 Good morning, everyone, and welcome to the 12th meeting of the Health and Sport Committee in 2017. I can ask everyone to ensure that the mobile phones are on silent. You can, of course, use your mobile phones for social media, but not to take photographs or film proceedings. The first item on the agenda is an evidence session on the preventative agenda. Good day, welcome to the committee. Dr Una McFaggin, consultant pediatrician at Fort Valley Royal Hospital, fellow of the college, and a member of the College Council of the Royal College of Physicians, Edinburgh. Dr Margaret McCartney, general practitioner, and Dr Helen Irwin, consultant in public health, we are due to be joined by Amelia Creighton, head of health services, public health, NHS Greater Glasgow and Clyde. We will move directly to the first questions. I would like to kick off with a question. I see that there are common themes emerging from the written submissions from all the witnesses this morning. Dr Irwin, you say in your written submission that the current demand that we are facing means that we need to prioritise and that no area should be exempt from scrutiny or regarded as sacred. There is discussion of the breast screening programme in your written submission and in that of Dr McCartney. How is evidence that counters current practice discussed in Scotland? Why and how are decisions to either continue or discontinue programmes that perhaps are not cost-effective made? How are those decisions made? When it comes to the breast screening programme and most of the other major screening programmes, decisions are made by a UK-wide screening committee and Scotland implements those decisions. One of the observations that I made during a bigger piece of work on routinely collected data in Scotland and my concerns about how we were adopting policies from England highlighted the same issue. I fear that sometimes we implement policies that are decided south of the border. I suspect that, when it comes to the breast screening programme, we do not review all the evidence in Scotland and then decide what we are going to do. I suspect that we follow the UK screening committee. Is that your view, too? Yes. The UK national screening committee is a very good organisation, but the franchise is almost part of looking at evidence agreements. For example, there is an advisory committee on breast cancer screening. What I am concerned about is that there has not been a good cost-effectiveness analysis for some time, particularly including opportunity costing. The amount of time that we spend on that when we could be doing something else of more value. The other big issue is how good we are at sharing decision-making around breast cancer screening and all forms of cancer screening in Scotland, because that is devolved. I do not think that we do it well enough. I do not think that we do it thoroughly enough. I do not think that we do it with the attitude that, if something is not working, we should really interrogate the evidence and ask whether we should stop doing that or not. For example, the health check programme, the keep well programme, there is now quite a lot of evidence that says that this does not work. It does not improve quality of life or extend life. I would ask why are we spending so much money on it when we know that there are other things that really do work and we could be spending that money on. We have this opportunity cost issue, which I think is a huge one, because if you have a limited amount of GPs and GP time and you are asking them to spend money on stuff that does not work, that means that we are not doing the things that really does work and does make a difference to people's lives. That is a huge issue and one that I think has been sailing under the current and not properly interrogated really for decades now. It is obviously a politically difficult decision if this were to stop. I see that it has been questioned in other countries and I note the evidence that you have given about Switzerland. There is a view that it just got passed the last UK review, the Sir Michael Maramott review. If we were to look at this more discreetly with that Scottish focus, we might come to a different decision. I do not see that looking at it from a Scottish perspective should be any different from looking at it from an English perspective. It should be looked at. Anyone who looked at it objectively would conclude that it was not a good idea to do it at a universal level. Screening should be considered for targeted screening at high-risk women where the return for the effort and the risks incurred will be lower and therefore the cost-benefit ratio better. I do not think that there is going to be anything different about a Scottish analysis other than that the stats will be about 11 per cent in terms of the actual volume. The beauty of looking at the UK-wide approach is that you are looking at a bigger sample size. If we did it at a Scottish level, we would be looking at a much smaller number of women screened, a much smaller number of women's lives saved and so on. It should be looked at UK-wide. It would be odd if Scotland went ahead unilaterally and tried to scrap it and leave England to carry on with the programme. It is one of those very sensitive issues that I think would be awkward to try and go it alone. There is certainly some evidence in the submission about how the programme originated in the first place with Margaret Thatcher's Government. I will add something about that point. In 1989, I did the MPH at number one Lillibank in Glasgow, Professor Jim McEwen. We studied all those reports in detail and many of us in the MPH programme, Master of Public Health, had major concerns about the screening programme even in 1989. In fact, that same year, Maureen Roberts, a breast physician from Edinburgh, who had spent 10 years looking at this subject and had advocated going ahead with the screening programme, wrote in the BMJ that she suspected that it had been an error of judgment and she wrote that posthumously. I have these papers with me. If you read that material from Maureen Roberts, it makes really compelling reading from the dead. The fact that this woman who devoted her career to breast screening and breast pathology dies from the disease and then writes in those last months before she dies that it has been a mistake to advocate a national screening programme and she cites all the criticisms of the programme. That was 1989, just one year after the decision was made by the Tory Government of the day to go ahead possibly because it would be a vote winner for women. It does worry me that there was a political dimension and then one of the Scottish experts expresses concern about it in those months before she dies from the disease. You spoke about a more targeted approach and making sure that we were seeing high-risk women. We can tell from health inequalities that concerns are raised about the worried well and the amount of resources used inequitably. I would like to understand how we go about making sure that we reach those women. You say in your written submission that a strategy is doomed to fail if it does not have GPs at the heart of any new model. I suppose that GPs are absolutely essential. We have heard from GPs at the deep end about their concerns about the inequity in funding. Could you expand on that, please? I am going to answer your second question first. I have done a major piece of work on the funding of the various components of the NHS, the amount of money that we are spending on hospital consultants, GPs, district nurses, social care, the elderly and so on. I have major concerns about the disinvestment in general practice. I believe that the entire NHS is at risk because of the progressive disinvestment since 2006, which is on-going. I do not see how we can expect GPs to pick up early cancer in patients who already have the disease and how they can promote health and discourage patients from smoking and drinking too much. All the things that we know would have a high return on investment because we know that people are more likely to listen to these messages from their GP than anyone else. The idea is that we spend vast sums of money on something like breast screening that exposes all the women aged 50 to 70 to radiation every three years, generates a huge false positive rate, has a very high screening to life-saved ratio and yet we disinvest progressively in the GPs. It seems to me a bizarre approach. The breast screening programme is just one of many programmes, public health programmes. You may think at all that a public health doctor would question some of the initiatives, but I think that we need to review all the public health initiatives and see what we are actually getting for the money and what potential harm we are creating and also if we are contributing to the inequality in health issue, which I believe we are. The first part of the question is, I am not an expert on breast screening and how you would go about targeting, but it would probably be around genetic markers. You would identify the women who have family history and are positive for breast cancer markers and you would focus on those women and you would get a better return on any kind of routine screening. I have a comment that I wanted to make. I suppose that my wee bit can say that I am just looking at this from a wider picture, that we talk about prevention but we immediately jump straight in and start talking about screening, as if screening equals prevention, prevention equals screening. To my mind, it is clearly much wider than that. I think that you make the point, Dr Irvine, that it is much wider than that, but you also say that in public health terms people talk about preventative medicine as if it does not include what I would consider the main part of that, which is what GPs do, et cetera, et cetera, the upstream stuff. I am a bit concerned about the terminology here and I think that we need to refocus back on the wider concept of prevention, i.e., doing stuff earlier to stop stuff happening later. I really want to focus down on the cost side of that and any data we have on that and the effectiveness and the mechanisms for judging interventions. You use words like huge substantial considerable costs. When you are talking about it, you have put some data in there and I quite look at that, you are talking about 250 million spend, which sounds a big number, but obviously it is less than 2 per cent of total health service spend in Scotland, so in the big scheme of things it is not a big number. I want to explore that a bit further and also bear in mind what Christy talked about in terms of 40 per cent of public sector spend was potentially preventable by doing stuff upstream. I want to explore that a bit more. I suppose the real nub of what I am trying to get to is what mechanisms are there that allow us to do data crunching to be able to, from a financial point of view, say doing this works, be that screening, be that investment in GPs, be that investment in primary versus secondary, be that whatever it is, what tools and mechanisms are there that allow us to actually make proper quantified evidence data-driven decisions on preventative spend in the wider sense. Are you asking me? I am asking anybody what you want to answer. Does anyone want to have a go at that? The whole thing, in terms of what the submission that I have put into yourselves, which areas of preventative spending would be useful for the health and sports committee to investigate, I am really interested in putting resources where they work. I think that if we do not have evidence-based policy making we are absolutely sunk in the NHS and I am really worried that we are throwing good money after bad again and again and again and you might say that it is only 2 per cent, it is only 3 per cent. Actually, those small numbers really add up and they make a big difference when you are talking about the general practice service, for example, you can give the amount of district nurses that we have. How can we do more work in the community when we simply do not have the hands-on staff able to do that? If you do not have the district nurses, you cannot allow people a good death at home because they cannot physically multiply themselves in order to do that work. Our health visitors are now working horizontally across practices. We are really risking that the primary care team that we know has had huge benefits in terms of vaccinations and so forth because women and families have long-term relationships with staff that they know and trust in their part of their team. In terms of where is the data, there is lots of data, but there is lots of data to tell us that we are doing stuff right now that does not work and is wasting money and is causing harm. With breast cancer screening, for example, the big issue is over diagnosis. It sounds so attractive, early diagnosis. You have a health check, pick up on something early, we can make a difference to you. It sounds so attractive. It is a political vote winner. Lots of politicians from many parties or from many generations and lots of areas of the world have used this, but the problem is that you do not get the full information about it in a sound bite. Again, you are saying things, we need to be data driven, then you are saying things that are not data driven. In terms of where you would spend the money, that is what I am trying to get to. You are saying that you spend it on nursing or whatever. What data do you have to say that that works, my preventive spend point of view, and what mechanisms are in place to analytically understand where we should spend the money? So what you are saying is, are you asking for randomised control trials or systematic reviews of where do you want to spend? In terms of housing, there is good coctern reviews to say that M people living in high quality housing that is not damp and cold have fewer asthma exacerbations, for example. I need to go back and look at the coctern reviews so you can google it. It was a few google coctern reviews, I think it was New Zealand studies, but I am primarily also someone who is English. You are talking about, I am trying to get to, a lot of people say, we should do this, we should do that, we should do the other, we shouldn't do that because of this, but at the end of the day what I am trying to get to is what data driven analysis is there. If we spend x100 million on nurses, we will save x billion on something else. What you probably want to do is a health economist to answer those questions, and if you wanted that kind of answer that would have been useful to have those questions framed like that, so that I would have spent more time in doing what you wanted, which was giving you the data that you were looking for, which is completely possible to do. Can I try and answer now? Sure, of course, please. You didn't think that the sums of money that we are currently spending are that big because as a percentage they are not that large. I actually think that we are spending a lot of money if it's not giving us the sufficient return on the investment, and the evidence for that is the rising index of inequality, the fact that the gap between the rich and poor in terms of life expectancy is increasing every single year, and the mortality rates are falling for both rich and poor, but the gap is getting wider every year. That's one obvious failing of our current strategy that we're spending that £250 million and we're leaving the poor behind. That's one obvious, the most cost effective way to improve public health is to reduce the gap in income and wealth and opportunity between the rich and the poor. Most of you, I'm sure, will have read the spirit level and the subsequent book by Richard Wilkinson and Kate Pickett. I don't want to seem simplistic, but that really is the essence of public health. You would improve hundreds of parameters if you reduce the gap deliberately and you have to focus on that. Once you start leaving the focus on that gap and you start introducing a myriad of other approaches, you get distracted and you create a lot of false positives, which means that the hospital is focused on dealing with all the breast slumps that you've identified and all the false positives within that cohort, and you lose sight of what you really need to do to ensure that the gap is minimised. I'll say that back again. I suppose that we did nothing that was on that last pandemic flu, health screening, tobacco control, alcohol measures, health protection, the whole law, all of that, 250 million pound. What would you spend on and what difference would it make? I wouldn't just cancel a lot of that. I would also look at the huge wastage that some spent responding to unnecessary admission to hospital. Because we've starved general practice, district nursing, social care of the elderly, we have a much higher emergency admission rate than we should, so we're then having to pour money into more A&E physicians, more acute physicians, more staff for the hospital, and we don't see it, and it's obvious. All you have to do is plot the data, plot the emergency admissions, plot the compliance failures in the A&E, and you'll see that they coincide with clusters of very, very old patients. The reason the old patients are pouring into the A&E is not because of demographics, it's because we've cut back on the GP, the district nurse and the social care of the elderly, and that is data-driven. I can absolutely demonstrate that. I didn't show you that data because you were asking me about preventative spend, and I chose the breast screening programme as an example among others that we need to review to see if we can liberate some funds, but the big money that's being spent is obviously in the hospitals, and you could shed a lot of that money if you reduced the demand for it by a strong community-based service, which you don't have. I've got two parts to that. One is you're talking about screening. If we stop screening, how much money would that save? Well, whatever is spent on the screening, depending on the different programmes, and I'm not suggesting that we cancel all the screening programmes. See, you don't have a number on that. I'm suggesting that we review each and every one of them to see what we're getting for the money, the cost-effectiveness of it, and then if it doesn't stack up, we then consider toning it down. You don't have any numbers on how much that would save. No, if you'll look at my submission, I said we needed to review them. Right, okay, so you're taking a view on that without the data? Yes, I am. I looked at the Marmot inquiry and it told me that in the whole of the UK, they estimated that 1,300 lives would be saved from breast cancer and that between three, according to other studies, up to 13 women would have an unnecessary mastectomy or lumpectomy with or without adjuvant treatment, and up to, well, they stated 200, but up to 1,000 women would need to be screened to save that life. Depending on the studies you look at, I think those numbers need to be examined. I don't think that's good enough, and I don't think that's a public health approach. I think that's an interventionist approach. If I can come back to the measure of spend, you don't have any data on how much the screening programme would save if we didn't do it. Can I come to this? So part of the problem is finding out what things actually cost. So, for example, if you look at the health screening, I've published on this recently, and we found wildly different answers from different health boards giving different figures, part of the problem is that it's so fragmented, the costs are not fully inclusive. So, for example, opportunity cost is hardly ever examined. Pharmacy time and patient time, patient burden in particular. So actually gathering data on this would be a PhD thesis within itself. It is almost impossible to find, and that is one of the problems. And just to emphasise again, opportunity cost is almost never examined. So you can say what the cost is of the drugs, you can say what the cost is of supplying a certain staff for certain minutes of times, but the distraction that it causes is a fundamental problem. The other issue... For the concern that we don't... I mean, there's 160,000 people employing the health service and spending £13 billion, but they can't find somebody to go and do their number crunching to justify or understand where the money's been spent. That looks to me like a problem. It's difficult to get this data. You find academics have published and written in small areas looking at it, and probably most of these people are doing it in their own time, but actually getting coherent numbers across the whole of Scotland is remarkably hard to do. The other problem is cost-effectiveness analysis. They're very rarely done independently of the organisation that's funding it. That's another huge difficulty. Do you want to command us? In terms of assessing the cost of programmes, the way they have been designed would be embedded into the delivery of the NHS. So it wouldn't be difficult to find out exactly how much we spend, because as screening coordinator I know exactly what staff we actually employ to deliver, so it's not impossible to get the data. The other point to make on screening programmes, we have a national screening committee, which is a UK committee that is tasked with reviewing evidence. They have actually commissioned the Marmor review, and if there are any issues, it's up to the national screening committee to go back to the evidence and look at the cost-effectiveness. The value of the lives spent as Helen have identified that the screening saves can be subject to either the NICE, because we have the value for money in terms of how much it costs to either get any outcome, whether it's life-safe or quality of life. The other point I would like to make is actually if what we have seen, particularly through screening programmes, you save people from one disease, but the way humans are designed, we will simply have another one. So if we look at Californians, they have saved coronary care beds by preventative measures for coronary heart disease, and now they have to do joint replacements, because degenerative conditions kick in as we age. So it's up to us to decide what's worth, certainly extending life and preventing people dying young from diseases that are highly preventable, and I would like to point out that having grown up in communist Romania where we were all equal, that hasn't stopped us from smoking and drinking excessively and dying young from preventable diseases. So there's a fine balance we have to find. In terms of the data that you have and the costs, could you provide a committee with that later? We can certainly, I will need to go back and get that. Alex, could I just add a small point just picking up on Ivan's question about prevention versus screening and just to pick up on positives of what has been shown to be preventative. One of them in relation to breast cancer is breastfeeding, and you'll see from the evidence that we gave from the college about early intervention that there is good evidence and good data that breastfeeding does reduce the risk of breast cancer. And perhaps sometimes pushing positive messages rather than potentially negative messages of we'll find you when you have a disease or when you have early signs of a disease to have true prevention would be to reduce the person's risks of ever having that disease. And so to emphasise, and there is data from UNICEF and the baby-friendly initiatives, to emphasise what could be a preventive measure, which would cost nothing to anyone other than the mum who's providing the milk for the baby. It actually protects that mother against risk of breast cancer. So there are a number of initiatives that could be positive preventive measures that are not specifically related to screening programmes. Another point that I'd like to make about data collection is that there is very little uniformity over the ways that data is collected across different health boards. And if you are going to ask a question that covers the country, then I think it would be really important to provide the, to ask the right question so that you're starting from the question and not trying to draw answers from data that was provided for a different reason and then also make the data collection easy to make it part of what's done routinely. So you're not employing people just for data collection and that you provide the IT facilities to make it happen. And I think the differences in IT across different health boards interferes with the reliability of some of the data that you might be hoping for. Can I just add that breastfeeding is much more likely in the privileged classes and that's another reason to try and improve the economic welfare of the people at the bottom end. It's, in my view, a bit cheeky to try and expect people that are really struggling, that aren't employed, that aren't well educated, that don't have meaningful employment, to get them to adopt healthy lifestyles and to get them to breastfeed. And anyone who's done it knows that breastfeeding isn't easy. It's inconvenient at times. It means that the husband can't just give a bottle because you're trying to fully breastfeed. So having breastfed two children myself and having witnessed my daughter doing it recently, it's one of these things that you have to be really committed to, very difficult to combine with a job. And the idea that we just get everyone to breastfeed when they're struggling and they have really major financial worries and housing problems, I think, is cheeky and unrealistic. Alex You've been a good morning to the panel. I'm very glad that Dr McFadgen made that point in that observation just before the convener brought me in, because it felt slightly incongruous to me that, as part of our preventative agenda, we were looking at screening, because screening, for me, is catching things after they've happened. And, okay, it's early intervention. But I think that's a problem in political circles that we often conflate early intervention and prevention as being the same things. But actually, we need to get to this before it gets out of the traps. I guess some screening can pick up DNA profiles which may make people more susceptible to certain conditions. Yes, that can be a preventative side of things. But my question was specifically in respect of health inequalities. And I think Dr Irvine, you articulated that very well when you picked up the point about breastfeeding just now in respect of those communities which are less likely to breastfeed because of their social deprivation and the various factors around them. I'd like to explore the uptake of screening opportunities because we don't screen everybody in this country because it's a voluntary thing. Nobody is mandated to go and get screened. As a result, you will have a heavier weight of demographic of the worried well, as it were, than you will have for people in populations who are perhaps more at risk of some of these conditions given the other commensurate lifestyle factors that they have around them. How do we fix that? I mean, because it strikes me that a lot of that time and energy and resource is actually spent checking people who keep themselves pretty well anyway who probably know how to check themselves for lumps and who are fine, whereas it's that sort of nucleus of people in deprived communities who aren't necessarily opening their mail, who don't see that there's an opportunity to have screening of one kind or another and don't take up that opportunity. What you're asking me to do is advice on how do we increase uptake of screening programmes by those people who have the highest risk? I suppose that I would backtrack and say that, first of all, I don't want to promote screening generally unless you have a very sensitive and very specific test. That brings us to the breast screening programme. It isn't good enough, in my opinion. It creates some false negatives and a lot of false positives. Therefore, the idea of spending even more money and more time and effort trying to target the other quarter of the population that has a better return isn't the way I would go. I would be looking at emphasising primary prevention. You hit the nail on the head when you said it's picking up disease that's already there. So it's what we call secondary prevention and that was outlined in the submission by my health board, GGNC. By the way, I need to remind everyone that I'm not representing the views of my health board today. I'm here as a consultant in my own right. But so I wouldn't be wanting to go down that route. I would be wanting to promote a healthy diet. Now, not by telling people repeatedly what to eat and what not to eat, which isn't working, but by public health protective policy, the trans fatty acids in the chip fat, I would even regulate the amount of salt that's allowed to come out of the salt shaker in your chippy. I would regulate the amount of salt and sugar and fat that's in all these junk foods. We have far too many different types of junk food to choose from. We have far too many different types of alcohol that are too close to us physically. We can buy it anywhere. Too many long hours on the pub. Remember when we had the licensing laws changed? That was one of the most bizarre things that I thought the Scots could do was make it easier to drink at all hours. Given the existing problematic relationship between the Scots and alcohol, why would we make it even easier? I believe in primary prevention, but I don't believe in relying on health education, which isn't working, because we can see the inequality gap getting wider. I believe in reducing the gap proactively using taxation and a whole range of other fiscal policies. The work of Chick Collins, the report he wrote about, I don't smoke and I don't drink, but I'm still unhealthy in brackets because I'm poor and I'm stressed. That's the way to go. I absolutely fervently believe that. I'm not going to change my mind. I've been in public health for 26 years. Just as a final note, when I was sitting in the MPH in 1989 and I was five years into the UK having left Canada, I disbared when I heard what the plans were for Scotland in 1989, which was to hire an army of health improvement officers who have no contact with patients, who produce boxes of leaflets that distribute out to people who don't read them, but they sit in the GP's office and they often don't even get used, because I knew that the solution was meaningful employment, not complex benefit systems, but meaningful employment where people can actually live on the wage that they're paid. It's as simple as that. You don't need to hire consultants like me. You just reduce the gap and everything will improve. Mental health, physical health, everything will improve, and if you read the spirit level, you should be persuaded, and if you haven't read that book, you need to do that. Sorry. Wow, thank you for that. That was very compelling. I think it's very much grist to the mill of those around this table who would like to see this committee generate an obesity bill to take to the Scottish Parliament to tackle some of those actual practical issues you described there. I think, as I say, I think your evidence is very compelling and I find myself educated by what you have just said in terms of the fact that, in some cases, screening may actually be a false flag. It may be a comfort blanket to politicians and to the wider public to say that your decision makers are doing something about this. When actually we're not, we're just spotting it in a few people and we're not preventing it in anybody. So no, this has been really helpful. So thank you. Can I just say one last little request one, because this has bothered me slightly. When I looked at the routinely collected data for our health board, the commonest medical elective diagnosis, i.e. reason for admission, of all the medical elective work, was breast cancer. Now that may only be 2 per cent of all the medical elective admissions, but we're talking about tens of thousands of admissions. The commonest one was the medical elective was for breast cancer. Now that to me is a symptom of our focus in the breast screening programme and also the general obsession with lumps and unfortunately breasts are lumpy. So if you become obsessed with trying to prevent every death from breast cancer, you end up treating a lot of lumps that didn't need treated and then you get what I've just pointed out to you that it ends up being your commonest medical elective admission. Now I would submit that it's going to be difficult to measure the actual cost of your breast screening programme because you have to measure the cost of the lady coming in and being worried about it, having a lumpectomy that she didn't need, taking time off work and so on, the fact that it's then difficult to feel the breast thereafter because there's a big scar on the breast after where the lump has been taken out. So there's all these costs that are impossible to measure and that's why overall I would concur with Margaret that totally apart from the actual costs financially of the screening programme you have to measure all these other unforeseen costs and the impossible to measure costs. Can I come in? So one of the things I really worry about with in the breast screening is one example but the health checks programme is another is exactly what you've said is that you've got people who are at low risk presenting themselves at the healthy attendent effect so you automatically think you're doing some good because you're picking up stuff early but that would have happened anyway you would have already got a good treatment. The problem with breast cancer screening and to a certain extent with health checks is you get over diagnosis so you diagnose bona fide cancers in the breast cancer screening programme but they would never have progressed an invasive cancer that would have done harm without the breast cancer programme. And the problem is if that's focused on women who are already well off and already have a long life expectancy you're putting more resources into that group that can never then reach other groups in society. And what you were saying is exactly right about true preventative healthcare is outside of healthcare it's social justice it's fair food laws it's tobacco laws it's active commuting it's been able to play outside with your kids knowing that you're not going to get run over by a car it's safe places to go to work it's fair laws fair employment laws it's fair play from ATOS the department of work and pensions and the absolute carnage in the benefit system has created so much stress and hassle for my patients I'm daily heartbroken by the effect it has on people so all those things have a profound effect on health but I am unable to influence them as a GP I'm happy to come here and tell you about them but I would love to see in this committee take flight and sort of start to say actually to get real preventative healthcare we need far more than the NHS. Coming back to the points that were made in terms of the discrepancies in uptake even if we use screening and picking on helens about the education the affluent managed to understand the health messages we put forward in Glasgow in particular we developed campaigns to promote screening programmes like survival that we tested on the least affluent and what happens time and again there's lower uptake among those that actually need it most and all the wider influencers are at play to prevent people from the least affluent to actually engage with whatever we put forward so the only way to be effective is to have policies that make the right choices easy choices if I'm looking at breast screening in particular a lot we know that obesity is a factor that actually drives breast cancers breastfeeding is indeed protective but also a number of cancers appear simply because of the amount of alcohol women drink so these are primary prevention now if we are going to have effective obesity policies that actually are going to have the right foods and increase the reduce the calorie density in the foods and the right nutrients in 20 years time we'll be here arguing whether it made a difference or not or how much money have we spent because if something doesn't appear we can't count it and we don't know what actually made the difference the reality is fairly complex and it's really hard to attribute causality to a lot of interventions we have seen with other screening programmes moving on from the breast to the treble A where we had randomized control trial evidence in terms of the effectiveness we put it in place in Scotland and because of the changes in how we dealt with cardiovascular disease and the preventative agenda luckily we do not find the number of cases that we expected simply because the world has moved on so it's how do we I think my issue is how do we get smart and understand that the world is constantly moving what we believe is going to deliver might not necessarily in the new context not necessarily give us or give us something very different so we need to have a constant process of assessing what we do and readjust our effort Can I just add a point to Mr McKeith in particular you were really focused on data driven and although I spend most days analysing data more or so than most consultant colleagues because I'm particularly focused on data analysis, routinely collected data I would accuse you of being excessively impressed by a data driven approach some of this some of this is just plain common sense if you make it harder for people to eat rubbish and drink alcohol a whole range of things will improve they're going to have less to see ischemic heart disease less of about 15 different types of cancers maybe 25 different types of cancers we know that tobacco is about 25 30 different types of cancers and we know that obesity now is a major risk factor for breast cancer as Amelia has just said so if you reduce the ability of the public to eat rubbish and high fat foods you'll improve a whole range of diseases there's no chance in heaven of actually measuring perfectly or even remotely what the impact was you just improve the obesity and a whole range of diabetes will improve so I don't need a data driven approach we only know that stuff because the data tells us that I sense you've seen this committee before Dr Irwin but Tom wants to come in on our supplementary on this then I'll bring Maria sorry it's now specific supplementary and good morning and thank you convener just I very much appreciate the points that Dr Irwin's making but we shouldn't agree that these unhealthy lifestyles propensity to drink excessively to eat poor food in themselves say our symptoms of economic inequality low pay to use an old fashioned word alienation and the dehumanising effect of precarious work now simply removing access to cheap alcohol and food it doesn't take away what's motivating people to pursue that I would just like to comment on that particular problem in that tension well first I just would point out to you that middle class people also pig out drink too much alcohol increasingly so so it's not just a problem for the poor and the unemployed but I absolutely agree with you I've always been focused on the poverty issue first because that is a social injustice so that's why I keep banging on about the spirit level so what we have to do is examine why living in this world is stressful and why a substantial minority has been left behind so that's how you really tackle public health but on top of reducing the gap between the rich and the poor in terms of income and wealth and opportunity, education and so on you also have to introduce public health protective policy which is why I'm very proud of the Scots for beating the English to their the ban on smoking in public places that was absolutely a fantastic piece of legislation and we did it first in Scotland so you have to have a number of approaches you have to have good quality health education which is available nationally you have to have GPs promoting healthy lifestyles and identifying high-risk patients but your priority has to be reducing the gap in income and wealth and you must never forget that because if you forget that you end up going down a whole bunch of tangents which where we are at the moment lots of different initiatives that are giving us a low return on the investment I'm just interested in the again the bias almost that's going towards the screening programmes and the interventions and I suppose as a paediatrician I might glass half full person and I have a lot of faith in children and I think that we've seen preventive health initiatives that have worked because children and young people have adopted them and taking that approach of everyone can help themselves as well as the state perhaps supporting them to do that has a lot of potential I think that when people talk about the worried well one of the things that worried well often miss is the risks and benefits of the decisions they're making and I think Margaret made early on the comment about giving people facts about the risks of interventions and the risks of screening programmes as well as the potential benefits from my perspective as a paediatrician I see worried parents of children in various from wellness to illness but I think that very often giving facts for the benefits and the risks of whatever intervention is important and not just going for the programme that offers an intervention of itself I think the Scottish initiative of the daily myelin schools has been an enormous success and has applied to all children and also social groups and I certainly see children and young people where giving them the respect to make the right decision for their own needs has a hugely positive impact on their self-esteem and self-confidence and then their potential to be peer supporters of other young people to make change begin to happen from the inside out I remember some years ago Bathgate academy presenting what the pupils had done in changing the attitude of their entire school to keeping themselves fit because they owned the programme and took it forward for themselves and I think there are a lot of potential areas where a different attitude to preventive health could reap benefits for possibly a lot less cost than some of the the major programmes that are in place at present Amivia Thank you I Picking on the argument about the the environment and poverty driving people to drink excessively in terms of alcohol consumption the most affluent drink just as much as the least affluent and we know that they're the if you're in the least affluent distal as a male you're 16 times more likely to die from that compared to the most affluent person so the unhealthy behaviours are pervasive within society the other thing in Glasgow it would be remiss of me not to mention the problem with we have with drugs heroin but also the new psychotrops and we see deaths and in fairly nearly close to me people that actually have experienced within their families deaths in very young people so looking at the evidence and what works is actually offering people young people alternatives and Yuna mentioned giving people choice to do something else so if you look at Iceland they simply engage families and children in alternatives what actually they're interested in someone interested in sport someone interested in cultural activities so we need to create an environment that engages people in something that they care about and they really want to participate food needs to be the right food not the junk you get at the counters and alcohol has to be more expensive we have seen through the school surveying Glasgow that the least affluent children now take by less alcohol because they do not have the pocket money so it's it's having the right policies as well extremely tight for time this morning so could we really be short short be questions and answers Marie I'm very interested in this tension between being data driven or evidence based medicine and intuitively sensible and I think it's an issue throughout medicine but it's probably a particular issue in public health I wanted to ask you about the flu vaccine which a number of people mentioned as an area where the evidence and you know I think a Cochran review a few years ago raised some questions about how much difference the flu vaccine had made to our health and yet you use the term intuitively sensible to use the flu vaccine and I just wonder why why do we take that different approach with a vaccine versus you know you raised lots of questions about a screening program and it is that because the costs of vaccination are less so there is a cost for the drug there is a but there's very little harm done clinically to people who get a flu vaccine unnecessarily but there would obviously be an opportunity cost so I just wondered if either of you had any thoughts on that The vaccine is different from MMR and things like that because flu changes every year and you have to predict what you think the flu outbreak is going to be like and that's It's not at all effective That's right and that's the problem so where things like MMR are highly effective they're very very good I think there are legitimate questions to be asked about flu vaccination there's high quality evidence that says if you have significant underlying lung disease you're far more likely to benefit so if you get really bad chronic bronchitis you're our group that's very likely to benefit but it's a healthy adult who just happened to be older that's the group that I worry about and I really worry that GPs get targets for payment to hit payment for vaccination as opposed to informed choice about vaccination so to me it should be the GPs choice the GPs job to say here is an intervention here are the pros here are the cons what would you like to do and that should be the intervention it should not be that we're paid to do more for some people actually for all kinds of reasons just don't want to have it but I think the decision that has to be made out with the general practitioner and a person to person basis is what our Scottish Government willing to fund do we think that doing this for everyone is the best use of this resources or could our doctors and nurses be doing something better with their time and that is very often what will happen in a consultation I let many GPs I start early and I finish late to give a little bit more time to every patient and I want that time to be for that patient to talk to what is important to them about I would like to have a dialogue as opposed to a very directed thing where I'm saying okay time for your vaccination now whereas the person might say actually I just want to talk about the bereavement of you know the death of my father or I'm worried about the symptom that I've got or actually I'm concerned my depression is coming back again that kind of thing and it's very hard to capture that kind of news from where opportunity cost goes and I'm just really worried that we're almost turning general practice into a factory setting where everyone automatically gets the same thing rather than making a really high quality choice Okay, Marie The other thing I wanted to ask about was the A&E fold-out target so a couple of people mentioned that and their submissions that had driven that attention into A&E when Harry Burns came and spoke to us about targets we all agreed that there were real problems with some of the targets said but actually it seemed that that one came out as being quite a useful target it was a canary in the mine target so it told us not about particularly what was happening in the A&E it tells us something about what's happening in the A&E but it tells us about what's the health of the whole system so who is coming in for unscheduled care how many cases of unscheduled care are appearing and where they move on to within the hospital so it seemed actually that was a reasonably to me looked like a reasonably useful target compared to some of the others Do you want to give me some thoughts on that? If I could say that the four hour target seems rather illogical on its own I think that again going back to what question you want to answer when you ask the question is important because taking the data from a four hour target without setting the questions beforehand simply tells you how many people are seen within four hours if the people that are being seen didn't need to be there in the first place then the four hour target is meaningless and so working back from the target to say is the target all that we need or is there something more to that one of the issues I work as a hospital doctor and see people come to hospital and many of them could have been seen in another way led me to ask what people are advised about how to find help for their health and we've heard a lot about GPs but sometimes there are other people who could answer some of the questions that end up with someone coming to an emergency department for instance I have a headache and no paracetamol I need paracetamol and I go to hospital which is completely illogical unless you think that maybe that's the only place that person needs to get help when they don't feel well and so I think again going back to young people to ensure that young people are aware of how to look after their health and their symptoms might be an important part of looking at the ED four hour targets so I think the target I don't know why four hours was the magic number but I think as a doctor the clinical priority is much more important than the number of minutes or hours somebody waits to be seen Emilia Fforsley very briefly and then you We know that when we have busy emergency departments the mortality increases in people who attend hospitals so we need to find a balance whereby we have the right venues for people to attend when they need care Targets are arbitrarily set and if we have targets we just find ways to manage the target not necessarily the patients so it's how do we take a whole system approach as Yuna mentioned to ensure that we see the right people in the right place and not just mind the four hour target Target was introduced in 2007 and I believe that it was useful at that time because it attracted attention to unschedule care and A&E in particular it encouraged the hospitals to invest in the A&E service to hire more A&E staff and so on and the quality of that service improved and the waiting time experience improved dramatically so between 2007 and 2010 the compliance performance in Scotland including in our health board was excellent but thereafter it deteriorated and in our health board in particular it deteriorated markedly with extremely low troughs down to 70 per cent for instance and now we're starting to go back to those really appalling statistics and that's because the four hour A&E target collapse is a reflection of the inadequacy of the community-based services and if you ignore the alarm bells when they keep going off intermittently every winter in particular and you don't address the inadequacy of social care of the elderly district nursing GPs and other community-based services what's the point of continuing to measure that for our target if you don't address the root cause of the problem and you simply hire more A&E consultants which is what we have been doing for many many years so I am not a fan of it anymore I think it's outlived its usefulness My final question is on breastfeeding so I'm delighted that you raised the issue and I'll just pick up on that I think in terms of health prevention of illness it has an implication in a lot of things that we've been talking about today like breast cancer and in obesity it's interesting that immediately when the topic of breastfeeding was raised we thought about you know we're thinking of this graph that we have of lifestyle drift so we thought about the interventions in terms of education and telling people that they should breastfeed rather than the issues which create a culture where breastfeeding is easier like in some of the Scandinavian countries where regulation of marketing is tighter where economic inequality is less acute so I'd be very interested if you could give me some thoughts on that quickly if there are things that we could do other than education to improve breastfeeding Thank you I think there are lots of things we could do and I see I work in neonatal care so I see lots of babies in their moments and I think that it is impressive to have one to one support for a mum trying to breastfeed is for me the thing that makes the biggest difference and that leads on in terms of health economics to the need for the people who can support mothers in the community and that is health visitors in the professional sense but also peer supporters in the community I think in Scotland we have had quite a challenge for the culture to change I think in wartime women were encouraged to go out to work and bottle feed with national dried and that culture is now two generations old but it takes a long time to change because at that time I think the media and now we have media involved even more actively the media at that time promoted formula feeding because the women were needed and to come away from that and say that actually that wasn't the best way to feed your baby means a whole culture changing its beliefs and so I think there's a lot of need for that I think the social discrimination between different income groups is something that we shouldn't accept as a given that there are lots of women in lower socioeconomic groups who would love to breastfeed if they were given the support to do that and I think that's where we should be targeting again it's like the daily mile that if we assume that one group won't breastfeed then they won't breastfeed and it may be again targeting the extra input to encourage the positive benefits and let people enjoy breastfeeding their babies which is what it's all about and the babies will be the next generation who hopefully will then be healthier and less obese and improve the economics of Scotland I'm going to have to move on we've got five people in five minutes left so Tom Very quickly with regard to screening and given particularly the prominence of false positives to what extent in the discussions that occur between screening and intervention is realistic medicine actually being practised and if I could just ask as a supplementary to comment particularly on the cultural drivers of demand and within healthcare and within the gas preventative agenda and specifically what role in altering these cultural demands cultural driven demands do you think health boards and government has for anyone just to ask Well I'm really worried I'm really concerned that the invitations and the adverts for screening always emphasise the importance of attending screening they don't encourage shared decision making so they don't encourage people to make a decision that's based on their values and what they prefer to do themselves and I think that's the biggest cultural problem that there is GPs very much are trained to believe in patient autonomy and in giving people good information on which to basis their decision but the invitations are sent from a central agency with my name on them so invitations go out with my name and I'm saying Dr McCartney says it's time for your cervical screening you have to come along for it now essentially without really giving people information about the potential for false positives and the potential for overtreatment I think that women who want to have cervical screening should be absolutely supported to do so but I think that we have to be very respectful of the people who for whatever reason have decided that they don't want to have it and I do not think that that's embedded in the current system just now Could I just comment on the realistic medicine document which I think has been a very positive and positively received document in relation to antibiotic treatment when you asked about the pros and cons and how it's presented I think that there is a huge potential to change people's demands if you like on the health service by truly allowing them to understand the benefits and the risks of the treatment that they might think would be the right one for them and very often they can change their attitude but it does take time and it does take person to person and I think that the one to one with a media backup is a very effective way to go but media alone is not going to be enough so if someone comes asking for an antibiotic and you say the antibiotic may make you have a tummy upset and may cause resistant organisms when in fact you probably have a viral illness that won't respond anyway then I find that most people would go for not having an antibiotic but it does take that brief discussion to make sense of it why would anyone understand if you didn't give them the explanation and we know that there's good evidence that if you have a continuous relationship with your healthcare professional you're more likely to be satisfied with your care and less likely to increase costs so your care is cheaper you tend to get less interventions and overall people prefer it I actually have I think that there's some wonderful material in the realistic medicine documents but I'm also concerned that there's a bit of a conflicting message that the government has encouraged the concept of screening generally and encouraged people to go see their GP at the drop of a hat including if you have a cough for more than three weeks by the way I've had a cough for something like eight weeks and I get it every winter and I've had it for many years now and I certainly don't go to the GP about it I just worry that with one in one voice we've encouraged people to become a little bit health neurotic and look for disease and worry that every time they have a lump or a bump or a sniffle that there's something seriously wrong with them and then we issue a document that says we now need to start practicing realistic medicine well it's a bit late now we've got a huge cultural demand which you just mentioned which is going to be very hard to put back in the bottle and I think governments have to take some responsibility particularly south of the border where for instance they encourage people to screen for depression and then we saw an increase in prescribing of antidepressants thereafter we're looking for prosthetic cancer encouraging people to get the PSA test done when we know it's not a good idea to screen the general population for PSA or the male population so I think the government has to be consistent now in the future otherwise we will not get out of the problems that we're currently experiencing okay Jenny good morning to the panel one of the things that's kind of come out from everyone's submissions this morning has been the need for behaviour change around about preventative medicine and rather the agenda of kind of preventive healthcare and one of the things you highlighted Dr Irvine was meaningful employment and how that could you know essentially help to solve the problems that we're facing at the moment obviously the education system has a key role to play in that in terms of giving kids the kind of currency to trade in the marketplace through their qualifications so I just wonder in terms of health education if there's a need to reconfigure what we understand tell the education to mean and if we need to look at behaviour change within the education system in terms of helping I suppose to help close the attainment gap between the poorest kids and the richest kids so by looking at one of the things you highlighted Dr McFaddon was the daily mile for example I think that's all good and well but we need to join up physical activity in school whether that be in PE with the kind of theory behind it so through modern studies we might look at social inequality and linking up behaviour change with that and also looking at food education I just wonder if the panel has any views on how the education system can play a role in that preventative agenda The curriculum for excellence just before coming to this meeting and I think there is a huge potential to incorporate more about keeping your own health as it should be within the curriculum there are big topics that will be presented in a number of ways like sexual health and improvement but that one to one the respect for the individual I guess I think is very important in relation to health and young people themselves have recently carried out a survey with Scottish Government and identified their mental health as something of concern now that's a population saying I want help and we should be ready to address that to go with what people feel they want because behaviour change happens when you want to be helped and I think that's back to listening to the users as much as imposing a service from outside I think Emilia commented on that too about addressing what people want to know about Just picking up in terms of the role of the education we have to have the right environments and we have to have them very, very early we screen children in the preschool year the envisioned screening and in this stand of Glasgow the orthoptics came back and said you know there are children who can't name common objects so how do we actually ensure that children by the time they reach school they have the cognitive ability to engage with the educational system so we need a preschool that has to be available for all children particularly those from the least affluent we need to have the bedtime stories we need to engage families very early to support them because by the time they are 10, 11 it's a bit late Do you think that there's a rule for the health service or GP or somebody from the healthcare industry to come into schools and to speak to children more readily about how they access the appropriate healthcare professional because that's one of the key points that's been highlighted today folk are going to A&E when they don't need to you know you want to change behaviour well try and get into the next generation and teach those behaviours accordingly do you think there's a rule then for the healthcare industry as opposed to have more of an input I know that Minutes Against Violence for example do inputs into schools in Glasgow and across the country and they go and they speak to secondary pupils about their work and that helps to kind of develop understanding do you think there's a rule then for a better link-up between education and health there Very yes you could teach children to do everything you want but you have to remember that the curriculum is already really tight and as you'll have read in the Herald today there are difficulties with teaching with pressures on the budgets and so on achievement so I think it's a bit utopian to think that we can now teach the general public at a very early age how to use the NHS as far as the abuse of A&E is concerned Dayside has cracked it by having a redirection policy somebody goes in they're triaged by a nurse who says you're not really supposed to be using the A&E for this go and use the pharmacy that this is where it's located at this hour you need to use your GP in the morning and their GPs are geared up for taking them the next morning and their A&E attendance rates are a fraction of those in our health board so you don't need to teach all children not to abuse the A&E at school you can actually teach the patient the very first time they abuse it with a redirection policy and I believe that's where the Scottish A&E departments will increasingly be moving out of necessity we simply cannot cope with the unnecessary attendances so very briefly we'll have to move on I'm just adding to that that rather than waiting till they go to A&E which will be important in itself I think school nurses are a force that could be utilised to help young people to feel confident about using health services and I think it's unfair on young people to expect them to know by instinct or following what their parents have always done to use the NHS as we see it appropriately OK, Donald Yes, following on from that Jenny Gilwit talked about education I just want to ask about the methods we use to communicate so preventative health messages to the public you know that there are obviously a range of things we've done we all remember the very striking powerful national advertising campaigns we all know about the posters in a GP surgery the use of social media but in a sentence what are we doing right and what are we doing wrong and particularly in terms of reaching the unworried unwell in perhaps highly deprived you know deprived communities who may not have internet access may not have ready access to broadcast media, etc. I see use the children because I think we had smoke busters in Stirling and they were the most effective force for stopping smoking in public places before the act came in I think if children know and believe a message they'll get it to their parents so maybe one way is to start young What we do right in Scotland is having the right policy so we were brave enough to have the banning in public places we're brave enough to go with a minimum pricing on alcohol and we have to be brave enough to say this is the right food you need to eat and the industry will follow and we see the readjustment of the sugar content in the soft drinks on the back of the sugar tax so its policy will affect everyone and it will not rely on intelligent processing of information that has to be there and then enable through behaviours I actually think that most people know what they should be doing they know they should be eating more fruit and vegetables but they don't like them where they're not used to eating them their parents never gave it to them so they just don't have a palate for vegetables and the way to encourage them to consume more of the healthy food is to make the healthy food cheaper and the expensive food more expensive so I think we should be taxing junk food and subsidising fruit and vegetables and subsidise the whole wheat bread imagine if it was 15 pence and the white bread was around 20 a lot of people would eat the whole wheat bread you get rid of stuff that doesn't work you have a staff in the NHS that will you know that love working in the NHS who are driven by vocation and yet that keeps getting subverted by asking us to do the wrong ineffective stuff Okay, thanks Donald The in-doctor evidence when we start to ask about the preventative agenda the answer says the implication in the question is that they're wonderful and initiatives out there to prevent ill health and premature death but we simply can't measure the cost effectiveness I need to try harder to demonstrate their existence and their value for money the truth is that the wonderful initiative is staring us in the face so it's the equalised opportunity to reduce income and wealth gap and use existing powers to do so I couldn't agree with that more I think you know all of those issues outside health are the issues that we have to tackle around structural change in the economy fair work fair pay all of that stuff Do you see evidence that that's happening? And I'm distressed at how little people talk about it I feel like I'm ostracised and a bit of an oddball for raising it I feel it's my job to do so and I'm not going to stop doing that for the rest of my career it's absolutely essential and my fervent belief in that comes from being brought up in Canada under Pierre Elliott Trudeau in the 70s when the gap between rich and poor in the 60s and 70s I was actually born in 1957 the gap between rich and poor was very narrow and I will never forget Canada in those days and seeing it change as it went into the 80s which is when I decided to leave to come to the UK we have to reduce that gap we have to show commitment to young people and I am a product of that attitude I don't think I would be what I am today if I was born in Canada today because it's now much more like America there is a much bigger gap and that is the way to go and if we continue to tolerate huge accumulation of wealth on the part of a tiny minority we're just going to have more and more problems and you can't there's not enough millions of pounds available in the public sector to rectify it you can't solve it with health promotion with health screening and none of that is going to work you have to reduce that gap and that has to be the priority Amelia it's a very difficult question and we're not in spite of our efforts closing the gap but in unequal societies what we can do in terms of narrowing the gap is the very early education so there's good evidence that neighbourhood-based education in the kind of first years of life is going to promote social mobility and that's the one thing we can do Bondining any willingness to tackle redistribution I sincerely hope that that is going to come there are some measures that have been put in place but we need to be bolder than that it doesn't mean that it's going to be the final solution because we will require vaccination programmes we will require many other things in addition to it final point and on the screening stuff if money was no object would you still get rid of it? I have to see what you're going to find it does harm yeah, target it make it target it for the higher risk women you're still doing harm you know so you're creating avoidable harms that's the problem and that avoidable harm it's something you want to try and get rid of and you can always spend money on something better Can I just see the screening for BBs is a different issue and so please don't take all screening away There are many screening programmes that are worthwhile even if there weren't many money a lot of money I would continue with those ones if you're allowed to individuals to do whatever they please you can go to the states and you'll see huge disparities because the wealthy they will think on balance I can have my mammography every year as opposed to the three-yearly programme a UK is offering and most countries actually do mammography every two years so we need to be critical in terms of what we offer to whom but just allowing a free-for-all it will widen inequalities even more than currently Okay, thank you very much Can I say I really welcome this session because we need challenging papers like this and we need challenging discussions like this and I think it's very healthy that we have that Thanks very much for attending this one and we'll suspend briefly to change the panel The second item on our agenda is an evidence session with the NHS national waiting time centre Some members of the committee had the benefit of visiting the golden jubilee hospital back in September and we thank you very much for hosting us on that occasion Can I welcome to the committee Jill Young, the chief executive Julia Carter, director of finance Mike Higgins, medical director and June Rogers director of operations all from the national waiting time centre Jill, I think you're going to give us an opening statement are you? Yes, yes, just very briefly Thank you and I'm sorry I wasn't there for your visit and I'm delighted that it was of use to see what we do That's it indeed Thank you No, we're delighted to make a brief introduction to the committee to tell you about the unique nature of our board which is quite different from any other health board in Scotland indeed in the UK We're delighted that next month we're celebrating our 15th year anniversary in the NHS 15 very successful years we believe But where we started is a national waiting time centre purely set up to address elective waiting time targets as they were at the time where you could have been waiting many years just if a cataract operation we have changed radically and significantly over the years and hence when we're commonly known as the Golden Jubilee Foundation I would like to highlight although we do a whole range of services for the people of Scotland that really we have three core specialties which are our core purpose of being there The first one is our heart and lung centre one of Europe's largest cardiothoracic centres providing a whole range of services from west of Scotland all adult cardiac surgery we treat not just elective but all the emergency heart attacks come ties by blue light ambulance or helicopter to be treated at the Golden Jubilee up to our national heart and lung services and the best known of those are of course the heart transplant where it's done once for Scotland based out of the Golden Jubilee hospital The second core purpose and specialties are orthopedic department again it's one of Europe's best known departments and one of the largest with pioneering work that's now being replicated not only across Scotland and the UK but further afield into Europe 25 per cent of every hip and knee replacement in Scotland was done at the Golden Jubilee with tremendous successful outcomes so it's not just about activity numbers it's actually about the clinical outcomes and the performance and the satisfaction of patients they're now moving into taking that into more health telehealth and telemedicine in orthopedics and are doing outreach clinics up into the highlands and islands and into Fife for example The third core business we have which sounds as if it's quite quite a short procedure to have as a cataract procedure and now it's done it takes about half an hour in theatres to have your cataract removed and replaced with a lens and it's almost totally as day case work but we do 18 to 20 per cent of every single cataract that's done people travel from all over Scotland even the highlands and islands to come to the Jubilee to have their cataracts one because of the excellence of the team and the expertise that we have but also about the clinical outcomes and the speed that we can deliver that service for them I'd like to just finish very briefly by mentioning two other dimensions that we are unique in having as a national board which is critical to underpin our success and that's that we have our own four star conference hotel which is quite unique not just in Scotland or the UK but into Europe and our research and innovation institute and our research department we are now running about 80 research projects with international interest and input to them to benefit the patients of Scotland and we have completely refocused the hotels business to be a conference centre of excellence and to focus on residential training conferences with highly specialised equipment for healthcare and the public sector so we've went even beyond the NHS but finally the thing that really has made us so successful in our performance over the last 15 years is our staff I mean their dedication and enthusiasm their commitment to constantly go the extra mile and to look to improve it every turn and to make things better has just been tremendous we underpin that with training and human factors and values and culture not just in the professional side of their training for doctors and nurses and allied health professionals so it's down to them really that we have such high quality and continue to improve in our innovation so finish there if that's all right thank you Ivan thanks convener and thanks for coming along this morning and I just say I also enjoyed the visit to the golden jubilee last year what I want to focus down on is we've got some data in front of us that I'm assuming you'll agree with which is roundabout the cost per get this right cost per case it's defined as cost per inpatient case at the waiting time centre compared to a range of other hospitals and yours is significantly higher so I'd just like to unpack that a wee bit and understand if we're comparing apples with oranges here given the nature of what you're doing and then I'd like to go a wee bit further and understand how you get loaded up with demand from other health boards and whether your under utilisation has got an impact on cost et cetera et cetera that's something we should we should be leveraging more but first of all I can just maybe explain why the numbers as we are seeing in front of us here are significantly higher I'll be the start of Nando's work to Julie, she can give you the detail so the complexity of what we do so for example in our the national services they're completely different so you're not comparing apples with apples that's the first point we also try to change the pathway of care so we're not bringing patients on unnecessary journeys down to the golden jubilee so we would put on alternative ways of treating them in terms of outreach so for example we send our ophthalmology team up to Orkney and Shetland and up into the Highlands to treat patients which we've been in is an additional cost to us but a saving to that local health board and that local community and population so there is not apples and apples that we're comparing in it but I'll maybe hand over to Julie for the detail yeah so just to to kind of you know kind of reiterate that is that you're absolutely looking at apples and oranges so if you look at for example orthopedics so because all of our work is joints the average cost of the implant going into the joint is about 1500 to kind of 2000 pounds when you're comparing to other health boards a lot of their work will will be obviously fracture work which doesn't have joints so that's one of the big differences you've got is that we are absolutely unique and there is 100 per cent elective work so we don't have any accident any urgency work coming through fine so we take that to the next stage then I mean is the data that compares apples with apples then what you're doing compared to right and how do your costs compare on that basis yes very very good so we absolutely compare our costs for you know if you look at joints and because our average length of stay is only three days whereas you'll probably find across across Scotland the average length of stay will probably be about five days then our cost comes out really really good and we're extremely focused on that because we have to be we have to be we are an elective factory so we have to be extremely efficient and we have to be looking all the time to make things better that's what I've expected because that model should work like that and of course the big advantage is it should be a lot cheaper so if that's the case you've got the data that says that you're cheaper than other health boards doing similar process you're doing 25 per cent of how you need 20 per cent of catrack from across Scotland but you've got an under utilisation of capacity 600 per cent and clearly being planned that should be and could be a lot higher than that why are you not more fully loaded is there a resistance in the part of health boards to give you more operations to carry out is there something in the costing system that creates that makes it look cheaper for them to do enhancement isn't really or what's the issues behind that no no could maybe tease out just what you mean by under utilisation because at the moment we are actually full so our capacity in terms of the hospital the board resources we are absolutely full and indeed we're working six days a week in some of the specialties so the and part of the expansion plans for the new elective centre is actually so that we can accommodate more orthopedics and take that 25 per cent up higher right okay now it's just we've got data here that says you're at 68 per cent occupancy versus a target of 73 to 85 sorry that's occupancy within some of the wards right okay so that's not on the operations right so leave that to one side okay so take that to the next stage then what would need to happen for you to do more work given that it is cheaper for you to do it than for other health boards to do it and high quality of course it's the quality that actually drives the efficiency and it rather is a given yeah but no but it is important because I've never seen an efficient a finance target delivering high quality but I've seen high quality targets delivering the efficiency so it's the expansion we need to do we are actually running six days a week we're exploring some of the services seven days a week so seven day working which we're doing in the physiotherapy department in the occupational therapy but to get the theatre running seven days a week you need more staff you need more resources you need more supply so we're exploring that currently to squeeze out every part of the current resources we have but there would need to be an expansion on the golden jubilee which is under planning at the moment and just lastly there was also some data in here on cancellations and it came out just under 3% I think is that a number you recognise or and again it came out higher than pretty much every other health board but again I must well I don't know maybe tell me or again not comparing like with like yeah yeah it's a bit of both because cancellations that we have so a number of our patients don't come to us for the first outpatient attendants whereas bos will count that in the cancellations so it's not apples and apples that is it's not acceptable 3% we're working hard to get that down perhaps June can tell you she drives some of the work to do that some of it's related to the distance that patients have to travel and if they deem the amount of time that they've had to wait or their own circumstances then we do get cancellations if they tend to live further away yeah okay yeah okay and sorry can I just squeeze one very last one in there's clearly a strategic intent to replicate what you do elsewhere and this might be a question you might not want to answer directly but given the nature of what you're doing and given it's obviously planned and elective and given you're pretty good at it on that site if you had to consider whether it made sense to invest that money in doing it in other locations around the country and having to start from scratch and build up that expertise or to invest more in what you're doing in double and treble in your capacity which do you think makes the most sense we're looking at both at the moment okay so the elective capacity expansion is looking at both how much can we expand and do on the golden jubilee site and what is best to be delivered locally so there are certain procedures should be done locally there is no need for patients to travel to us but you have to consider the resources not just the physical of the money but the technology and the equipment and the recruitment of staff and sometimes that can be quite challenging in smaller sites back to your point about what we are doing the actual model of care for the planning of the new elective centres is the golden jubilee model of care and we've been asked to take a lead role in that to make sure that even if there is expansion in other areas around Scotland that they will then be run and operated and the same model of care that we use okay and I suppose sorry for very final if everybody did what you were doing how much would we save across the health board you might not know the answer to that you might want to get back to me on that a lot but if you can maybe get back to me with some analysis on that I'd be appreciated yeah thanks so the only thing to answer is that we do work very very closely with other health boards so it's not a kind of them and us and we share models with them and we obviously share with them if we're able to do things better so we work very much on a kind of creative basis with them Donald and likewise it's good to see some of you again after the visit last September I'd like to concentrate on one of the issues that Ivan raised and that's the cancelled operations because I think this is a real problem actually the with the exception of a couple of months last year I think you were above the Scottish average for the whole year and as has been said you were the second highest in Scotland and these are operations cancelled due to capacity and non-clinical reasons my first question is is just to find out why that is what is the reason for this this high rate of cancelled operations there's a couple of things we have the cardiac program in there and you know often cases are cancelled because more urgent cases come in transplants come in etc the other thing is that we have a general surgical service that is run by visiting consultants and on occasion or maybe more than on occasion it will have to cancel lists fairly short notice because consultants have been held back at their hosts board with more complex procedures that they have to carry out there it will be mostly things like endoscopy and minor general surgical procedures additionally in the cancellations that you're looking at probably for the last year we had some equipment issues with ophthalmology and that's large numbers of patients in one day so that inflates the percentage you're seeing there so I think what you're looking at is probably orthopedics probably endoscopy where you're doing up to 14 of these in a day and it doesn't take long to rack up that 3% the ones we've been more concerned about as I say would be cardiac ones that are being postponed rather than cancelled to make way for more urgent procedures Given a lot of what you do is elective surgery which I presume is easier to plan plan in advance for by its very nature and you rightly have a reputation for quality and being the gold standard and being a national centre of excellence for this would you accept that you're going to have to sort this out to maintain that reputation? Acutely aware of the areas that we need to fix the areas that we have typically concentrated on are orthopedics and cataracts etc as Jill said and we do perform in the upper quartile in both of those services and that's been evident in some peer reviews so I think we work really hard not to cancel patients we work really hard to if we cancel a patient they'll be given a new date at the same day as we're cancelling them so they're not waiting outside their waiting time guarantees so we're still able to treat them it's not a great number that 3% and yes we're working really hard and we're very focused on what we have to do Okay Colin Thanks very much Can I just touch on the point that you made regarding the challenges of consultants so we have a national shortage of consultants in almost every area yet you're expanding and you're looking to expand and given the figures that Donald touched on of cancelled operations how challenging is it going to be to meet that expansion when you have issues such as a shortage of consultants and some of the points that you made, dear I'm going to start and hand over to Mike to give you the detail there's a number of things we're doing so the expansion is three to five years away before you know it well two years for phase one and then three to five years for phase two assuming it gets approved we've set up our own training academies for theatre operating staff and for radiology that have been very successful so we're actually taking people in and training our own staff so that they're ready when the new expansion happens there's a number of areas where the services are only delivered at the golden jubilee so when we recruit we're not taking staff from other areas in Scotland we're actually trying to advertise the market in the UK and further afield in Europe and internationally to try and recruit into the areas we've also spent the last 10 to 15 years building a reputation and credibility as the place to come and work to get experience and to get high quality professional career progression and we do tend to we do have a couple of areas where there's shortages in certain skills but we do tend to have a number of candidates when we have a vacancy coming forward and today I would say there's only perhaps one specialty that we have where we have not been able to appoint into that vacancy for doctors for doctors primarily yeah so that the challenges we face are the same challenges that are faced by the rest of the NHS and broadly speaking the solutions we put in place to address those challenges are the same solutions that are being put in place across the rest of the NHS so we have looked at what consultants do and we try to use consultants in their roles in such that they're doing tasks that only consultants need to do so for instance in the optholmology service we've undertaken major redesign so that those parts of the cataract procedures and the outpatient appointments that can only be done by consultants are done by consultants and we have used optometrists to take over many of the tasks that are where you don't require a qualified eye surgeon in order to do that task that redesign is on-going and we've reached a certain point in it and where we've made major efficiencies major improvements and we would like to take it much further and that is a process in place our orthopedic service we've grown from when I came to the Jubilee in 2008 I think we had six or seven full-time orthopedic consultants and we've now got 15 or 16 depending how you count them and there was scepticism at that time as to whether a centre which concentrated on a relatively small number of elective procedures could attract people for a professional career but we've found by making that the job intrinsically attractive by concentrating on high standards by our recruitment process which is highly focused on non-technical skills, team-working and non-technical competences and it is rather than just a simple one-hour consultant interview by making it harder in some ways to be appointed we've found that it has become a very attractive place to work and people are out there who want to come work in the Golden Jubilee on a wider scale I guess if those consultants are being attracted from elsewhere in the health service then it's really important that when they're working in the Golden Jubilee they're working to maximum efficiency so that their input into the health service is maximised I think that works very well I think there are specialties where as Jill pointed out particularly where there's a very, very tight super-specialised areas where there's a very tight international market and I'm thinking about areas like heart transplantation our Scottish pulmonary basket unit adult congenital cardiac care both cardiological and surgical where there's not only UK shortage of skills but there's an international shortage of skills then we are playing, if you like, on an international market and we have a number of international and European appointments to our jobs in the Golden Jubilee You made the point that you are though sometimes competing with other parts of the health service for staff particularly more routine types of operations so given the fact that myself and other members maybe represent more rural areas and quite some distance from the Golden Jubilee patients want to go where they can get the best treatment but they would also like that to be in their local area if that was at all possible so how do you think given the fact that you are competing with other parts of the health service for consultants how do you think the expansion of the Golden Jubilee will impact on local services elsewhere in Scotland? So it should be a win-win situation and we would work really hard at that I think there's a sense in which every single appointment in the health service anywhere is in competition with an appointment elsewhere in the health service What you want to do is to provide the maximum benefit from those appointments wherever they are and that's to do with did partly do the efficiency of those, talking about using consultants efficiently it's also partly to do with being creative so for instance we've been looking at split appointments where consultants might spend half of the time in one of the surrounding geographical boards and part of the time in the Golden Jubilee I think that's one practical solution that's quite useful One of the issues for instance with our anaesthetic team is that because we do a fairly limited range of operations and because much of it is focused on what we call regional anaesthesia which means patients aren't put to sleep but they're part of the body is numbed in order to carry out the operation then there's a worry that people's skills in putting people to sleep are being diluted and we're certainly one of the solutions to that that we're looking at will be joint appointments where people have a general anaesthetic workload in one board and then would have say an orthopedic workload in our board so I think there are some simple practical things we can do I think it's really important as Julie mentioned earlier that we would want to work collaboratively with other boards we're not setting ourselves up in competition we want to create win-win situations to these sorts of problems You don't think that'll impact and set local services? Well we work hard so that all the services we set up are if you like win-win so that you'd have to take I mean it's a question that it isn't simply possible to give a global answer to Broadly speaking no we would hope that we wouldn't be impacting on local services you wouldn't be working to the detriment of local services so we would take a global view in terms of how do you provide the best treatments for the patients at the best place for the patients so that both the patient experience and the patient outcomes are optimised and we would work with other boards in order to do that Maybe give a very brief practical answer so Dunfries and Galloway we're having challenges recruiting ophthalmologists and we were looking to expand so we've been working closely with them to see if we can make a joint appointment so that it would work some of them time down in Dunfries and Galloway in the local area to treat patients where they could locally but where they required more intensive complex operations that same surgeon would come up and work in the golden jubilee with the team that are in the theatres there so we really are genuinely trying to work closely so we don't remove local services but where there are challenges we can collaborate together Can I just say in recognition of the issues that there are in Highland and in the rural boards that you've mentioned we send our consultants, their orthopedic surgeons up three times a year to Rhaigmoor hospital in each visit they see at least 100 outpatients in for orthopedic surgery the patients that require surgery come to the golden jubilee for their treatment it's all agreed and arranged in advance the patients know that if they see our consultants in the clinic the expectation is that they'll come to the golden jubilee to have their procedure carried out and that they'll have the follow-up arrangements carried out using a telehealth link so we've monitored that all the way along to make sure there's patient satisfaction and clinician satisfaction to that service that we provide there we've replicated the same thing in Shetland for orthopedics also and we have an ophthalmic surgeon that goes to Shetland three times a year so we're really in close contact with every single board in Scotland to make sure we make it accessible for the patients to come to us and as simple as possible so when the surgeons go and do these clinics they have their pre-op assessment at the same time we send an administrator from our hospital up there to talk to them about what their experience will be when they come to the jubilee where a relative can stay in the hotel what their transport arrangements will be so we recognise there's a gap and we try to fill it so it is a very collaborative arrangement that we have with every single board Thanks Claire Can I briefly pick up on something that Mike Higgins said in reply to Colin Smyth there about staffing and your current staffing you talked about having EU staff how do you see Brexit impacting on recruiting and retaining the staff for Golden Jubilee? I think we have a very small number of EU staff I think like everyone else we're waiting to see what happens about the EU so the very simple answer is that we don't know we don't see any major difficulties that we can't cope with at the moment that we won't be expecting to cope with but I think we're waiting to see what happens We did just add when the Brexit decision was taken we did quite a detailed depending on the information that was available a review of that and took it as a risk paper to our board to see what risk there was both in terms of we looked at all the dimensions of export which we don't really do but in terms of workforce and in terms of procurement and especially because of the technology and the very highly complex equipment we have, same arise you know are built and bought from abroad and the value of the pound could potentially have an impact on that so with the information available at the time we did our best analysis of that and took it to our board to decide whether or not we should go on our board risk register and what mitigating actions we could put in place in terms of recruitment in particular but also the expansion if we need to take that forward and buy two more MRIs theatre equipment we're lucky that we have national procurement in Scotland so it is a wins for Scotland and it is the best deal you get but again the outcome of where Brexit takes us will be a you know we'll determine all those and was it put on your risk register stuff? No it wasn't because it was determined that it was a low risk at that point so it's the matrix we use to determine the risk of the impact and the likelihood and at that point in time it would come out after full discussion at a board session that it was a low risk which therefore would not go in the board register but we still keep it and we still keep an eye and we still monitor it okay, thanks for that and like most of the MSPs around this table people, constituents approaches when their experience of the NHS is perhaps not being as good as they expected or it's not met their expectations or they feel they've not had the service that they wanted so I was quite keen to explore with you some of the data from your latest inpatient survey where it found that 98.7% of patients had a positive engagement score with 94% rate near services is excellent that the board delivered more than its planned activity for inpatient day cases and diagnostic examinations with activity 12.5% higher than in the previous year which obviously you have to be congratulated on that you're achieving that so can I ask what learning is there for other hospitals from the experience of the golden jubilee and that positive engagement that you have with your patient group? Well there's so much I mean those of you that managed to visit would have seen the presentation of our quality framework for the past six years we've been working very hard to say that quality is about being an exemplar employer for our staff because they will deliver that front line care to patients and their families and carers it's about looking at the actual pathway of care for the patient and making sure it was the highest quality and it's about what matters to the patient not what's the matter with them because that's quite a different thing if you ask someone who's having a hip replacement what matters to them they might say they want to run the next 10k or they merely just want to go out and dig the gardener take their kids for a walk without being in pain so it's about what's important for the patient so we've done a huge piece of work in training our staff and looking after them to raise that satisfaction of staff that contributes to the satisfaction of patients having high quality having good communication with them starting that communication before they come anywhere near the jubilee so that very first contact is a phone call once they receive their letter of appointment to explain to them what will happen and to follow that right the way through and to constantly look at the indicators of the hard facts and the targets that are coming out from that how many infections we have how many complaints what's our length of stay cancellation rates and DNAs so we triangulate the staff experience the patient experience and the actual targets and we look at that we have a live digital platform in apps that are in every warden department and are on all the board members iPads and laptops that you can look at that any day in any hour of the week from wherever you are in the world to see how quality is the patients we encourage them to give feedback in a whole range of ways so they can do it before, during and after so for example North of Perics they found the experience of patients was they were so grateful they would tell you it was wonderful as they were leaving because they just wanted to get out they don't want to get home and they found that actually between seven and 10 days post-op once they were home was when the true reflection of how exactly did that go and they talked over with family and carers so they then get a phone call now between seven and 10 days after they've gone home to ask about their wound to ask about how their mobility and their operation is when but more important to ask them was there anything we could have done better to improve satisfaction by you Thanks, so that you one of the other areas that the committee has looked at is staff governance and you mentioned there what was your exemplar employer for staff how have you rated that and what's it engagement have staff had particularly through things like the staff national staff survey for the NHS I mean the we tremendous reply back from staff in the staff survey I think I'm just looking at my notes I think it was 84% employee engagement satisfaction we were one of the highest if not the highest in Scotland about the staff satisfaction rating which is absolutely tremendous but I think there's other indicators that we gather and show in our quality framework things like turnover we have one of the lowest turnovers of staff now sometimes it's good to get fresh eyes and to get new staff coming through but over the last 10 years we've been expanding every single year so that gives us that freshness of new staff coming in to get those new ideas so we constantly offer staff the opportunity to tell us when things are going well we include them right at the start and our partnership forum has its own values which we table every time the partnership and the staff side in the unions meet with management and we do a 360 review at the end of those meetings to say how are behaviours you know how is the workplace what more could we do to improve things so there's a whole range of ways that we have staff there's also confidential contacts there's a board member that staff can approach directly if they've got any concerns and we have a whole team that in the HR department we've trained 60% of our staff so over a thousand staff in the last year in what we've got the human factors training and that's a very basic exercise to allow them to find a voice that if they are in any way feel as if they've been bullied or intimidated or harassed or put under pressure for workload in any way at all they have the words and the training to actually raise it and do something about it so that's we made a commitment just over a year ago about 18 months ago that we were going to train every member of staff and indeed we are all trainers and we're now over a thousand members of staff which allows them to question when things are not going well but equally to tell us how to improve things I'll just take briefly a convenient when you refer to your staff do you refer to staff right across the estate so that's your hospitality staff your nursing staff your medical staff your facility staff All members of staff are employed by the Golden Jubilee Foundation but we take it a bit wider than that so we include our volunteers when we talk about staff and we talk about some of our young people because of the gold award for investors and young people so we have a lot of interaction with the schools if they're in for work experience or some of the young people volunteer work and we include them in the staff governance Just related to what about the level of use of agency and bank staff and private sector etc Well private sector none We are trying to repatriate all the private sector work for the NHS The banking agency we do have bank I don't think Joly can give you the detailed agency We did quite an intensive piece of work as did all of Scotland to reduce the use of agency one high high cost but two you could not give the assurance of the clinical governance and the expertise and the skill levels of staff coming in at short notice to work because in very highly intensive areas you tend to use agency staff in areas like your operating theatres or your MRI scanners rather than just lower grades staff that are in the world so I don't think we've used any agency No no let's It's really low in agency Just pick up on that you've seen because you couldn't verify the skills is that what you've seen there No because you're not aware of the level so you would have an agency in us who was a band 6 with intensive care training but you couldn't plan that they would have experience say if you had a heart transplant patient that just came out of theatre because that's quite dedicated to what we do If you are having to employ banker agency for those very niche posts are they massively expensive? Agency is we don't use agency for that we have our own bank and therefore they come under our training so we make sure that anyone in our bank who then comes in to work in those areas has been trained by us Yeah no I was just going to say I think I said already so our agency usage is very very low across Scotland and we are very keen to keep it like that obviously Okay thanks Alison So following on from that question when NHS boards can't provide a service locally they cannot to send patients to yourselves or to the private sector and we know that in 2015-16 boards spent 81.8 million on the private sector for NHS patients obviously exceeding your income from boards which I believe was 50.4 million So has there been any analysis of that spend in the private sector you know when I look at what if there's any gaps there that you could be filling are people going to the private sector because there's something that you couldn't pick up on has there been a look at that There's both so there are certain specialties we don't do so they couldn't be picked up by us but they could be picked up by other hospitals and boards around the country but we are trying to repatriate all of this special to what we do from the private sector within reason we need that expansion I referred to Ella to do that we've done predictions projections up into 2030 of the demand of orthopedics and ophthalmology in NHS Scotland and the rise in elderly population and the translation of that into how many operations would be required we've also looked at the history of how much work has went to the private sector for those two specialties in particular so we know how much has went to the private sector before what we need in the future and therefore we're using that as our planning assumptions for the expansion So you would hope that that private sector spend may decrease over time Absolutely that's a key purpose in the expansion Yeah and I read in the papers that you're funded through a combination of Scottish Government funding and payments due to referrals from other health boards that £50.4 million There seem to be some reports of boards a few boards Grampian, Highland, Greater Glasgow and Clyde no longer referring to yourselves although at the time of writing SPICE couldn't confirm the position regarding these referrals I just wondered if you could comment on that is it the case that some boards or specialties aren't referring or is that incorrect That's not correct You said Grampian, Highland and Greater Glasgow and Clyde Glasgow and Clyde they all have an allocation of capacity at the Golden Jubilee and they have done forever So they're continuing to refer to you at the moment They continue to refer Yeah so what we have is a three year contract with all the boards we have referrals from every single board in Scotland now that's taken some time over a number of years actually but we have referrals from every single board in Scotland we have a three year agreement with these boards they can choose to send whatever they want within their allocation they can choose for wherever the patient is on their waiting list or new referrals we have what we refer to is seeing treat referrals and those would be patients that have never seen a consultant in their home board they come to us they see our consultant they stay in our system we also have treat only patients who exist on a waiting list elsewhere and they come to us just for the surgery because they've already been diagnosed in their own waiting list so there's a variety of ways that people come into our system but every board is an allocation of capacity depending on what their particular needs are Thank you Thank you Thank you Thank you, I just want to ask a resupplement to that particular question I represent the Highlands and Islands and I wondered is there either particular perhaps cases that aren't being referred because it was reported certainly reported in the press earlier this year that a high profile case of a young woman with a cataract who had a weird year to be seen by NHS Highland and when the press made inquiries the NHS Highland said that since last September they were no longer referring people to you guys I know of that very lady actually they had an allocation of ophthalmology capacity at the Golden Jubilee they had a difficult we talked to them at the time about how appropriate it was for generally elderly patients to travel down for what is a half hour procedure to the Jubilee but they needed the capacity we were happy to take the patients we talked to them about how we might refine or test pilot initial consultation by telehealth link to avoid that unnecessary travel because 30% of patients don't proceed to surgery so they hadn't managed to get that happening because you need an optometrist or a specialist nurse at the Highland end to conduct the consultation and tell the consultant what they can see he can see a certain amount so they actually passed across their capacity to five who are now carrying out that pilot in the hope that we can then take it back to Highland as a done deal if you like it looks like we've found a way forward so they were unable to use the capacity that we had given them so but they do send us orthopedic patients and they have done now for three years and that's the ones that we do the outreach clinic for and we do the follow-up by VC etc so I'm hoping we can get back to helping them out with ophthalmology that lady was quite an unfortunate one I did hear about that obviously had the made the phone call to say can you take this lady then we would have taken the lady and they have severe recruitment difficulties in that particular area so it's not like they're providing a service absolutely and that's why we send one of our ophthalmic surgeons up to do the Shetland clinic they used to do the Shetland clinic from Rheigmore so we send someone up there to do that so we're trying to help as much as we can but I hope we can get back to doing a bit more for them thank you we highlight to all the boards and not just at board level to the clinical teams and the GPs who refer you know the management the redesign of pathways and the work that June's described should never impact on an individual patient's care and they just have to lift the phone and if it's causing that a patient should not hear about how we are redesigning and moving things around and how we are working with other boards and if that is the case just lift the phone they've all got our phone number it's June's number direct and we will fix that for that patient should not have been caught up in the middle of that okay Miles good morning to the panel I wanted to press a bit more with regards to the monitoring of aftercare of which patients receive and specifically maybe when they're returned to their home health board area physiotherapy and things like that access from the monitoring which you say you've been doing is there specific boards where that is a problem that people aren't having that pathway put in place and certainly from some of the constituents I know from Lothian which have gone through that seems to have been the case and I wondered if that was a sort of postcode lottery when people return home to their home health boards yeah I'm not I'm not sure if it's a a postcode lottery so there's a number of things that we do so before the patients are admitted we actually prearrange their discharge so we would not bring patients in who didn't have that already in place and it was and it was agreed we have never had a delayed discharge for over 10 years with the golden jubilee and that didn't just happen by accident and that's taken a lot of hard work and planning because if we did a delayed discharge of a patient who was fit and well to go home but needed physioaroccupational therapy or a stair you know to some kind of lifter or toilet aid then that would block the bed and therefore the next patients couldn't come in that's a bit obvious but we've negotiated with health boards that the next patient that would be blocked from coming in because of that would be their actual patients and therefore breach of their targets etc so we've worked extremely hard we've contacted with every social work department in Scotland whereas most boards only have to have that partnership with their local social work departments and as I said we have not had a delayed discharge we haven't had a huge amount of feedback that even though it had been agreed up front that it wasn't in place when they went home that the kind of care that's received now that Mike outlined is especially in our orthopedics where patients have no general anaesthetic they control their own pain they're up walking the same days that have replacement they have it done in the morning they're up walking the afternoon home two days later means that the majority now don't require that additional care in the community whereas before when there were 10 days in hospital and at home with perhaps a wound drain or some big kind of dressing they would need a district nurse and aftercare so the numbers of people who need that has reduced dramatically but we I can't say I've had a lot of feedback and we'll look at all the feedback that comes in I'm just wondering is it one particular specialty that your constituents have issued with is it orthopedics or is it this specific case I don't have authority to speak about that specifically but it was a hip replacement that was a hip wasn't it so that would be unusual I mean Lothian send us over 4,000 cases a year they're one of our highest referers in fact they probably they are our highest referer so you know I'm almost pleased to hear it's only one albeit that one is bad enough but I'm wondering not a complaint with yourselves but with regards to what access to physiotherapy there is once you get home if you need that yeah it's generally organised in advance actually most patients don't have any specific physio post-operatively when they go home they go to what we refer to the joint school and within the hospital when they come for the pre-op assessment they leave with a video they leave with a book they leave with a phone number and they're encouraged to do their exercises at home and if they have specific problems beyond that they would call us and we would then call their GP practice to get them some additional support but that doesn't tend to happen very often The one area that would improve that dramatically for everyone is access to 70 services in the local area in the community and that is not everywhere at the moment The amount of delayed discharge across the country then is it the planned nature of the work that you do that prevents that from happening? Yes, it is indeed because you're in a unique position that others aren't in you know when people are coming therefore we're ahead of that services can be arranged so that there is no bit blocking yet Absolutely but there's another part to that the other part is that the new innovation in technology that we've put into place to do that means that they don't require to go back to a nursing home or to go back to another host or to go back to get care in the community so therefore you don't need to do all those arrangements so they can go back to their own home with their own family Give me an example of that that technology give me an example So the enhanced recovery that's now been rolled out around Scotland where there's no general anesthetic you do not have a urn recathor inserted so therefore you don't need to be discharged home with that in place and therefore require a district nurse you're up walking in three days so you don't get chest infections and we have all that evidence behind it so you don't need antibiotics so you don't need to visit your GP so there's a whole complexity of discharge arrangements had to be done five, 10 years ago that are no longer required now So is there stuff that you're doing in that regard that others can learn from or are they already doing it and if they are why we've not seen the eradication that they did this start? It's being rolled out I think all health boards are now doing an anti-recovery in orthopedics we have now spread that into our cardiac surgery and orthoracic surgery because it's a principle of care it's not just purely for one specialty and so we are now spreading that out and we share it in our team action around the country and trained people on how to do the enhanced recovery Okay Okay thank you very much for your attendance this morning and we'll just suspend briefly The third item on the agenda today is subordinate legislation we have one affirmative instrument as usual with affirmative instruments we have an evidence taking session with the minister and his officials on the instrument Once we have all our questions answered we'll have a formal debate on the motion The instrument that we're looking at today is the registration of social workers and social service workers and care services Scotland amendment regulations 2017 draft Can I welcome to the meeting Mark McDonald, minister for childcare in early years Diana White, senior policy officer at the office of the chief social work advisor and Ruth Looney, principal legal officer of the Scottish Government Can I build a brief statement from the minister Certainly convener thank you for the opportunity to introduce the regulations made under sections 78, 2 and 141 of the public services reform Scotland Act 2010 The regulations amend regulation 5 and the schedule to the registration of social workers and social service workers and care services Scotland regulations 2013, the principal regulations Regulation 5 of the principal regulations read with the schedule requires social services workers within the scope of registration to register with the Scottish social services council SSC Specifically that all new workers commencing employment for the first time in any of the groups within the scope of registration must achieve registration within six months of commencing that employment and where persons are already working as social service workers the dates specified in the schedule are the dates by when these workers must achieve registration The registration of social workers and social service workers in care services Scotland amendment regulations 2017 before you relate to the latest groups of workers for whom registration with the SSC will commence in October 2017 These are support workers working in care at home and housing support services These are the last groups of social service workers within the current scope of registration who will require to register with the SSC The 2017 regulations amend the schedule to the principal regulations to specify the two additional descriptions of social service workers requiring to register with the SSC support worker in a care at home service and support worker in a housing support service and set the date by which existing workers working in these services must achieve registration with the SSC as 30 September 2020 So in summary the regulations maintain and fulfil the policy intention which has commanded support from all parties that registration with the Scottish Social Services Council is a prerequisite of employment and continuing employment as a social service worker and provides the final dates for the achievement of registration for these final groups of workers and move the regulations Thank you Could I ask in relation to the fee that is being asked to pay the £25 fee? Is that being is there any sort of evidence of who is paying that? Is it all falling on individual staff because we know that staff in this field are some of the lowest paid and have some of the most precarious employment practices of a lot of public sector workers are they having to pick up that fee themselves or is the employer paying it for them? So the individual workers usually pay their annual registration fee and it's an annual registration fee to the SSC and as you identify the fee for these groups will be £25 which I believe beyond outside of social work students is the lowest fee charged by the SSC for registration it's also worth noting that individuals can claim tax relief against their registration fees and that would reduce the cost from £25 lower to around about £20 Okay and are there any employers that you've got evidence of who are actually picking that up? I'm not aware convener of whether there are employers who are paying that fee I don't have the kind of comprehensive information in front of me that would make me have awareness of that but obviously there may be some employers who choose to do so but I'm not personally aware of any who you're doing so Okay any questions? Alison? It's further on that convener I realise this is a requirement of the SSC but the Government's consultation on this issue has there been any and what feedback did you receive because this is an area that we're desperately trying to recruit more people into and you know while I realise for some people it may not be a lot for others it may be a barrier has there been any discussion of a waiver for those who find this a barrier that they can't overcome? So it was the SSC who consulted it wasn't the Government's role to consult it was SSC's role to consult and they consulted with the sector with over 90,000 individuals contacted as part of that and they received 3,813 responses so a 4.2 per cent response to the consultation now undoubtedly there will have been individuals who will not have been happy at the fact that the fees were going up across the piece however if you look at the general trend in terms of the monetary increases the monetary increases for most of the lower paid end of the spectrum was very small in terms of the uplift but I have also asked SSC to look in future at the possibility of introducing an income-related system when it comes to registration fees and that's something they're taking away to look at Yeah, I think that the fees probably for an average care work about equivalent to three hours pay roughly I would say which is quite significant Any other questions? No? Thank you Can we move on to agenda item 4 which is a formal debate on the affirmative SSI and which we've just taken evidence I have to remind committee members that they should not put questions to the minister during the formal debate and officials may not speak in the debate Can I invite the minister to move motion S5M-05208? Moved, convener The motion is that the health and sport committee recommends that the registration of social workers and social service workers and care services Scotland amendment regulations 2017 draft be approved Can I invite members to contribute to any discussion? No, thank you Would you like to sum up, minister? Don't believe I require to, convener Question is that motion S5M-05208 be approved I will agree That's agreed Thank you I suspend briefly Agenda item 5 is subordinate legislation This item is a negative instrument and instrument regulation of care social service workers Scotland amendment order 2017 SSI 2017-95 There has been no motion to annul and the Delegated Powers and Law Reform Committee has not made any comment on the instrument Can I invite any comments from members? No Is the committee agreed to make no recommendations? That is agreed, thank you and as previously agreed we will now move into private session