting that care package absolutely right for them Just to the thought that you mentioned Fife and you also mentioned the example in Lanarkshire where examples of good outputs are being achieved and where there's clear evidence of that being a good performance where how is the system of the span of control at a Scottish level able to capture that and then normalise that across the different health board territories because it seems to me that there's quite a cluttered landscape and shall we say in terms of management structures so I think we're doing that in a number of different levels from a purely performance level we now have made some really significant advances over this last year in the amount of performance data that we're able to reflect back to the system so we've worked really hard with partners to to put in place data sharing agreements so that we can reflect back some of that performance so actually a local level it was quite difficult for areas they could see their own performance but perhaps more complex as to how they would benchmark themselves against other areas so that is now in place and we're rolling that out that will be in place for this winter so local areas will be able to have that level of scrutiny as I say not just on their performance but how other areas are doing that John referenced the whole systems oversight group that we've got in place now so that's co-chaired between local authority, NHS chief executives and chief officers so they are taking that kind of lead role in identifying that good practice I think perhaps what we need to do in my opinion would be you know really linking up that improvement the performance and then perhaps asking the question what would that look like in local areas so I think that obviously there remains that local control as to how they wish to commission their services and arrange their services but I think we need to highlight what that good practice means for individual people in terms of outcomes and then start to ask those questions around that so I think there is absolute sharing of good practice that is there and that is clear to see across Scotland I think we need to maybe sometimes probe on the so what question at a local level so that that level of scrutiny is happening at that local level to help inform their decision making and the commissioning going forward. Has a supplementary. Just to pick up on what you said earlier John Burns about national treatment centres because Pamela Millican in the previous panel said that like winter planning you have to think about slips and trips on ice which can lead to emergency orthopedic injuries which then need surgery but the national treatment centres are for elective approaches for instance to tackle ophthalmic orthopedic upper GI endoscopy things like that and so John Paul offering the previous panel said that staffing them would be like Robin Peter to pay Paul but my understanding is that our now First Minister when he was cab sec said that 1500 additional staff would be used for the national treatment centres so can you give us an update on whether we will be Robin Peter to pay Paul or what is the status of recruitment of new staff for the national treatment centres so in terms of the national treatment centres we have recruited additional staff to the centres that have opened we have been able to recruit across all disciplines to be able to open these centres I think what is is important that in doing that it's also about integrating those staff so they're not just you know standing in isolation to the wider board team but the this enables us to protect planned care within the system but we have I don't have the exact numbers that we've recruited to but but that was essential to us opening those NTCs was that recruitment of additional staff and we funded that through the NTC programme thank you I'm just curious because of of like my background in orthopedic surgery and working in the operating room and looking at like the flexibility of staff and the ability to not work in isolation as well so I think it is important that we make sure people know that we have our national treatment centres with these goal of challenging waiting lists for instance for hip replacements and knee replacements and ophthalmology thank you thanks one of the issues that was raised from the last panel was around about the short term or targeted funding that often comes for winter resilience initiatives and the challenges that that then poses for health boards particularly rural and island health boards in terms of short term contracts for staff so I'm just keen to hear if the Scottish Government recognises the challenges that are posed by that short term non recurring funding and any plans that there are to move away from that model given that you've you've already acknowledged that winter planning is one thing but actually the the health care service and social care faces challenges throughout the year because of different variants absolutely so we absolutely recognise the challenges that are associated with that short term funding particularly around the inability to recruit staff on permanent contracts and and therefore you know the the likelihood that that leads to more staff turnover and potentially we don't build a capacity that we that we need to as a result so so whether it's around winter resilience or whether it's around planned care overall we have as part of one of the ways of trying to alleviate some of those pressures on our boards we have increasingly moved in this year towards trying to make our allocations to our boards recurrent rather than non recurrent wherever possible and that will continue to be a work in progress to try and make sure that we're actually baselining the funding that is needed as I've said whether that be for for planned care or whether it's around supporting you know a really solid unschedule care system but that that's absolutely the approach that we're taking thank you I'm going to move to Jillian McKay thanks convener what assessment has been made of the upcoming winter pressures impact on staff wellbeing morale and resilience across health and social care we've obviously had several years of very high pressure and that's not going to let off any this winter and that's if we have a winter with relatively mild weather compared to a bad winter there are obviously significant concerns what action can be taken to address this such as bolstered wellbeing support and that practical support around meals and and breaks and things as well and does the government anticipate a higher rate of turnover as a result of winter pressure okay thanks for that so how do we how do we assess and monitor that we monitor staff absences on a regular basis we've also got the i matter survey that that we can use to assess you know how people are feeling particularly in our NHS boards it's more complicated in social care because of the you know the range of range of employers there we are also continuing to support the staff wellbeing initiatives and those are incredibly important to us so at national level we've still got the national wellbeing hub and the you know the psychological interventions as well we are also ensuring that local boards continue to support some of those really quite simple things around being able to get access to hot food and a drink through shifts so that is still a key part of our approach we will always see turnover and we're a very big employer so you would always expect to see a high turnover in staff but however you know we do see peaks and troughs so we've we've got just yesterday I was down in Ayrshire and Arran and they have their new newly qualified nurses all all all coming into the workforce there so we do see the workforce shift over over the course of the year as well and I think just today we've seen some stats published by the SSC around the social care adult social care workforce it's really encouraging you know we you may want to ask us questions about some of the some of the work we've been doing in that area but it's good to see some of the impacts start to feed through in terms of those some some of those stats. As a central Scotland MSP I've got particular interests in NHS Forth Valley and NHS Lanarkshire I'm given some of the pressures that those health boards in particular have faced around A&E in in um Forth Valley and across the board in in Lanarkshire is there extra thought resource things being put in place in these health boards which which do have issues in in particular places considering if you take Forth Valley's A&E for example the number of times the stats are reported in the news and things I can't imagine for the morale of those staff who are absolutely working flat out to make sure that that patients are seen the damage that that that does to their morale and that's without us being in within the winter pressure territory given that pressures are more universal now is that resource and thought going into these health boards which are having particular issues? Yeah absolutely so we recognise that health boards will all be in a slightly different place you know in terms of their locality the needs of their local population sometimes their footprint as well and how much space they have but we do provide John can say a bit more about the national support teams that we have who can go in and and help boards to we talked about the unscheduled improvement work earlier but that's about really helping staff and teams to focus on those improvements because sometimes in the heat of the moment it's very hard to actually be thinking about the things that you could do to help to improve the situation John do you want to say something more about that? Yeah the unscheduled care improvement team that sits within the centre for sustainable delivery works with all our boards in terms of support and to help them with their improvement plans because I think it's incredibly important that the improvement plans are owned by the local system but we are there as a critical friend to provide some of that learning and sharing best practice but also where we can give them additional capacity in terms of analysis or support for the work they're doing. As Caroline has said every board is different and so we will provide different levels of support depending on need NHS 4 valley we work very closely with in terms of the improvement work in terms of not just the the emergency department but in terms of that flow through and support the team there to to to drive those improvements. NHS Lanarkshire has a very detailed operation flow programme which is a whole system programme and we can see the the leadership and the way in which they are taking that forward in an inclusive way with their their teams across NHS Lanarkshire and across social care which is I think a good example of whole system working. That's great thank you thanks. Thank you and I'll move to Tess White. Thank you convener I've got three questions if I may so my first question to Caroline Lam if I may so Caroline you said that you always expect to see a high turnover of staff so with my a fellow of the Institute of Personnel and Development and in terms of percentage turnover of staff voluntary turnover there are red zone levels it looks as though the NHS is in the red zone level with the staff percent the turnover being extremely it's too high so in terms of staffing levels it was reported last month that doctors in NHS Grampian have used whistle-blowing procedures to raise very serious concerns about conditions and staffing levels in A&E departments and one doctor tragically said there have been avoidable deaths as a result of the situation. So what action is the Scottish Government taking with NHS Grampian to urgently address staff shortages especially as winter approaches thank you. Okay thanks so so yes we would always expect to see turnover in an organisation the size of NHS Scotland and you know looking at our demographics and the age and also the number of new trainees and newly qualified staff that we have coming into the system every day. I think that in terms of overall staffing so we have seen the numbers of A&E consultants in Scotland have tripled since since 2006 so we have seen huge increases in our consultants but we do recognise that that we still have some issues particularly around middle grade staff in terms of the support that we're giving to NHS Grampian John do you want to speak on that one specifically? Yes so in terms of NHS Grampian again we have worked closely with them recently we facilitated a support visit with the Royal College of Emergency Medicine and other clinical colleagues to see if there was further advice that we could give to support colleagues in Grampian as an opportunity for that visiting team to engage with the clinicians in the A&E department and other parts of the system and to point to any recommendations that we think NHS Grampian might be able to take forward and of course central to that is the importance of communication with all colleagues and teams. In addition to the specific issues that they're facing I know from speaking to the medical director and the chief executive there that they are engaged with the department with the clinical colleagues in the department to work through what the best arrangements are for providing that cover recognising some of the staffing challenges they have in that senior middle tier rota and they are continuing to work to put in mitigation to ensure services are safe and we will continue to stay close to them in relation to both the visit that we facilitated and also the actions that they are taking to try and improve upon the issues that you've highlighted but I think beyond that it's important that in speaking to Grampian that we also think about other wider issues that we need to address so we can engage NHS Education Scotland in those discussions as well. Thank you and my second question is and probably best to Mr Burns as well is how confident are you going into the winter that staffing levels are at the right level and in terms of confidence not being not confident at all and 10 being extremely confident? Where on the scale would you personally put your confidence levels? I think it's a difficult question that answer in terms of not to 10. I think what I would say is that from the engagement we've had with all of our systems across Scotland in relation to their service delivery and their workforce we can see that every board across Scotland is looking to ensure that they have the right staffing levels but also recognising that where they have vacancies what actions they are taking to meet that gap going into the winter because there will always be vacancies as natural turnover but that's where our winter checklist comes in is seeking from each system the level assurance that they have in terms of their readiness. So we really haven't answered my question in terms of confidence levels on a scale are you confident or are you concerned? I think they would also I don't think anyone could sit and say we are completely confident that everything at the staffing levels that every board has is where they would want them to be but I think that what we have is a level of assurance from the work that our boards are doing in terms of their readiness assessment for this coming winter recognising there will be challenges within that for different boards. Thank you and my third question convener is it's clear that incentives to attract GPs to rural and remote areas are not enough to help GP vacancies so what assessment and this is to any panelist what assessment has the Scottish Government made of the available financial incentives and difficulties for GP recruits assessing accessing housing and projects such as rediscover the joy of general practice towards the sustainability of primary care in remote and rural settings thank you. Okay so in terms of in terms of recruitment to general practice as a whole I think we were really pleased to see that we filled 100% of our training posts in general practice this year we actually had really good fill rates across our entry training grades and I think that reflects the efforts that we have put in to increasing undergraduate training places and also to programmes like scottgem which are absolutely designed attracting people who want to work in general practice and who may also be interested in working in general practice in remote and rural I'm not going to say that we think that we've completely cracked that yet so as you as you're aware we have had the additional the bursaries which have been I don't have the numbers in front of me I can supply them to the committee afterwards but have been pretty well taken up in terms of attracting people into areas where it's been traditionally hard to recruit GPs and also have been additional incentives for deep end practices as well I also don't have any assessment of that rediscovering the joint work but again we can revert to the committee on that thank you if you can to the committee that would be great thank you thank you convener thank you still on the on the subject of staffing and recruitment and retention so research by the Nuffield Trust published in November last year found that Brexit worsened the UK shortage of doctors in key areas of care by more than about 4,000 european doctors they suggested chosen not to work in the nhs and that the separately data released by the nmc last may found that the UK has 58,000 fewer nurses than if the numbers arriving pre-brex had continued are we seeing that effect in our nhs currently in scotland and what if anything are you able to do to attract some of those EU nationals to come back to work in the UK or to come to the UK and come to Scotland particularly to work so I think a couple of things on that I think that whilst anecdotally we feel that absolutely there has been a has been an impact and and not just in the NHS but in social care I am not aware of any statistics particularly around scotland again I will come back to the I would check that and come back to the committee if there are any what we what's what to focus on the what are we doing so we have recognised that we also need to look at international recruitment so and we are now up to I think just over a thousand international recruits are in nursing midwifery and allied health health professionals who will have come into the country there are some challenges around providing housing but again in there sure now and yesterday I was hearing really positive stories about how the health board is supporting those international recruits supporting them in temporary accommodation whilst they find housing and enabling them to orientate themselves in the new local environment we've also been really keen to look at the opportunities for international recruitment in social care as well so we commissioned NHS education for Scotland as part of the centre for sustainable workforce supply to look at how we can support employers in social care to bring in international recruits that's quite complex compared to health just because of the number of employers that are involved in all of that but there is now a pilot underway and we're expecting around the first cohort of around 50 social care staff coming in by the end of March next next year so that is now underway and we would very much hope that we can then build on that that going forwards we've also been looking at what we can do more in terms of recruiting locally within Scotland so we've engaged really strongly with the DWP and you might want to say a bit more about that in terms of their job fairs and I think I've had some good success around that as well. We worked with the DWP to look specifically at what resources they could offer to work with us around this so they've delivered around 25 specific careers, fairs, looking at across the range of employment opportunities across health and social care so currently we're seeing over 500 people who've been offered an interview in various different parts of the health and social care Scotland who've been specifically supported through that we're continuing that work in an ongoing basis to look at if there's people who are maybe not quite ready for employment how could they work with us to support people to get them to that point where they can maybe move into that I think the other really important part of this obviously people that work within health and social care are really valuable in the labour market and often we find that they're developing really core people skills that are really really wanted in other other environments so we're doing quite a lot of work. I think we're going to weave it off the question here because my question was specifically about the EU. I'm moving now to Paul Sweeney. Thanks very much convener. The written evidence suggests that the rate and frequency of reporting performance data was a challenge and that the processes for feeding back data was labour intensive. Has any consideration been given to how this process it could be streamlined so that pressure on staff can be reduced? Absolutely so one of the things that we are really focused on is trying to minimise the additional demands that we put on systems particularly through the winter periods but actually overall as well so we I think there's reference earlier to the to the dashboard approach that we've been taking to enabling particularly our health and social care systems to be able to see their own data and compare that to others. We very much worked on working with partners so that everybody understands what those data requirements are and where possible trying to ensure that we are pulling those from sources that are already available to us or to Public Health Scotland rather than than looking to have people return separate sets of data to us so we are really conscious about the need to minimise that data burden and the same for our health boards as well that we are increasingly looking to ensure that we can pull data from common sources rather than seeking to get people to submit things to us. It's just also to highlight that a number of submissions have questioned how previous years data has been used to evaluate the impact of winter planning and to identify gaps and opportunities for improvement and it's clear that there are multiple concerns regarding last year's plan alone. In Public Health Scotland and the Scottish Directors of Public Health submission one of their recommendations is to to quote stop things that have not worked and to not introduce anything that has not been robustly evaluated so have the Scottish Government undertaking any assessment of what has and has not worked well in previous winter plans ahead of this year plan and could you highlight perhaps some examples? I think we absolutely went into the process of planning which as I think we've described has been a pretty continual process seeking first of all to learn the lessons out of last year. That's probably been more about our approach to planning and but I think that that leads into some of the concerns expressed by Public Health Scotland because absolutely engaging partners from the get go in terms of what we're planning and what we think will make a difference means that we're drawing on the best available intelligence in terms of what will make a difference. We are then able to evaluate based so for example the work that we put into providing interim care home beds last year was that absolutely had an impact in terms of the take up of those beds. We then need to I think reflect on the extent to which some systems were able to move people on and out of those beds in order to release that capacity so yeah I think we're through working with our partners much more closely to understand what will make a difference and what are the things that are tried and tested which is back to the question about how we spread that good practice so that people understand what are the things that do work and I think our focus has been very much more on emphasising the importance of focusing on the things that we know work and really sort of bearing down on those things within individual systems but the colleagues want to add to that. Yeah I think the the you know we always do a lessons identified and what we did feed but get fed back was that the priorities we had were the right priorities strong support for that but we've touched on many of the other things you know start planning earlier has to be whole system but but you know we touched on data just a moment ago and we've worked very closely with Public Health Scotland this year in relation to that data and reporting piece so I think that we have progressed our approach significantly this year but I'd also say that the work we take forward through the unscheduled care program does have an evidence base to it so that we are going forward with the things that have an evidence and an impact and where we see something that doesn't then we will change tack because the point that has been made is that building from a strong evidence base and doing things that that do work and have impact is the right thing to be doing. Is there a particular instance that springs to mind that might just help to illustrate the point for us? Of things that we have stopped doing? Yes. Nothing immediately springs to mind I think that in terms of the unscheduled care program because it has that evidence base then before we go into it we want to make sure we're putting our resources and our effort into the right things but I think that it was more process for the planning that was where the lessons and as I say we've really made the significant improvement in our approach this year. Okay thanks. I have two short very brief supplementaries please, one from Tess White and then I'll move to Emma Harper. Thank you this is a brief and it's more it's a practical question so you talked about the programme of hiring the 50 GPs and I'm thinking particularly of the issues that rural GP practices have so in the example that we've got and there's one Breymor where the GP practices trying to find their own GP and they're going globally to look at it but they're having to do all the recruitment themselves the work with visa is there a programme that they can link in with the Scottish government to help them or do they have to go through the health and social care partnership to do it for them thank you. Okay I'm not not familiar with the detail of this one but what I would say is that we are we do through the NHS boards run a programme because we recognise that all that applying for visa etc is really complicated so the part of the infrastructure that we have supported and we funded from Scottish Government is so that each NHS board has the capacity to be able to have somebody who's expert in that sort of stuff so I guess maybe out of this committee there's a question about how those individual practices can link in with those centres of expertise. Okay thank you we'll take that away with the committee thank you. And Emma. Thanks it's just to pick up on the question about bursaries for paramedics and nurses and midwifery students you know I'm as a Scotland MSP so south of the borders 30 miles away from Dumfries so are we tracking whether the bursary that is available for nurses and paramedics in Scotland which isn't available anywhere else although it's been recently introduced in Wales and are we tracking whether the bursary is encouraging folk to come from south of the border for training places in University of West of Scotland for instance. So I think I'll need to come back to the committee on that one so clearly we do get the Scottish funding council would be responsible for monitoring the overall numbers of students both paramedics and nurses in our system and I think we would just need to check with them what level of data they have around the country of domicile effectively of the students taking up those but I think the other important thing is to track where they go afterwards and we do through NHS Education Scotland have a mechanism for tracking where the students with students study in the University of West of Scotland where they then end up going into employment so that is certainly something that we can track. Okay and I'm going to move now to Carol Mawkin. Thank you morning I'm very interested to know about how we support the public in terms of our messaging about just the situation that NHS finds itself in and we had a discussion in the previous panel around public messaging so I'm very interested to know what the government's plan is over the winter period and longer about how we message access to the NHS in Scotland. I also have a particular interest in alternative pathways which I'm very very fond of and I think are a good thing but I think it's unrealistic to expect people who have done things in a certain way for huge amounts of time particularly when they're under pressure for their own health or a family member's health to really understand that at this point and what plans do you have in place for that? Thanks, we absolutely recognise the importance of clear communications, clear and consistent communications to people both at a national level but also at a local level so there is the messaging that Scottish Government will put out around accessing the right care at the right time in the right place and ensuring that people understand the options that are available to them and understand how NHS 24 can support them in accessing the the option that's right from them and that might be through the telephone call system but equally it might be through looking at the online resources and the self-help guides that I referenced earlier and we work with all the communications leads across our NHS boards to ensure that there is a consistency to that that messaging and that we are both at a national level reinforcing the message that is put out locally but also that that you know that local message relates to the national level as well because it's clear that people can help to support services through the winter and through other pressurised times and they can do that through accessing the services that are right for them and by also using the resources that are online to to help to help support their their own care. I'll ask John if he wants to add anything about that I think I think your point about different pathways as well is really well made and that we also need to I think be mindful that that some people will be quite resistant to accessing health and care services in a in a different way but we need to work with them and support with support them in terms of being really clear about how they can access different services and in a different way. Can I come in just very very briefly you might be heard in the first session one of the medics talking about last year one of an enormous pressures was around the stray cases for the parents and he felt that the the system wasn't easily able to change its message in quickly do you think you've learned lessons from that from last year it might be better in the future if we had that sort of situation so yes i'm sure we have learned messages from that I mean clearly that was a really difficult situation because I don't think anybody would question any parents concern about about their child in that in that sort of environment so you know that that was a high pressure situation and I think you know on the system responded really really well to that as well but yes there is learning in that for for all of us and I think the the consistency of message over the last four years or so in the back of redesign of urgent care we are seeing people are across Scotland you're really embracing those messages and and behaving and engaging differently so that increased use of NHS 24 the use of NHS inform you know an average week we'll see two and a half million views and in winter that can go up to over three million so I think that the people are accessing services differently but I think we need to continue that consistent message we're also seeing it through pharmacy first and again more people using and accessing that service on a weekly basis as well so I think we have seen change but we need to continue with the consistency of that thank you thanks we move on to our final topic and I'll come to sandish gohani first thank you it's going to be the same as I asked at the first panel to be honest the the thing that gps find very difficult the thing that I find very difficult is when a patient is going to A&E on the weekend and then turns up and says oh A&E asked me to come to you but I have no idea why because I haven't received that that document from the A&E our systems are not in communications with each other efficiently what are you doing now to ensure that we have consistent good messaging between us given that we have been talking about this for an awful long time yeah so first of all um I accept that we are not yet where we want to be around having joined up systems and I think this applies not just to that interface between A&E and gps but to to many other areas as well so as we've already talked about we have been through a process of putting in place data sharing agreements with all our health and social care partnerships just in order to be able to share performance data around how the system is operating clearly we also need to focus and we are focusing on how we can improve that connectivity so connectivity across all bits of the system so between primary care and acute care between acute care and social care and that you know that there is some progress being made through some of the portal approaches but that is not consistent over the country yet we have some opportunities I think in the national care service legislation to be much clearer about some of the information governance requirements and therefore to be able to be much clearer about what data we would expect to be shared because I think the other that's really critical here is what information people are able to see in terms of their own their own records as well so I would agree we are not where we want to be yet that we have an ongoing programme of work that is absolutely looking at how we can smooth some of those information flows I don't think we'll get to exactly where we need to be for this winter but it is an ongoing bit of work for us okay and and so ongoing work it's been a decade yeah plus and we're not then it's actually dangerous I think the interface that we have between all our different areas which include within primary care includes in fact within a specialty itself but something that I'm asking about all the time when it comes to repeat prescriptions for GPs in other countries you can do it automatically I don't need to as a GP sit and sign a stack this thick where I can't really read them either I just have to get on with it when are we going to have repeat prescriptions in this manner so that's part of our digital prescribing programme and John got an update on the where we are so I think the latest update that I had was that in terms of the the interface between general practice and pharmacy there's been engagement in terms of the what that service needs to be and they're looking to to take forward prototyping um but I think we're not that's not going to be something for this winter it's going to win when I repeat prescriptions I would have to get more detail and from colleagues that are more directly involved in this work and that we could add that to a response to committee thank you Emma Harper thanks convener I'm interested in the digital care like we've got near me now and then when I was reading my papers I found out about this thing called connected me and that seems to have evolved from using language that was remote because so that people feel more connected rather than feel remote and so we've got all this telehealth telemedicine and tele stuff and now connected me but none of my nursing colleagues have heard about connected me so what work would you think needs to be done to help people understand like what connected me is all about because I understand that technology enabled care is beneficial especially as John was mentioning in the chronic obstructive pulmonary disease like cruise scoring in the community to keep folk out of hospital and things like that something I'm really familiar with so I'm interested is how do we get the info out to people about what digital solutions there are out there so I'm sure you're aware to connect me is is the one of the systems that does the remote monitoring work for us so provides that link between whether it's wearable devices or whatever it is and and the central ability to monitor that and I think I think probably is part of the the the push on hospital at home we need to be thinking about how we're able to describe exactly what hospital at home is and the opportunities for that because remote monitoring is obviously an integral part of that but I think your point is well taken that we both need we need our healthcare professions to be confident in using digital technologies so to understand what's available to them and to be confident in using that so again I think that's probably something that we we need to be thinking about with our digital colleagues around how how we take that programme of work forward and just like technology enabled care in Scotland has a twitter account or an x account but folk and of reason gallowed any do to it I think goodness but they do facebook so should we be using these kind of social media platforms to help raise awareness about the work that the Scottish Government is doing to take forward digital tech solutions for instance so I think one of the things around our technology enabled care programme is it has we've got some really good strong pockets of adoption and now the challenge is you know a bit like good practice in other areas how we spread that across Scotland I suspect that probably you know we may want to use social media platforms but equally I think there is something about how we make sure that that awareness of these things is part of our sort of core package of improvements within within local systems and that we ensure that our local systems are taking advantage of all those opportunities to educate their staff their workforce and to promote them across their workforce as well using whatever method is most appropriate for the locality okay thanks thank you very much can I thank the panel for their attendance today um and uh you can you can now leave and we'll continue on with our agenda items thank you the next item on our agenda is consideration of a negative instrument national health service free prescriptions and charges for drugs and appliances scotland amendment regulations 2023 the purpose of this instrument is to increase prescription charge applied to English prescription forms presented for dispensing in scotland the policy notes states that this upgrade aligns scotland charges with english charges which were increased on the first of april 2023 the delegated powers and the law reform committee considered the instrument at its meeting on the 27th of june 2023 and made no recommendations in relation to this instrument no motion to anull has been received in regards to this instrument i propose that the committee do not make any recommendations in relation to this negative instrument do members disagree with this thank you our meeting next week will be a session with the cabinet secretary for nhs recovery health and social care concerning the programme for government 2023-24 and that concludes the public part of our meeting today