 Welcome everyone to the 27th meeting of the Health, Social Care and Sport Committee in 2022. I've received apologies from today's meeting from Evelyn Tweed, and she is going to be substituted by James Dornan, who's attending online. Our first item today is to invite James Dornan to declare any interests relevant to the committee's remit. James? I have no interest to declare and to ask members to look in my declaration of interest, register of interest. Thank you James, and the second item on our agenda is to decide whether to take items five and six in private today, are we agreed? We're agreed, thank you. Our third item today is two evidence sessions on winter planning. The first session is going to focus on NHS and social care in Scotland. I welcome to the committee Caroline Lamb, chief executive for NHS Scotland and the director general for health and social care, Donna Bell, the director for social care and national care service development, Alex McMahon, the chief nursing officer from the Scottish Government and John Burns chief operating officer for NHS Scotland. Good morning to you all and thank you for coming in person, what a treat having a panel actually in person. So winter planning ahead will obviously be a big focus, and Caroline, it may be the slightest to give me an overview of the challenges that you see this winter in particular and how you're preparing for them. Thanks, convener, and I'm very grateful for the opportunity to be here today, particularly in person, to update the committee on the actions that we're taking to support our health and social care services this winter. I also appreciate the committee's support in rescheduling this date following the passing of her late Majesty Queen Elizabeth II. There's no doubt that this winter we faced an extremely challenging period. As we went into last winter, we were hit by a new Covid wave driven by the Omicron variant, with Covid bed occupancy peaking at 1600 in January 2022. Only weeks after that, in April, we saw a resurgence of the virus, with Covid hospitalisations rising to 2400, the highest level recorded throughout the pandemic. That pressure then fell slowly down to around 600, only to rise again and peak in July at 1800. I'm setting out this detail just to remind us all of the context in which we are still operating. Our health and social care systems have barely had chance to draw breath between Covid waves. Even now, as we approach winter, our Covid occupancy is still sitting at around 600. It was 629 on 18 September. It's clear that Covid is still very much with us and very much part of the pressures that we face. Surveillance and modelling remains critically important to us. We're continuing to work with Public Health Scotland, who will shortly be publishing their national respiratory surveillance plan, supported by up to £7.5 million of funding. Vaccination also remains our best line of defence, so our health and care system is rolling out the vaccination programme for flu and Covid. That builds on our existing vaccination programme, which has delivered more than 12.6 million Covid vaccines since the start of the pandemic. Covid boosters are now being offered to priority groups and everyone eligible can safely receive this and the flu vaccine at the same appointment. Not only will this run to be very difficult for people across the country, it will present extra challenges for our staff and colleagues working across health and social care. As well as the increased numbers of patients that winter weather brings, the country will be continuing to face the challenges of the ongoing and escalating cost crisis. That adds further pressures to our NHS and social care systems, which are already dealing with very high levels of continuing pressure and demand. Convener, you will have noted that recently the First Minister set out the programme for government and in her remarks she emphasised the importance of the NHS recovery plan for rebuilding our health and social care services. That five-year plan, which was published in August 2021, sets out the course we're taking to drive additional capacity, improvement and innovation to support recovery. It's backed by over £1 billion worth of funding and supports inpatient, day case and outpatient activity, as well as the implementation of sustainable improvements and new models of care. It invests in a network of national treatment centres, increasing capacity for diagnostics, general surgery, orthopedics and ophthalmology. The committee will also be aware that, on 4 October, the Cabinet Secretary for Health and Social Care is due to update Parliament, setting out the progress that we've made against the NHS recovery plan and also setting out our winter resilience plan. Just last week, the UK Government announced both their plan for patients and the changes to taxation outlined in the fiscal event. Work to assess these plans and to understand the impact of these measures is on-going. You will be aware that the Deputy First Minister has promised to undertake an emergency budget review within two weeks of last Friday's UK Government fiscal event. That review will set out the next steps we'll take as we manage our budgets, both across government and within health and social care. As we approach winter and as an inherent and important part of our planning for winter, we're fully aware of the difficult circumstances front-line staff face. So we're working hard and we continue to work hard to ensure that staff are supported and that we grow our workforce. We know that those pressures are apparent not just in the NHS but also in social care. We continue to see difficulties in the social care system with pressures on people providing people with the levels of care and support that they need to go home from hospital. That's been exacerbated by increases in staff absences and long-standard recruitment and retention issues. It's important to remember that social care is the responsibility of local government but we have announced additional support to help address delays by increasing capacity for care at home, increasing the hourly rate of pay for care workers, supporting interim care arrangements and enhancing multidisciplinary teams. We've also introduced legislation for the National Care Service to Parliament which will put in place the long-term reform to ensure that social care, both as a profession and an essential service, is protected and improved. With regards to the NHS, we've been working on ways to continue to supplement the workforce. Last month, working at pace in partnership with unions and employers, we published the new national guidance for retiring NHS staff to return and to support the service. We also continue to support international recruitment, the increase in multidisciplinary teams to support primary care and additional healthcare support workers. We know how essential our health and social care staff are. Throughout the pandemic, they have shown extraordinary commitment working under pressure to support people. Their wellbeing remains our key priority and we are determined to offer them fair pay deals in what is a very challenging financial environment. You will know that we have made a 5% pay offer to NHS agenda for change staff, which is the most significant single year uplift in the last two decades. Whilst being disappointed that that has been rejected, we remain committed to negotiating a settlement which will avoid industrial action. Of course, the health and social care system is also not immune to the rest of the challenges facing society. Hospitals, clinics and social care settings will all face increased energy costs. We're investing over £73 billion in health and social care over the resource spending review period and a further £1.3 billion capital funding through to 2526 to support recovery. We've put in place the NHS climate emergency and sustainability strategy to support boards to implement energy-efficient measures and to generate on-site renewable electricity. We're also investigating at least investing at least £200 million in our green public sector estate decarbonisation scheme to reduce emissions and energy costs across the public sector. Nonetheless, the challenges facing health boards are very real and we will continue to work with them on the financial pressures across the system. The plans that the cabinet secretary will publish and announce to parliament on 4 October will set out more of this. In conclusion, I'd like to thank once again our exceptional health and social care staff who've made such an incredible contribution to keeping us safe through the pandemic and are continuing to do so in this period of recovery. I'm very happy with my colleagues to take questions on those matters or any others that you'd like to ask this morning. Everything that you have said in response to me are details that my colleagues will probably want to pick up and delve into a little deeper. I don't have any further questions for you on that statement just now. I'll hand over to Tess White, who does, and I'll come back in later. I'd also like to support and say thank you to the exceptional staff working in the NHS and social care as well. Are you nervous that the NHS won't be able to cope this winter? I think that it would be foolish to be complacent as we go into what will be a very difficult winter. However, we have been involved in intensive planning with our NHS boards, and that's not new. We work alongside our boards in partnerships throughout the year. We engage with them around their remobilisation plans and around their annual operating plans. They all have in place plans to deal with surge capacity when required. We know that our NHS has a strong track record in the past two years of responding to unprecedented demands and pressures in the system. However, as I've said, it's impossible. We can't be complacent, so we are continuing to focus on additional measures. The vaccination programme is absolutely critical. It's our first line of defence against pressures caused by new waves from the Covid pandemic, and that's not just about limiting hospital admissions, though clearly we don't want people getting ill with Covid, but it's also about reducing the number of days that we lose to staff not able to work because they themselves are impacted by Covid as well. The vaccination programme is absolutely key. It's great to see strong uptake among the most elderly and most vulnerable parts of our population, and really strong uptake in care homes. We will continue to move through that programme. However, as I've said, and I'm very happy to go into more detail, we're also very focused on what are the things that we can do to improve capacity and to reduce occupancy levels in our hospitals as we head into winter, what are the areas where we can make interventions that will support increases in the workforce, and there's a lot of that work that's already underway. Again, I can come back to you with details around the precise measures that we've put in place and where we've got to in terms of some of that. Reducing capacity, continuing to support our workforce, looking at new and innovative ways of providing treatment, and being out and about, talking to staff a lot, and really understanding what those pressures are like on the ground, as well as seeing them in some of the numbers. Thank you, convener. Anyone that's watching, I think it's really important that we do say that if you're eligible to get a vaccine, please, please, please go get one. It will actually save your life. Thank you very much for coming to see us today. I was listening to what you said earlier, with a lot of interest, and just to pick up on Tess White's question, £7.5 million you said has been spent on modelling. In everything that you've said, you haven't talked about any specifics or any actual things that are being done to improve what's going to happen and what's going to come. From your answer, are you confident the NHS is going to cope this winter, based upon the £7.5 million spent on modelling and all the work that you are doing, and if you could maybe tell us some of the things that you have done and the strategies? Yes, so just to clarify, the £7.5 million that we're investing in public health Scotland is around the work that they're doing, both in terms of supporting modelling around future ways for Covid but also around surveillance, so making sure that we are in a position to identify new variants of Covid and to act on that. So that's a tiny element in terms of the work that we've been taking forward. Maybe what would be helpful if I start by talking a little bit about some of the work we've been doing on workforce and then I'll pass over to colleagues to talk about some of the work that we've been doing to increase capacity and flow through our hospitals because yes, we have confidence in our NHS, we have a strong service and we are not underestimating the challenge going into winter but we are working across the system to do everything that we can to support that. So if I just maybe talk a little bit about workforce, so we've seen since 2006 an increase of only over 28,100 whole-time equivalents in the workforce and I appreciate that that's a long time. So if we go back and just focus on pre-pandemic, we've seen an increase in 8.9 per cent on our workforce since December 2013 and that's on top of the increase that we've seen in GPs with GP numbers up 3 per cent since September 2019 and indeed in the increase in our multi-disciplinary teams there to support general practice which numbers up from 1,683 in 2020 up to 2,427 in 2021 and now sitting at over 3,200 and those multi-disciplinary teams are absolutely critical to supporting primary care and giving us more capacity in primary care supporting the GPs but also improving the access that people can get direct to to see for example physios for people with muscular skeletal problems. Over and above that last year we increased the number of healthcare support workers by over 1,000. Those are people who are still in the system making a contribution. We've supported the Scottish Ambulance Service to add to their increased staff by 540 last year and by an additional 574 this year. I can say more about workforce in terms of training numbers as well but I'll maybe just pause there in terms of that. Some of my colleagues will be coming in and asking questions specifically on workforce but that's certainly a good springboard for that conversation later in the session. I'll maybe just then pass to John to say a bit more about the work that we've been doing around unscheduled, unurgent care and also improving capacity and flow across the system. Yeah, thanks Carline. I think that there's four things I would highlight that we have been working with our colleagues across the health and care system on. The first is continuing to take forward right care, right place so ensuring that we are giving best advice and clear information to citizens in terms of where best to access their healthcare. Within that we are building on the redesign of urgent care work that was started about two years ago and central to that is the flow navigation which again is helping to support and direct patients to either the right practitioner, the right professional or the right location. Within that it's also important to flag the good work that the Scottish Ambulance Service has been doing in terms of seeing treat so being able to attend and treat individuals at their home or at the point of incident and not convey to hospital and we've seen some I think significant improvements there in that scenario that we'll want to continue to support. Also the work at NHS 24 do in terms of working to complete a patient care at that first point of contact and we know that they have high success rates in doing that so right care right place is the first. The second area that I would point to is the work we've been doing to increase capacity out of hospital often called virtual capacity and our focus there has been hospital at home, opat, the outpatient, parental, antibiotic therapies, community respiratory and last winter we introduced a Covid remote health monitoring pathway and we've seen again across the country these services grow and grow with strong support from our clinical teams across the country. Probably the equivalent of a large district general hospital in terms of bed days that we are utilising through these different pathways of care and that's an area again that we will continue to build and develop and as we've been out round the country we've seen the benefits of this and the benefits that local teams have described for the care for individuals. The third area is working with our health and social care partnerships so really building on the strength of integration across our health and care systems. I think two areas of focus there one is really building and maximising the opportunity that the new MDTs give us and the skills that we have in community to support patients in the community and avoid a hospital attendance or admission and I think the second area that we clearly have a focus on is trying to work to improve the position on delayed discharges because that of course is an area where that impacts on hospital bed capacity. The final area is the urgent and unscheduled care collaborative that we launched on 1 or 2 June this year and this was an opportunity to bring together the redesign of urgent care along with other impactful high impact changes and to work with health systems, health and care systems across the country to look at the areas that would provide greatest impact for them so within that programme we are building on some of the work-around redesign of urgent care but we are also looking at areas like discharge without delay so that we can reduce any unnecessary delay in discharge, bringing discharge forward in the day and we know that that can improve flow through hospitals as well. Those are the four principal areas that I would draw out in terms of our discussions on capacity. I will hand over to Emma Harper who has some questions on A&E. A&E discharges in the four-hour breaching of targets is all over the news all the time and I know that it is really complicated in looking at what causes those breaches in the four hours and that the whole on-going thing about delayed discharges or the whole throughput and John Burns is just describing what actions are being taken so I'm interested to hear specifically what causes the delays in A&E treatment, what causes people to breach that four hours because it's not just that people are sitting on a trolley waiting for somebody to see them because they're still getting some care at that time whether it's blood pressure assessment, vital signs waiting to see an x-ray or whatever so it's not that people are just sitting there doing nothing so I'm interested to hear what causes the delays and then what can we do about what further action can we do specifically to help reduce that. Thanks very much for that question and I thanks as well I think for highlighting that this isn't just about people waiting to sitting and waiting to be seen that a lot of the long delays are people who are actually being cared for and quite often in beds rather than on trolleys however this is a situation that we're working really hard with colleagues to improve we have some we in terms of the work that we've been doing to identify exactly what does cause those delays then there's a number of factors which revolve around flow through the hospital the occupancy levels in hospital but also length of stay but maybe just ask John to say a bit more about the detail of some of those elements. Yeah thank you so I think the the first thing I would want to say is and I absolutely agree with that the point you make people are being treated they are receiving treatment whilst they're in A&E. I think I want to just acknowledge the incredible work that our teams are doing right across the health and care system but also within our accident and emergency departments and of course the A&E measure I often describe as a barometer measure because it's a measure of how the system is working and in terms of pathways in and out of A&E clearly what we want to do is to maximise the number of patients that we can discharge directly from A&E and only admit those that need a hospital stay and so there are a number of flows into the A&E department where patients are waiting for an acceptably long periods of time it is because of the flow into a hospital bed and that's why we're focusing on a number of areas clearly delayed discharges is one area of our focus for improvement but also discharged without delay it is important that we are able to properly discharge people in the morning so that we can maintain and manage flow through hospital and do that throughout the day not just a single point in time so we want to improve our work in terms of discharge I think the other things that we are looking at is around maximising the opportunity for senior decision makers in A&E because again we know that that can support perhaps a decision to discharge rather than admit so that focus on assessing to admit not admitting to assess is very important just last week we had a debate about out of hours and some of the percentages that I was quoting about out of hours reducing the number of hospital admissions so that's been quite successful and I know there's challenges about staffing out of hours in some places in Scotland but out of hours has been a good way of reducing hospital admissions as well is that great so yes that is correct I think we need to think about all aspects of out of hours so out of hours encompassing the work that John's already already referenced around what the ambulance service are doing but also the work that NHS 24 are doing in terms of actually managing to deal with somebody's issue on the telephone rather than have somebody you know rather than phone back or have somebody turn up at A&E but John do you want to add to that yeah I think the that out of hours is part of a wider urgent care provision is incredibly important and and I think that as we have developed the redesign of urgent care as we have brought flow navigation forward then that has supported out of hours but I think it's also important to recognize again the multidisciplinary skills that we have in that out of hours urgent care team that affords the opportunity to support individuals differently so I think that again is a strength that we've seen in those MDTs in developing those multidisciplinary teams over the over recent years just a final question ahead of winter so this is about winter planning today's session ahead of really getting into winter do you see that we're going to be able to make the numbers or the waiting times reduced compared to the current data are you optimistic about winter ahead as I said earlier I wouldn't be complacent or about the challenges that face us however we are working very hard with our colleagues in in the NHS on our colleagues in the health and social care partnerships to improve that flow and therefore to start to see an improvement in the statistics that you've seen published and I think we have to remember that that we do still have the best performance in A&E across across the UK okay thank you can I bring in test weight thank you convener um may I ask a alex a question please um so fourth valley has very much been in the in the spotlight sadly because of shocking statistics in terms of A&E however yesterday it emerged that um A&E departments were at over capacity at every single hour of every single day in august that's august so we're about to enter winter it's very serious that there is a massive issue what are your thoughts on on levers that can be pulled to help so I might pick up some of the points that carline made by way of an introduction around what we're doing in terms of workforce so carline mentioned the router to return policy so that that's a once for scotland policy that was published four weeks ago and that came in the back of the cabinet secretary hearing from staff directly about what it would be what would improvements would be for them to want to retain working within the United States once they retire so quite normally or normally people would be registering the staff bank and they might pick up shifts here and there but actually what people were saying was actually i'd like 10 hours or 15 hours guaranteed at hospital y or ward b so this policy enables us to actually offer that to retirees so we're hoping that that will yield benefit for people who are retiring from september onward so we will track that with boards carline also mentioned the work we're doing around international recruitment as well so we're looking to recruit internationally not just nurses but ahp's and midwives too and we've started that process and we've got circa 250 already in nhs scotland as part of that work but we're also doing a significant piece of work around developing a career framework for bands two to four so that's the unregistered workforce in particular looking at the band four level that can free up registered nurses and others to do the more direct clinical care that they're qualified to do so that's also part of the work that we've been doing as well and we're also looking to have a piece of work around final year students being placed with their vacancies in board so that they get they get ready to pick up that post dimensionally so they get the training prior to the registration coming through so their match fit as it were to actually be a registrant at the point of the registration come in to force as well and there's another piece of work that we're doing similar to that in nhs England around looking at the issue of reservists actually how could we pull people in who maybe have retired some time ago and equally the the new secretary of state in england for health has agreed that they would keep the emergency register open so that people who wish to remain on that register nmc register can do so for another two years is also all of these things are part factor about what we're doing around nursing and the hq workforce particular very helpful thank you convener you can bring in james dawnan james we'll just get your microphone on thank you as somebody who's unfortunately been a user of the health service quite a lot over the last 12 months and continue to be so i want to start off by saying just what a great service i think it's it still is we've been in every single department i've been having to attend the caring attention has been just incredible also when you're waiting in action an emergency it's pretty much like Emma said earlier on most people are getting some kind of attention but the issue i want to talk about is we've talked about targets and obviously we'll talk about this winter but during the sort of emergency situations that we've gone through over the last couple of years and we may well face again this winter who knows the targets help or the hinder i understand why they were brought in and sometimes it's great to be able to say we're the best in the UK but also it gives them it sometimes i i feel from outside it focuses attention on the wrong thing as opposed to the people who are getting treatment it's maybe those who haven't been able to get it because of the pandemic or other things okay that's a caroline okay thank you very much and that's that's good to hear your personal reflections on the experience that you've had with the nhs and i think that that's echoed i mean i would certainly echo your views around the care and the compassion the commitment that i see from staff when i'm out and about in the system and talking to people and also i think the levels of satisfaction that we still see with the service that people get across the system in relationship question about targets i'm inevitably over the last over the period since since the Covid pandemic we have had to respond flexibly and to be really clear about the priorities that we were setting our health and social care system so as you'll be aware in the early stages of the pandemic that meant stepping down a lot of planned care a position that we are we are still working very hard to recover from we've also we initially issued a clinical prioritisation framework in response to moving back to getting back to more normal pit length of weights and and we've actually worked with both to relax that over the last couple of months and that's been in response to trying to get that balance between dealing with people whose condition is is urgent and important and but also dealing with some of those people who've been waiting a long time and as you'll know the cabinet secretary announced targets at the beginning of july for for for helping to ensure that we get through those very long waits so as we've made those changes we've worked closely with colleagues in boards and and they absolutely understand the need to balance off different aspects of how we're able to to operate the system in order to to make sure that we're able to to to give people good quality care. John described the the A&E standard as as a barometer and I think that whilst we do recognise the the challenges in meeting that at moment because the pressures across the whole of the system this isn't just about what happens in in A&E departments. Actually I don't hear voices in the system suggesting that we should step back from that target because it is seen as being an important measure in terms of how quickly we're able to respond to and treat patients but I'm going to be asked Alex as a clinician amongst us if you want to add anything to that. I think that as Caroline said there is a value in having a target but it's got to be proportionate and so the A&E target as Caroline said is one that any clinician would probably say is actually helpful one because it is about patient safety it is about making sure that people are seen and treated as quickly as we can from that point of view and we all want to see that performance improved but I think the points that have been made already are that people are still being seen the treatment might start however they're having to spend more time in the A&E department until we can move them through the system but people are actually doing everything that they should to make sure that they're safe at the same time within that so I think it's right to ask the question but I think the fundamental point around this particular one is about patient safety and quality of care. Thank you can I bring in Paul O'Kane Paul question from you and then I'll bring in David Torrance I think Paul might have frozen can I take David Torrance first then Paul will come back to you. I appreciate what Paul O'Kane has just said about that. Sorry Paul, try and ask your question and we'll see if we've still got you. I understand what Corde Doto experienced in NHS and the comments made about staff however John Paul Lockry the vice president of the RFCM has actually said that in his view you know frail elderly people are being left on trolleys for hours because of shortages and that the initiatives that the Government has put in are not delivering the change that's needed you know in terms of moving people with minor ailments away from any and things like that. He actually said every hospital in Scotland just now is under the cost so I just wonder what the panel's view would be of those comments and indeed what interaction that has been with our RCEM on this issue. I don't know if I like my man wants to come back in on that. I can't comment particularly in the dialogue with our all-cogin emergency practice from that point of view. I think the principle though about people in trolleys is one that we recognize that people do wait sometimes too long however everything is done to ensure that that person is safe whilst they're in the ED department on a trolley for example so it's not that people aren't being supported, being looked after, ensuring that the right level of care is being provided to them but they're just not in the right place but every effort is being made to move them to the right place as quickly as they can. Thank you. Can I bring in David Torrance? Thank you convener and good morning panel. Victoria hospital way any last week seen record numbers every day turning up because in some cases the seat is an easy pathway when they can't get other services in the area. How can we quickly assess them and get them on to these different minor ailments services or community pharmacies or whatever in the area just to take pressure off any? That's a very good question and it sits at the core of a lot of the work that we've been doing around improvements to urgent and unscheduled care and what John was talking about in terms of being seen at the right time but crucially in the right place as well. There are lots of other pathways through NHS 24 as you've mentioned yourself through pharmacy through the investment that we're making in extending the multidisciplinary teams that support our primary care colleagues and through the minor injuries units but John John do you want to say anything more on that? I mean I think this is getting supporting citizens to make the decision that's right for them in terms of where they receive care is important and I think that we've had some strong communication messages around right care right place we've previously leafleted and done a range of things NHS inform is a very good resource for supporting individuals but I think we need to just keep strengthening our messages supporting citizens so if I come back to redesign of urgent care through the redesign of urgent care we introduced planned for minor illness or minor injury planned attendances so again an individual can subject to a condition go at a time that suits them rather than just turning up at any department we're seeing more and more people take that offer of a planned appointment and the anecdotal evidence is that people find that helpful because they can fit that then in around other responsibilities that they have so we'll continue to develop that so that we can manage the flow into our A&E departments as effective as we can I think it's also important to recognise that the minor injuries flow is a separate flow to critical and life threatening care so we do have very clear understanding of and services to support minor injuries and minor ailments but I think the messaging continues to be an important point move on to focusing on waiting times and cancelled operations which carline's already referenced can I go to jillian mckay first thanks convener during the most acute period of the pandemic the public received a large amount of information about services and what their care will look like and many very much valued that many will understand why operations have to be postponed but some constituents feel more information about next steps another support while they wait for a new operation date is lacking what work is being done to ensure that patients have information about how to keep themselves well and get support while waiting for an operation or indeed when an operation is cancelled and could I maybe go to carline yeah I'm very happy to to kick off on this I will hand over again to to john for some of the detail um so yeah absolutely we want to make sure that we understand that people are waiting longer than ideally we would want them to so we are um we do still have you know prioritisation in terms of the most urgent cases we're also trying to get through and the cabinet secretary has announced the targets around dealing with the people who've been waiting longest but but we do understand that this means that people are still waiting and are maybe waiting in pain or discomfort so we're really keen to ensure that they have the best information around um what what the likely wait times are and we've recently just started to make available that information public through through Public Health Scotland um but we're also very focused on supporting people to wait well um and to understand the support that's available for them in in communities john do you want to say anything more on that I think wait well is is incredibly important and that needs to be in that is an area around preventive and proactive care that we are we are focused on but we're also improving our communication with patients in terms of the initial letters that they will receive in terms of the wait pointing them to the the new information that's been launched but importantly um if they have concerns or they feel their condition deteriorates giving them a contact point so these are important in terms of how we support patients in terms of their wait on the list. Thank you um so I asked an earlier question uh and you know you talked about um the increase in workforce but BMA say 15% of consultant vacancies are available 6000 nursing vacancies are there we spoke about right care right place so David Torrance asked a question about community pharmacies and yet community pharmacies on a Saturday choose to close for half a day because they can then move staff to another pharmacy and get paid double um we're seeing your out of hospital capacity opat that was in raid more in 2015 and you talk about the strength of integration with delayed discharges yet we've got a decrease in bed numbers and we've also seen a record number of people being delayed in hospital ready to go um and the redesign of urgent care isn't really liked by staff or patients and so looking specifically at what you've said has happened and the problems that we're seeing now cancer stats just out 76.3% are meeting the targets of being seen this is the worst on record and this is a priority area so how are we going to address this and fix it okay so when you just to start off with the levels of vacancies in any any big system that is employed as many staff as NHS Scotland does there is always going to be turnover and there will always be a level of vacancies that the number of vacancies also is impacted by the areas in which we are increasing the establishment so we are looking to recruit more staff particularly with areas such as our national treatment centres coming on to stream with new treatment centres opening in Fife and in in Highland and at the golden jubilee over this period so so that the vacancy rate will always be impacted by that you refer reference particularly comments by by the BMA and as you know the the fill that our pipeline for filling those consultant vacancies is absolutely dependent on the number of trainees of doctor trainees that we've got through going through the system and I think one of our good news stories is the fact that 2022 has seen the highest ever fill rate of junior doctor training posts for the last five years so we're sitting at 95 percent full at the moment and that includes 100 percent full of GP posts in the first round and I'm sure that colleagues will understand this but just to be absolutely clear these are doctors in training who are in clinical placements so they are not yet fully qualified consultants but they are all providing critical services to patients as they go through their through their programs of training so I think that's actually a good news story in terms of that healthy pipeline through to enable us to both support consultants through their having juniors in place but also fill those consultant posts in future. I've talked about the multidisciplinary teams and the increase in the multidisciplinary teams who are critical to supporting our general practitioners to be the generalist expert in their communities and whilst that is still a relatively new development and interesting I quoted you earlier the increase in the number of those teams which have almost doubled by 91 percent since March 2020 and you'll have seen in the NHS in the plans announced by the UK Government for their plan for patients that they talk about extending those practitioners who work alongside GPs well you know in Scotland as I said we're already up to over 3,200 staff working in that and in terms of the impact that that's starting to have some work done in Lothian indicates that providing one physiotherapist and a GP practices increases the number of effectively freeze up two and a half days five sessions of GP time which obviously increases the capacity both of that GP but also the access to to consultations for patients. We've also seen about a nine percent reduction in referral rates for musculoskeletal instances in 4th valley where where physios have been involved so there is lots of lots of lots and lots of good staff happening across our systems. You've talked as well around delayed discharge and I'm conscious that Donna hasn't had a chance to say very much at the moment so I might want to hand to Donna just to say a little bit about the work that we've been doing. A couple of our colleagues actually want to talk about delayed discharges in a more focused way but I'm happy to bring in Donna just now just to give an overview but several of our colleagues want to talk about that in depth so Donna over to you and then I'm going to ask a question if that's okay. Yeah thanks very much so we've been working really closely with COSLA and SOLIS on issues around social care throughout the pandemic into this summer and in preparation for winter so we meet regularly, we meet minimum once a fortnight usually more often and the cabinet secretary and ministers meet very regularly with local partnerships to include NHS chief execs, local authority chief execs and health and social care partnership chief officers so communications I think are very strong in that partnership sense. Last year the cabinet secretary announced 300 million of funding in October last year for this financial year that equates to 20 million for step down care or interim care home beds, 124 million to improve the capacity and care at home and to consider other options like technology etc. Further 40 million pounds for multidisciplinary teams and also 200 million to ensure that the rate of pay for social care staff is increased to 10.50 so we've been as I say working very closely with partners we are seeing some impact from the investment that's been made so we've seen in the most recent quarter from the returns that we have from 24 partnerships more than 300 people have been discharged to interim care home beds more than 2,000 community alarms are now in place more around 30,000 items of community equipment have been provided to people and there are around 400 full-time equivalent internal front line staff who've been recruited so we are seeing some traction on the investment being made and certainly we know that our partners in the field are working very hard and in a joint up way John's already referenced the need for a whole system approach to these issues because the flow doesn't stop at the hospital door the flow needs to be out in the community one other point that I would make is that the pressure on the system in social care is very very significant in the same way that it is for the NHS and we know that the bulk of people who are waiting for care are in the community so that's usually I don't have today's figures but that's over 90% of people who are either waiting for assessment or care are waiting in the community so we need to make sure that we are not losing focus on those people given their need for care given the need to have that care in the right place and thinking about their health and well-being in the broadest possible terms there's also the potential impact on public services more broadly if people are not being supported in their own homes they're more likely to be admitted to hospital creating that kind of cycle so I think as an overview a very significantly pressured system lots of staff and providers who are working extremely hard to address those pressures and doing that in partnership Cube, bring it back to waiting times. I mean this theme is supposed to be about waiting times and cancelled operations so if you don't mind I'm going to ask a question on that if I've got time I'll come back to you there's lots of people wanting to ask questions we've got lots of themes still to get through thank you I want to bring it back to avoiding cancelled operations we've mentioned about the backlog that we have in the pandemic and we've referenced some of the things you're trying to do to address that I mean I'm happy to hear more of what you're trying to do to address the backlog but how are you trying how are you planning to avoid cancellations of a non-clinical nature we're talking we're still we're still Covid still out there you have staff absences any kind of like pressures that come that might cause cancellations this winter what are you doing to to avoid that so you're quite right in identifying that the number one cause of cancellations has been Covid whether that's been around the the pressures that Covid has introduced to hospitals that has meant that they've had to switch capacity towards treating treating patients with Covid or whether that's been around staff absences caused by people not being able to come to work because they themselves or their families are impacted by Covid so one of the things that we're really keen to do is to look at how we can protect sites from Covid so the the golden jubilee hospital has been invaluable in terms of being kept as a green site and being able to push through planned procedures that's also absolutely fundamental to our work to develop the national treatment centres in terms of having a clear separation and being able to keep working through those planned ways but also fundamental to this is around some of the work that we've maybe just touched on around moving some of that capacity out of the hospital so as far as possible getting us to the point where we're able to deal with much more in the community so you know John's talks about some of the hospital at home work and some of the remote monitoring work so all of that is really important and the final thing I just referenced and I'll come to John maybe for some of the details is around the work that the centre for sustainable delivery are leading which is around where we can look at innovations and improvements that release appointments that release appointments for outpatients for diagnostics for and for other other aspects critical to planned care yeah thanks just to to build on that I think that it will it will be a difficult winter and we know that but we are clear that we need to do all we can to protect planned care so maximising virtual capacity optimising day surgery in 23-hour surgery again when I've been out round speaking to colleagues and boards I've seen very good examples of where they've been able to use their day surgery facility to maximise the surgical procedures that they're able to offer and I think the 23-hour surgery has added to that as Caroline says we need to maximise facilities like the golden jubilee and make sure that we are utilising those theatres and facilities to best effect but I think also to recognise the importance of collaborative working across boards so we've been encouraging and we have seen some early impact where boards are working together to support care either by a consultant team moving or patients moving to get the treatment but that has added capacity and support and I think that the centre for sustainable delivery and working differently is an important part of this so being able to utilise new technologies being able to work with clinical teams to change the way that they work so patient initiated review would be an example of that and the final point I would make is that we are seeing new roles come in to support elective care that aren't always the traditional consultant or medical role and that equally is giving resilience in some parts of our service. Sandesh, you particularly wanted to ask about cancer treatment waiting times. I'll be able to bring you in quickly and then I'll need to move on. So my question was about the new cancer stats, the 76.3 per cent which is the worst on record and obviously it's a priority area so what are you doing to ensure that we get this up? My apologies I realised that I didn't cover that point of your question so I'm sorry for that. So we have consistently met the 31 day standard but we have been really struggling and consistently challenged against the 62 day challenge standard. What are we doing? We have invested 10 million in additional diagnostics. We have currently got six mobile MRI units and five mobile CT scanners that's helping to increase our capacity for early diagnosis and we're investing 44 million in our detect cancer early programmes. We have within that data clearly we're looking to try and understand where we're challenged and what we have seen is a quite a significant increase in the number of urgent suspicion of cancer referrals so there is more work on going to look at that but this is absolutely a focus of our attention. I'll bring in James Dornan before we move on to talk about bed numbers. James. Thank you very much convener. I just want to go back to something that Sandesh Gohani said and it concerns me greatly. He said that pharmacist staff close in a Saturday at lunch time so that their staff can go and work for double time elsewhere. Either way if that is factual that would be shameful for pharmacies to behave in such a way but if it's not factual it's shameful for that accusation to be made in a public committee such as this. Can we clarify if there's anything to back up that statement? I don't know whether any of our panel will get any comment on that or where we can find out. I think we'd be happy to take that back and come back and respond in writing to the committee. I want to be quite clear that I accept that the panel want things to be working and are working hard themselves to get this in but I want to talk a bit about the reality that I've observed. If we're honest with ourselves we're inboxes from patients who are waiting on trolleys who are finding the staff absolutely working 100% and above and beyond but acknowledge that things are difficult, that staff trade unions are telling us how much stress staff are under in the terms of beds, the professional organisations are telling us, I actually did a visit myself in a local hospital at nine o'clock on a Friday morning there was three ambulances to unload every single bay in accident emergency had had a patient in it for over 24 hours and the capacity for beds was basically non-existent and I was told by staff managers everybody that is not unusual so I think we need to be realistic about where we are and talk a wee bit about whether there is enough support in the system from the government to help health boards and realistically will we have enough bed space but not just bed space what I've been advised is the ratio of bed space to staffing is actually not up to the numbers that we need before we even start to look at filling these beds so they're constantly having to get staffing again and again and appreciating that you do want things to work how realistic is it this winter that things are going to be in a good space so I think as I've said we do not underestimate the challenges going into this winter we are heading into this winter with a situation where our hospitals are running at higher occupancy levels of their beds than we would ideally want to be in and therefore our efforts to try and support boards to manage that is based around a trying to ensure that people are only in hospital if they really really need to be in hospital and that's about the work at the at the front door if you like around whether people can be treated through the ambulance service in their own homes whether there's the option of seeing a multidisciplinary team member who's supporting a GP practice whether they can get an appointment an organised appointment for a minor injury through through through NHS 24 and basically keeping keeping people away away from the front door at the same time is done as referenced we need to make sure that when people are fit to be discharged from hospital nobody wants to be in hospital for any longer than they absolutely need to that we're able to get people both through the hospital systems quickly john's talked about discharge without delay but also out into the social care system where they are able to be looked after in their own homes or in a in a homely setting because that is far better for people and I'm sure what we would all want want for ourselves the the the bit around beds I mean we're also focused on increasing our capacity but in people's own bed so the work around hospital at home and some of the remote monitoring is around how we can take services to people and we've seen some brilliant examples of that in our remote and rural communities that are absolutely transferable into into the central belt but I think we also need to be really clear that that the current situation is putting a huge amount of pressure on staff and you know believe me we all understand that I'm out regularly in ed departments I'm talking to staff and I really do understand the pressures that they're under I think the question earlier about trying to support the public to make the right decisions about where they're going for care is important in that we've all got a responsibility in terms of trying to help our system and then the final point I think was just around the staffing that staff to beds beds ratio and I'll maybe invite Alex to say something about the work that we're doing we've talked a lot about what we're doing to try and increase the staffing but there's also something about how we match staffing to acuity of of patients yeah picking that thread up from Caroline I mean in terms of the position of Scotland in terms of the number of nurses per 1,000 beds we have a higher ratio Scotland than the UK so that's a good baseline to start with however we can't be complacent as you've already said and so the things that I've already referenced earlier in the answer are amongst the number of things that we're doing and there's also a big piece of work that we're going to commence around agency supplementary staffing spend as well because the principle that we want to work with within that is about stay local work local rather than staff going across different bits of the country because actually staying local means that they know their hospital they know their wards they know their patients and actually that's a hugely beneficial piece and but we're treating that staff aren't necessarily out of pocket so what are the things that we can do around the terms of conditions within the agency for change terms of conditions that would allow us to achieve that outcome for both patients and for staff so we're about to commence a piece of work around that we're also implementing the safe and effective staffing legislation that was paused in 2019 with that to be fully implemented by April 24 so just now what we're doing is we're working with both to test out those those tools that say what ratio of staff the patients do we need but the important point I would reference here is that's not just about nursing it's multi disciplinary and actually we need to think about HPs physios occupational therapists and other staff in and around that complement so that we actually get the right complement of staff not just looking at it in a unique professional way and I guess the other thing I would say and it goes back to some of the previous questions about how we're ensuring we're sustaining services going into the winter vaccination of staff hugely important that staff themselves get vaccinated just as the patients and residents should get vaccinated and the work that we do continuously around looking at the evidence around infectious prevention control measures to ensure that we're keeping people safe from infectious control while still in hospital but also where we can flex that we're flexing it to allow movement within hospitals safely for both patients and staff as well and again work around testing of staff so there's quite a lot of activity in that space and we're kind of talking about bundling that as a kind of package of work that's actually about supporting this winter but in the longer term as well just very quickly and that was very helpful I like it you know is there enough urgency placed on this to get it through quick enough I mean that is what I feel the urgency from that point of view I mean the cabinet secretary will see quite a number of bits next week in his announcements around winter so I wouldn't want to pre-empt anything that he might say but yes I mean a lot of the things that we're doing we're doing now actually. The number of members want to come in on this specifically can I go to Emma and I'll go to Paul. Thanks thanks convener it's just a quick question you know ahead of winter we're planning for winter I'm thinking about how do we avoid admissions for people with asthma or COPD or diabetes for instance and telemedicine is working and tele monitoring for folk that have COPD so that they've got a plan so what work is being done to support preventing folk that have got asthma or folk that have got COPD from coming into the hospital in during winter? So as you've rightly picked up that a lot of our focus is on how we keep people out of hospital so the remote monitoring work is really important to that and we're looking to make sure that that is appropriately spreader and scaled across across Scotland and that so it's the remote monitoring the telehealth agenda and let's not forget just what an enormous success we had with the rollout of near me which went from around 1200 consultations a week pre-pandemic to it's still running at between 40 and 50 000 consultations at the peak we were running at 90 000 video consultations so I would like to see if there are ways that we can push that back up again as we head into winter so that we are able to talk to people and so our consultants are able to talk to folk in their own homes and we avoid people having to travel through the winter months. Is there anything anybody wants to add? I would just simply add the impact of the community respiratory pathway that's well established and continues to be progressed. Can you just make Paul Keynes live broadcasting? That would be great. I just perhaps following this thread obviously there is a kind of basket of approaches that need to be taken in terms of capacity. I was concerned to read about the lack of surge capacity in terms of beds which has been identified across boards with obviously a large number of beds from last winter in terms of surge still being occupied so I really just wanted to get a sense from the panel about how will we ensure surge capacity is required when it's just not there. So without doubt as I've said we're going into we're heading into this winter with a situation where our hospitals are fuller than we would like them to be including with surge capacity already being stood up. Our focus therefore is how we can get people out of hospital faster through making sure that they're being if they don't need to be in hospital then they're not in hospital any longer and how we can prevent admissions through all the work that's going on through hospital at home, remote monitoring, remote consultations and the work around the urgent and unscheduled care pathways. Apologies to members that still want to come in on this theme. We might be able to pick it up. We've got time at the end but I very much doubt we've got so many other things to cover before we change panels. Can I move on to talking as I said about delayed discharges in more detail and David you have some questions on that. Thank you convener. In July 22 it was the highest number on record of people in hospital day beds taken up with delayed discharges since guidance came into place in July 2016. Can I ask, I know we've had measures on how much money is going to be put in it but what measures are we taking now to increase the social care capacity before the winter peak happens? I know Donald wants to come in in detail but just to be clear the measures that we've talked about they are already in place so we've already put that that isn't that that we're not just starting off on that we've already taken those measures to increase investment in social care to increase capacity. The measures are often quite bespoke depending on the areas and questions so when I referred to the discussions that we have with local partnerships we quite we usually do that on a often quite a focused basis the cabinet secretary and ministers are sometimes involved sometimes it's John and I who are having those conversations. So working with those partnerships to develop there are I think underpinning things that as I've referred to in terms of set-down care care at home and improvement multidisciplinary teams recruitment etc most of this is about workforce and making sure that we have the appropriate workforce so there are underpinning things that all areas would say they need to do but then there are other specific actions that some areas are taking so I know for example John and my colleagues were speaking to Dumfries and Galloway over the past few weeks and they have re-profiled the way that they operate in terms of providing more care at home and less care home beds so that they can get the they can optimise the resource that they have and there are many other areas who are considering their own provision of support and services increasing the number of providers that they commission and most of that as I say is done on a bespoke basis remote and rural areas will have particular issues areas of very high employment may struggle to recruit and may have to think differently so there are some underpinning measures that are in place that I've already referenced and then there are some specific service redesign actions that are being taken at a local level see the 1,000 additional staff that you mentioned it's been put in place what are variations being taken to see how they have helped reduce the bed blocking and helped social care services so that's the 1,000 additional health and care support workers what we've done today is just identify where those staff are where those staff have been deployed in the system we still need to go back and do further evaluation I think that I think that's the same in terms of having much more clarity around exactly what contribution so I've quoted some statistics around the contribution that the multidisciplinary team makes we're still quite in early days in these investments so we still need to assess exactly what the difference is that that is being made but I think certainly what we hear from on the ground and the work that Alex has been leading which is looking at exactly that that those health care support worker work groups they're the band two to fours would indicate that we believe that there is a lot of potential for them to take some of the pressure off our qualified nurse nursing contingent and enable them to act the top of their licence but Alex do you want to say a bit more about that I think it's really important point so if we take some of the work for example we reference that then retire to return policy actually can we monitor how many staff want to come back using that policy to do additional hours and actually where are they working and how is that helping the system to improve the lead discharges or flow or patient safety for example the worker in the band two to four so we know that that's a workforce that we can grow and we're developing a career framework but particularly the band four so we're explicitly working with boards to identify how many they need and where they want them to be so that it's not just sticking up we'll have 40 we'll have 40 but they're going to be in explicitly important areas to support the work that you just referenced there as well so we're trying to make sure that whatever we're doing we're kind of able to monitor and count and evaluate the impact that we're having and just to add to that I think part of that as well as making sure that people have got a good career pathway so they can see ways in which they can develop their careers within the health and social care system and we would like to see that being much more flexible between people being able to move between different roles as their careers develop. Colleagues want to come in. Paul O'Kane get your microphone. My question was asked to David so I'm happy to for the sake of time. That is very kind of you can I move on to a question on this from Stephanie Callaghan. You don't have one okay about apologies. That's great we can move on to talking about the social care capacity and Paul if you would like to lead off on that please. Thank you very much convener. In light of the work that's been done by CCPS in terms of their survey of their members around resilience we're seeing countless examples of difficulties with recruitment. Do you just keen to understand what steps have been taken to begin to address that issue? As I said we're working very closely with COSLA and with local government officials on recruitment issues. We did some work with COSLA on the joint statement of intent last year to work through the issues that we need to address on workforce pay, terms, conditions, learning, development etc. We're working with COSLA at the moment on an update to that statement of intent which will set out the next steps both for workforce for improvement for models of care and for practice. We are speaking regularly to CCPS, to Scottish Care, to providers more widely about the pressures that they are under, about the sustainability issues that they are facing and also about viability. I think colleagues in COSLA, Solace and the third sector are all very conscious as we are of the pressures that are on the system and we have those lines of communication open all the time. Paul, do you want to follow up on that or can I move on to Stephanie? No, I have to move on to Stephanie. Thank you, Stephanie. Thanks very much, convener. My question is for Donna Bell. Last week I met the chief executive officer of Enable Scotland and we spoke about the high quality self-directed health and social care provided through their successful personal assistant model. That was an example of how focusing on individuals and building the care and support around the person's own needs and priorities can not only improve outcomes but it can also improve costs as well going down the line. Thinking about the ambitions of the new national care service, my question is about doing things differently. Firstly, can you tell us about any examples of positive innovations that are under way in social care just now that are improving people's lives? Secondly, how scaling up such innovations can influence sustainability in the social care sector with the national care service going forward? Thanks for picking up the good practice in Enable. That is one good example of very person-centred and self-directed support. I think that there are countless examples of really good innovative practice across the country that we see all the time and there are some key themes that are within that which are person-centred care focused on people being able to access their rights and secure their own wellbeing. There are a number of areas where we see great support for self-directed support and there is an improvement programme going on at the moment where we are drawing out aspects of good practice. There are some areas that are excellent at supporting self-directed support and it might be something that we could provide to the committee where we could set out some of those examples. That might be a good idea to do that. There are also innovative models of care where we see across the country a range of different means of providing care. There are very community focused provisions that are being made and some of those are in rural areas where it makes sense to provide care in that way. It might be useful for us to give you a few examples of that in writing, so I am very happy to do that. The sustainability point that you make is a really good one. We have already referenced CCPS and its concerns about sustainability and viability. It is feeling very tough for some providers at the moment and speaking to the CCPS chief exec only a couple of weeks ago, we had a long conversation about what further support could be put in place. The bulk of that was about energy costs. In the most recent couple of weeks, the UK Government has made some changes that we do not have a full understanding of the impact that that will have, so we will need to keep in close contact with colleagues in the sector to ensure that the impact is having a positive one on viability. I have certainly been in touch with enable more recently, just in the past week, around the sustainability questions that they are asking, so it is certainly something that we can look at to follow up and see what can be done. That leads very nicely on to some questions that we have about the financial viability, given the pressures coming from elsewhere. Questions on managing the cost increases, which Caroline Lam has already alluded to, in more depth from David Torrance and colleagues. The rising cost of energy but also inflation on medicines and food. Do you have an estimate of how much that will cost NHS overall in Scotland? We are starting to work through what we expect likely cost pressures to be in the system next year. As you have alluded to, there are a combination of factors there, drugs pressures, pay pressures, and maybe some that have come more to the fore in the last few months, particularly around energy and inflation more generally, in fact. I cannot give you an estimate at the moment. I think that this is a picture that we are very focused on trying to understand. My colleague Richard McAllum works very closely with director of the finance across our NHS boards to understand the pressures that they are facing currently and what that looks like going forward into the future. Clearly, we are investing £18 billion in our health and social care system. In the current year, that is a not inconsiderable sum. It is up a billion from previous years. Part of our approach has to be to look at how we can be as efficient and effective as we can. I already alluded to some of the work that is going on around energy efficiency and the opportunity for some of our boards with the estate that they have to look at generating renewable sources of power. The whole climate emergency approach to sustainability is a key priority for NHS Scotland in terms of how we use energy, drugs and some of the waste that occurs around plastic items. It is certainly something that is a key aspect of our focus. I am one that our chief medical officer is very engaged with. In terms of the impact of fuel costs on the health of the nations, I can question some Stephanie on that. Just thinking about the current cost of living crisis, certainly there have been some recent changes by the UK Government, but they seem to do not very much to help the very most vulnerable people. I am thinking about people on pray payment meters, for example when the money runs out of the light scoff and on a rural basis to people who have oil tanks or coal bunkers, where you are talking about big sums of money to get those refills happening there. I wonder what impact you are expecting that to have on the national health service and on social care. If I can maybe just comment briefly on that one. I think that we are really clear about the impact from a number of perspectives. If I start with staff, so clearly the cost of travel, the cost of getting to work, may be particularly acute in the social care sector, where people are moving from house to house, particularly when they are providing care at home support, and traditionally the rates of mileage paid in that sector have been lower than they are across the NHS. We have already discussed the impact on NHS boards and the inflationary aspect there. I think that we are also, from a mental health perspective, concerned. I think that some of the early indications of research are starting to surface the impact that worrying and anxiety around not just fuel costs but inflation more generally is, and the impact that that is having on the mental health of the population. When we look at pressures for the winter, that is something that we are absolutely mindful of, and the impact of people who maybe are not able to heat their homes as much as they need to stay well. Clearly, we welcome many measures that the UK Government is taking to address that, and we would obviously want them to go as far as possible in doing that. Let's do it with patience and whole care. I'm dealing with a constituent just now who is on dialysis every nine hours, needs to preheat it, can't afford the energy bills that she's going to get. Will that put additional pressures on the NHS if they have to come and get treatment back in the hospital? Certainly, as far as possible, we would always want to provide treatment in people's homes because it's much better for them. I'm not going to speak definitively. I can provide more to the committee, so I'm aware that we have made additional provisions, the NHS boards are making additional provisions around people who have home oxygen and the additional costs associated with that. I'm not so familiar with the issues that surround people who are getting renal-based treatments at home. I don't know if any of my colleagues are. We can certainly respond to the committee in writing any specifics on that. Tess White has some questions about workforce planning and a supplementary question around bed numbers that he wanted to come back in on. I want to touch on vacancies but also retention rates. In terms of vacancies, nursing vacancies for example are at 25 per cent on last year. There seems to be an issue with students at the front end, so if you could comment on that. In terms of retention, that seems to be a very serious issue as well, with 15,000 NHS workers leaving the service in the year to March 2022, which is the highest in a decade. It's the inflow and the issue with the students, but also the high retention rates. Alex is itching together. Alex, I'll pass this on to you. It's something very close to my heart. The numbers of nurses that we have in the NHS Scotland are higher than they've ever been, and that's a statement of fact. The point you make around the student nurse and midwife numbers. The process, again this year, has led us to a higher number than last year, and it's a higher number from 10 years ago so each year we've seen incremental increase in the number of student nurses and midwives we've been taking in to undergraduate programmes. The issue is more about attrition during the programme, and that's everything we need to focus in on. Equally alongside that, do we need more than one intake per year? Because what the system, the service that I and John in the Cullin have just come from, would say that the number of students that we need is growing, and we need to grow that number, but the pressure that puts on staff to provide the quality of experience that they need is sometimes being compromised because there's too many students, so could we spend them a bit more throughout the year? So we've actually commissioned a piece of work to look at that to see whether or not we should take more. The Wales, for example, of twin takes a year, and that's a model that we want to look at. See that reduced attrition, because some of the reasons why people leave are because their experience as a student isn't as good as they hoped it might be, or they don't necessarily get the support either in university or in the placements that they might want to get, and that's multifactorial as well, so that's about the academic level. The other things we're looking at are all the things I said earlier, but we're also looking at access programmes and accelerating that, and particularly more work around open university, who do degree programmes, but for healthcare support workers, and actually can we increase the number there too? So we're looking at all these different factors about the number we bring in, how we keep them in, and how we retain them at the end of their... Rates are a serious issue, could you just mention that quickly? Yeah, so I think I mentioned earlier we're going to do a kind of bundle of work, and one of them is retention. So we've already had some discussions with exec nurse directors, for example, but also the RCN, the RCM, and Unison as well, about what are some of the factors that would actually retain people, and again they're multifactorial and we've probably touched on a number of them during the course of the discussion just now. But one of the big pieces in and around that is also the hours that people work, the way that people work, you know, how they're supported within that, and particularly about their career development, the education, the training that they need to have in order to make them a much better condition, to make the needs of patients as well. So it's not just pay, it's not just the others, it's much bigger group of things. Tess, would you like to ask your bed question? I do. I do have a very quick bed number question so that we know that bed blocking is a massive issue affecting capacity. I know there's an increase of 3.6 per cent in bed numbers from last year, but still we're down by about, I think it's 716 since 24 2015, so just if you could comment on that please, thank you. Yes, so maybe just to start off by saying that I think our focus has to be, and I think all of us would want our focus to be, on making sure that people who are in hospital absolutely need to be in hospital and can't be treated in their own bed or in a place that's more homely for them. So in terms of bed numbers, also the pressure that we're under is partly delayed discharges, it's also, right at the beginning I quoted some of those Covid peaks, and I think it's easy for us to forget just how many beds we've got occupied by people who have tested positive for Covid as well. So that we need to manage all these things in cohort. It would be wrong to just continue to increase bed numbers when that's not the right place for people to be treated. So all the work that we've described about trying to move care out of our hospitals, trying to prevent people from being admitted to hospitals unless they absolutely need to be admitted and then enabling them to get back to a homely environment as quickly as possible is a huge part of what we're doing to manage that capacity within the system and the flow through the system. Anything else you want to? I think the only thing I would add to that is to recognise that when we look at the total beds, we see a lot of change in surgery with more moves to day surgery, so that also has an impact on inpatient beds. Thank you. Thank you. Final question on Covid and respiratory viruses, Emma. Okay, thank you. Thanks, convener. So again, it's back to we're planning for the winter, are we projecting an increase in Covid cases and if so, obviously, I was part of the vaccine team given Covid vaccines last winter and I absolutely agree with Sandra Schulhane that we need to encourage folk to take up a vaccine, whether it's Covid flu, pneumococcal, whatever, that's absolutely important. So that's one thing we need to encourage people to do, but other things I'm thinking about, wearing masks, like instead of face coverings, should we be encouraging folk to be wearing FFP2 type masks, which do require fit testing, I believe, but instead of the surgical mask, because I'm concerned about what happens when we head into the winter and we're indoors again and the windows are closed and there's people, I know the healthcare professionals are fed up wearing masks already, but how do we find a balance to support everybody to reduce the risk of spread of Covid? Yeah, so you're absolutely right that the balance is important and therefore keeping the situation under review is really important and Alex and his colleagues are right up the middle of that and they're working with colleagues across the UK to make the best decisions that you can make. Alex, I don't know what you're talking about. Yeah, I mean, we follow the evidence every week just to see where things are in terms of variants and increases in prevalence across the world, from that point of view, obviously try to project what might happen this winter as well and what's the best evidence and guidance to give to staff and to the population more generally as well. The basics of the Covid prevention still stand about hand washing, physical distancing, wearing a face covering if you wish to potentially wear one. You know, we're also looking at the testing issue with ease back on that wee bit, but that doesn't mean to say we won't step that back up. The point you make around FFP2s is not an easy one to answer because actually that's a health and safety legislative point and actually we've actually raised that as an issue previously but we're currently with FFP3 masks because that's a requirement from a health and safety perspective and of course that does take a lot of time in terms of face-fit testing and actually there's a lot of staff who don't necessarily get successfully face-fit tested to some of those masks too so we sometimes lose staff from the area that they would normally be employed in because they cannot work in that environment because of the requirement to wear that type of mask. Those are all the kind of things we're continuously looking at. Okay, just a final quick question about procurement of personal protective equipment. Basically shop local, you know. Is NHS Scotland procuring our PPE from Scottish companies, for instance, where possible? Because I know one company in De Fries was making 80 per cent of face masks, Alffasallwy, and so that would obviously reduce costs and emissions rather than purchasing from China, for instance, so and of course there is an added cost now if you're planning for winter about stockpiling or procuring of masks so I'm interested about a wee bit about that. So you're absolutely right, so Alffasallwy based in De Fries are a company that are now generating most of the masks that we wear in NHS Scotland and need them in other settings as well from that point of view so that's good for the local economy but it's also good for us more generally as well from that point of view. We will take a stock take in the next few weeks around the PPE and infection prevention control requirements heading into winter and what we will be doing as part of the winter response will be at what points in terms of our escalation do we need to go back and reinstate some of the prevention or extra the wearing of masks for example in different scenarios, the issue about testing in different scenarios as well from that point of view. Okay thanks. That's your leaving on to a question that I was going to ask about surveillance and about the public messaging around the very still real risk of infection and would you think that maybe we need to really give a very clear public message as Covid's not away and a lot of the things that you've got very good at doing in the last couple of years for me to remember to still do them. I think that's a really important point and I guess alongside the vaccination and the Covid booster programmes using those opportunities to reinforce those messages to the general public of which we are part about the importance of hand washing you know that's one of the single biggest things we can do things like masks are actually further down the chain of prevention ventilation as others said as well you know keeping your windows open when you've got people in your house and again you're right we should go back and we will go back rather and revisit some of that messaging that we had during the peak of Covid and as you said it's not going away there might be less people in our hospitals there might be a slight decrease in number of people with Covid but it's still in our system. Okay thank you very much I want to thank the panel very much for your time this morning and I'm aware that Sandesh you want to make a quick comment I don't know whether we can wait to the end of our next session or whether you'd like to make it now it's just it's just very quick to be clear sadly it's not pharmacy staff that are getting double pay it's the pharmacy chains that are getting double pay so if when you write to us if you could okay thank you very much for that clarification thank you to our panel we're going to have a brief suspension to allow our panels to change over thanks okay welcome back to the health social care and sport committees meeting today our second evidence session focuses on winter planning within the nhs and we have some representatives from across scotish nhs boards with us we've got jeffy is the chief executive of nhs drifeson galloway jennifer armstrong medical director of nhs greater glasgo and clide and we've got dr adam coldwells the deputy chief executive and director of strategy for nhs grampian so we're covering quite a few different geographical areas to give us a flavour of their plans for winter planning with that in mind if i could go round all three of you in turn just for you to give us an overview of your winter planning strategy and some of the challenges that you foresee in this winter not necessarily compared to last winter because it was particularly challenging last year as well but just as um what your focuses are going to be so if i can come to jeffy's first of all thanks yeah i think um it's probably important to recognise that this winter will be at least as challenging as last winter whilst we're not anticipating perhaps quite the level of of covid activity if our vaccination programme works in what we've seen in the summer and autumn already in terms of acute admissions and our ability to flow those admissions through the system is us enough reason to think this is going to be an extraordinarily challenging challenging time an extraordinarily difficult time for our staff so our plans are really focused on how do we minimise the number of admissions to hospital how do we turn around people at the front door who it's appropriate to turn around through things like enhanced frailty pathways so we can get those people home and then when people are admitted to hospital how we can safely discharge those as quickly as appropriately possible and i think for my own board and a number of probably rural boards that discharge flow is is proving really difficult at the moment and we're anticipating it will continue to be difficult through the winter um that's largely due to uh capacity issues through our staffing issues that we're that we're working with across the partnership and it's meaning that at any one time certainly for a system such as myself as such as ours we've probably got three boards or so of individuals who really don't need to be in acute hospital settings but i hear because the appropriate um community packages aren't available so that gives us that consistently high occupancy that is so difficult for staff it's it's it's a relentless feeling in hospitals and again we have to make sure that what we're doing in our winter plan it really makes the maximum opportunities to try and reduce that occupancy where we can so we're working on all of the um the the redesign techniques that you'll have heard about this morning in terms of enhanced discharge planning early discharging working to use our our best forecasting techniques each day to ensure that we can flow patients through the system but the levels of occupancy we're consistently seeing at the moment are they're of concern and i i certainly expect this winter to be an extremely tough one happy to go through any details of our plan convener but as an overview i think the the key worries for me and what we're attempting to address in our plan is that consistently high occupancy how we keep people safe flowing in and out of our system and how we support our staff in this relentless pressured environment thank you as an overview that's that's great and my colleagues will come in and dig into some of the detail there um can i come to um i'm cold wells first of all and then i'll bring Jennifer Armstrong in afterwards yeah thank you very much convener and good morning to everyone um our winter planning or planning for the next six months is really based around three things so we're trying to give real clarity for the whole system about our operational delivery system so how do we work in our normal objectives against our delivery plan so we've got some key ones particularly around unscheduled care and planned care so do we have real clarity in the system about how we're trying to deliver those um we work in a portfolio a system a system leadership manner is how we we've been trying to work for a number of years and so absolutely the heart of that is thinking about how does the system work together uh both in hospital systems and in the health and social care partnerships right through to to the care system um and we have a an operational pressure escalation system which works across all of the parts of the system to try and equalize pressure between bits so that's our sort of sense of the operational bits that's part one but two of our thinking is trying to think about our improvements and you've had lots about that from this morning and indeed from from Jeff just then so how do we redesign our urgent care system so we're doing that how are we working as part of the urgent and unscheduled care collaborative and the three or four key priorities that we we're working on from from that national programme of work and all of that really is about how do we optimise patient flow through our system so that that's the second bit trying to think about improvement and then the third bit is trying to think about our contingency arrangements so how do we have surge capacity and you heard a little bit about that this morning um and how do we have surge capacity for for example a civil contingency event so if the system's under enormous pressure how would we respond to that and if the if the system's under increasing pressure resulting from high levels of admissions or or or things that the system being very near capacity how do we try and create some surge capacity there and in terms of the commentary of those bits that the first two bits I've spoken about so the operational delivery system and the unscheduled improvement plan those two bits try and have our system running as close to normal whatever normal is as we possibly can so that's where we would try and maintain things like all of our planned care activity an area that we typically in our system we go to to try and increase that capacity when we're under high pressure how do we maintain research education although it's really important things that we experienced during the pandemic have been switched down so how do we try and maintain those that's our first two bits and then our third bit if we have to get into contingency arrangements how do we draw on those in the most balanced way that we can to do it if you want a sort of a scale of the challenges there then it's certainly around our contingency arrangements that are the most challenging for us to deliver in terms of how do we draw staff in to create surge capacity how do we pay for that and all those sorts of things and what are we having to turn off to do it so that would be I think a starting overview and again very happy to tease into those through the questioning over the next hour or so. Thank you and I will but before I bring in my my colleagues I will come back to Adam Caldwell's and Jeff Yes particularly around the challenges in rural areas that you're dealing with but can I bring in Dr Jennifer Armstrong to talk about the situation in Greater Glasgow and Clyde? So there's a very clear planning process for winter it actually starts really as the last winter finished and that involves bringing processes and groups of senior clinicians and managers together to look at what happened last winter what key lessons we can learn then what we need to present place. So we can just talk briefly through what will be in our winter plan. First of all as everyone else who said the vaccination programme both for flu and for Covid so in Greater Glasgow and Clyde that will mean upwards of 600,000 people that we need to vaccinate and we need to try and get through all of these people and encourage everybody to come by early December as you know winter really kicks in around a bit January. The second thing we need to do and underpinning all of this issue say staffing staffing is the key issue right across all of our services so looking at the staffing models that we need to do and how we can recruit. The second thing is dealing with high and fluctuating levels of Covid and if you look at Greater Glasgow and Clyde indeed the central belt that's been hit hard by multiple spikes and looking at how we model and how we predict spikes look at the data that we've got. The third issue would be primary care and community care services so that involves GP during the day GP hours as well as the wider community teams and looking at the escalation plans around them about how we can step up services as we get further into the winter. The other issue is as you've heard is things like I would call directing away from the front door so flow navigation centre as well as all of the other things that we're doing which we can talk about like O-pat and various other things. Then as we move into the acute hospital it is about as Jeff and Adam have both said about maximising flow through the acute hospitals as well as an acute hospital bed plan and we need to try as best we can to open additional capacity. The other thing that we then do is getting people out of hospital so there's a whole series of work streams going around discharge planning, getting people out by their dates of discharging and making sure that we work with the community teams progressing to do that. The other element is care homes so we've got a care home collaborative so it's maximising our support care homes both in fixed control terms but also in terms of maximising capacity. We also want to try and protect our planned care programme as much as we can in order to try and operate on as many patients as we can and addressing these long waits and trying to protect that over winter. The other thing we'll do is we do this daily anyways in our weekly analysis of demand and we predict surges as they come. Finally it is a proper communication strategy so we have a gold command seg which we at the moment meet twice a week during the height of Covid that was daily. We also have that going right down GGC through all aspects of community primary care and acute so that we can make decisions rapidly as we see the situation change. The publicity campaign is very important both to the public in trying to encourage them as John Burns has talked about the right place right time as well as to our internal staff communication and support to our staff because it will be a very tough winter. I'd like to just pick up on the rural aspect from Jeff Ace and Adam Caldwell's. I imagine that you both will come up with similar answers but in terms of the particular challenges there are for health boards that have a large rural part of the services that you offer. If I can come to Dr Cobals first of all, what are the particular challenges that you foresee there and how are you dealing with them? Thanks very much. I guess just as a bit of context the challenge that we have for rural regardless of winter and the pressure and where we're feeling at the moment are access to provision so again some of the travel times that we have for patients as they need to access services and then certainly in our very large rural parts of which we have lots both in Aberdeenshire and in the Murray part of Grampian. Certainly small communities and recruitment of staff so be that health staff, be it care staff. At the moment we're certainly in Aberdeenshire having real challenges in some of the care staff provision that's particularly apparent at the moment and the health and social care part should be working extremely hard there to try and establish how they create robust services whilst their recruitment is challenged. I think beyond that there's something about then again the vaccination programme which has been spoken about lots today and the access and how people do that. So at the height of the pandemic people are having to travel a bit and they seem very very willing to do that. I guess there's a real question about will that be consistent now so are people still going to be coming forward for vaccinations at the rate that we want them to with the sort of distances and travel that they're going to have to do. So those would just be some of the initial obvious challenges that we have from a rural perspective. And if I can come to Jeff Ace from the De Fees and Galloway perspective. Thanks, convener. I think probably similar issues. Recruitment is a huge one for us. And I think we probably didn't fully understand the profound impact of Brexit that since that has become very clear to us. Our competitor industries, if you like, in rural areas are often things like hospitality, agriculture, forestry. And these were quite reliant on European workers. As these were not replaced and as the original workers left, the impact on the workforce market was quite significant. And I think that that's something that we've been affected by quite significantly. So coming to terms with that workforce shock, in the midst of, I think, a much longer term shift in our demographic, rural areas are older, our working age population is shrinking, so the pool of workers that all of our sectors are competing for are shrinking. So we're really reliant on our ability to bring staff in from outside the region. And we've had some success in overseas recruitment, but it's quite a small number compared to the demand that's constant. So I think that recruitment is far and away the most significant issue facing rural boards. I do think that the travel issue is another important one, though. And I think that if you look at NHS Scotland now, part of our service plan, if you like, to meet elective waiting times, is to focus on things like elective centres, is perhaps to consider patients travelling greater distances than previously. I think that that's a much bigger challenge in rural areas. Particularly those like Dumfries and Galloway, which is not planned to have an elective centre if part of the future is a significant transfer of that activity out of the region. I think that that does cause significant issues for our population, particularly at times of fuel costs and fuel poverty. I think that those are the two issues that I'd like to highlight, convener, but recruitment and that ability of rural areas to sustain a viable workforce at the moment. Both in the short term coming into this winter and then looking ahead five, ten years, I think that those are really profound issues. Thank you, very helpful and colleagues will probably be drilling into that in more detail. Sandesh, you wanted to ask a question on this. Thank you, convener. My question most importantly is really going to be looking around what's going to happen with other things. Yes, we're going to get a winter surge, we know that, but tell me how we're going to help cancer patients, for example. Our stats have come out, 76.3% is the worst on record. This is clearly a priority area. How can we protect these patients when it comes to winter and ensure that we can get that flow continuing? Who would you like to ask that to initially? Initially, Jeff, because he's nodding, but it goes for all the boards, I'm afraid. Thanks, convener. It's really critical that we look at it almost cancer pathway by cancer pathway, because there are specific problems and specific pinch points in some of these pathways and they need separate fixes. For us in Dumfries and Galloway, colorectal cancer is an issue and our link there is with Lothian, so we need to make sure that that pathway has the right capacity. It's important to chunk down the cancer journey problem into each of these tumour site pathways, particularly for a rural board such as myself, where a lot of the specialist complex care takes place either in Glasgow or in Edinburgh. To make sure that at each stage of that pathway where there's a diagnostic stage or a treatment stage, we've got the right capacity and the clarity of that pathway. Whilst cancer as a whole, as you rightly point out, the overall stats at the moment are not where we would want them to be. The real critical thing here is to start looking at breast pathways, colorectal pathways, lung pathways, et cetera, making sure that that demand capacity modelling is accurate and that we've not got those blocks in the system that cause us difficulties. There are two or three tumour site pathways at the moment that are causing us particular problems and probably across Scotland particular problems, and that's where we should focus our efforts to make the maximum impact on that overall figure. In Dumfries and Galloway, we've been relatively successful in being able to ring fence our local capacity. As I said, cancer is a root because of the complexity of the journeys. It's one where the tertiary centre and the local centres all need to be working in that same-demanding capacity model to get the rapid access for patients that they need. There's some raise of positivity in that. We're one of the pilots for the early detection of cancer projects. There are three or four pilots across Scotland at the moment. That is showing some really positive results at the moment, showing our ability to take cases that GPs are concerned about but that don't fit with the classical rapid access cancer referral guidelines, but being able to refer those into multidisciplinary clinics locally is showing a good detection rate for the amount of investment that we're putting in. I'm very excited about that in terms of our ability to spread that across Scotland. As you know, the UK is relative poor performer compared to the rest of Europe in early detection of cancer. This is one of those areas that I think we can make some rapid gains. We've got huge challenges in particularly a number of tumor pathways, but there is some very good work going on in the midst of that, to understand that capacity, to fix those capacity gaps and also to look at the problems slightly differently through the early detection lens. Other colleagues on the panel want to come in specifically on Sandesh's question that you're most welcome to. First of all, we might go to Dr Armstrong. Yes, it's one of which we put a huge amount of work into because it's very important that, as you remember, when the first Covid surge hit, cancer was not stepped down, but a lot of other activities were. Therefore, that left us with a backlog. What we've been doing in order to maximise cancer capacity—we're just taking a few examples, and Jeff is absolutely right—there are different issues for different tumor groups. Things like in Glasgow and Clyde endoscopy, we have maximised the use of endoscopy. We have just down the road from me a brand new unit, which has just started in Gartnavel in May, to maximise the throughput for endoscopy because endoscopies are a key investigation for a lot of bowel cancers and things like that. We've also looked at the going jubilee to maximise the endoscopy use and use of sessions there. In addition to that, we've got things like the breast cancer activity pathway, so we're doing weekend clinics and we're running them. We're helping other boards as well with that. We're doing weekend clinics to make sure that we keep up so that women are not kept waiting until they're seen because it's an extremely worrying time, as she realised. In other things like prostate cancer, we're running lots of weekend sessions there. What we're trying to do is maximise everything that we've got in order to do that. The other issues, I should say, is maximising imaging capacity, because that's a key indicator of detecting cancer. On the broader question, which has been asked over winter, what we're going to try and do—and the Beatson is actually over in the Gartnavel campus, which has helped us over Covid because we've been able to make that a green site as much as we can—but for things like theatres, what we've got in Glasgow and Clyde is that we've got amblytum care units when it's still going on at the Vic, but we've also got amblytum facilities at the Vale of Leven in for Clyde, as well as Gartnavel. What we're trying to do is maximise the use of that, and if you like, protect patients as the surges happen in the other sites. We're really keen that we're working with the anaesthetists and the clinicians at the moment, so the chief of medicine for Glasgow, and he's also searching, is developing lots of amblytum care pathways and also making sure that the pre-op assessments are right, because what you don't want is somebody turning up, taking a theatre slot, and you find out that clinically they're not well enough to do it. So there's a huge amount of work that we've done, we've done a huge amount of modelling, we're doing our best to catch up, we're doing our best to protect over the winter time by doing things differently, as well as doing them in the other sites. Thank you. Was that made to come in the convener? Yes, it was, thank you very much. I'm sorry, I didn't quite cut out slightly for a moment. Apologies. Probably nothing to add from Jennifer and Jeff about the specific cancer improvements, similar sorts of things happening in Grampian. I'll perhaps just spend a moment on the winter context, though. Our plan that we've got at the moment, our tactical approach to winter, has a really clear aim that we don't disrupt elective care, and we're trying not to do that through all sorts of improvement activity around unscheduled care at the moment and testing all sorts of things and getting them in place, drawing on a very wide clinical community who are co-designing and establishing how to improve the flow through the hospital and into the community and of course all the stuff that you've had lots about this morning of trying to prevent people coming into hospital. So if that can be successful, and that's obviously an if, it depends on demand, though we're then doing, our next bit of planning is based on four scenarios that we're trying to think about, and perhaps if I could share those now, that might help with the context. Our first scenario is this idea of a best case where our system has remained at absolute high level for many, many, many months now, and so maybe that fully maximally stressed system that's fully stressed is winter-like demand and continues without a further surge, so that's scenario one, which is our best case. We're then thinking a bit about a standard winter surge observed on top of this sort of high demand, which would relate to balls, trips, the normal sort of cardiovascular and stroke events that increase through winter. Our third scenario is thinking about a sort of respiratory virus-type winter, be that flu or Covid variants or those sorts of things. And then the fourth one we're thinking about, which is very new for us, is what might the sort of cost of living crisis place a sustained stress on our system with the population kind of, you know, that increased pressure over winter and potentially much, much longer term. So we're thinking about those four areas, and this is full planning that's on going at the moment. And what can we do in each of those as we surge into them against any sort of peak for a different duration that tries to minimise the disruption of electric care? And of course we use a prioritisation system already, as you know and it's been described earlier this morning, for surgical activity if we concentrate on that. And so again, the cancer prioritisation is high in that, and the SCAT level that people get there is high. Now of course the consequence of that will be people who absolutely need an operation and it's terrible for them, but in clinical terms the impacts slower to impact so along the lasting effect. I guess that's the really big worry, isn't it? So these sort of people who end up as long waits clearly in a distressful situation for them, but in the very strict clinical terms that right prioritisation is happening. So I guess that's kind of what we're thinking about for the winter bit, to try and minimise that disruption, try and get the planning as well as we can to avoid the surge into where particularly our system, we historically do go into that elective care quite often within our constrained system, within our system. It's very difficult for us to get any mutual aid across with kind of quite a long way from another nurse, another big centre, you know, Dundee's, a long way from us and Hyland's equally as long way, although closer to some of our northern bit, the Dr Gray hospital and things, they have quite good mutual aid there. Thank you very much. Thank you. Moving on to talking about funding, just a word to members. If you can direct your questions to the panel, and if other panel members want to come in, if they can use the chat box, just put an R in the chat box and I'll know to come to you, because I don't think we're going to have time for every question to be answered by all three panellists with the best will in the world, but it was useful to do it on those two occasions there to get a feel for an overview. Questions on the funding from David Tollans. Thank you, convener. Good morning to panel members. What evaluation have your boards made of the impact and effectiveness of additional winter plan funding provided in 2021 to 2022? I'll go to Dr Allan Caldwell. Just check up on the question, so that's the value of the funding from last year. Just like Jennifer described in her opening answer, at the end of each winter we do an evaluation, so all the communities come together from the acute hospital, the community, clinicians, managers, support staff. Everyone comes together in a very formal debrief and explores what's worked well, what hasn't worked well, typically with an eye to looking forward to say what might we do. There was part of that. We look at the additional things that we put in place for winter, so how we've spent the money and basically make an assessment of are we likely to put those in place again for future pressured events. Typically, we're speaking less and less about winter, we're just talking about pressure and surge, actually much more as our common language. We don't do an assessment of sort of qualities and value like that, but we certainly look at against the funding and how we've spent it, what's been useful and what we're likely to use again. Last year we had all sorts of additional capacity put in place in posts and roles to try and increase flow through the hospital system trying to prevent people coming in. Off the top of my mind, I can't think what was most useful and what wasn't, but certainly that's fed into our planning for this year around how we're likely to commit resource again in the coming surge period. If anyone has anything additional that they want to highlight in the work that they're doing in your health board, please let me know. Dr Armstrong. Dr Armstrong is going to be frozen, slightly. There we go. We'll go to Dr Armstrong first of all and then I'll go to Jeff Ace. Okay, so we do a very detailed cost assessment of winter, of what happened last year, and as Adam was saying, one of the complicating issues is Covid continued through last year. So just to give you an idea, the likely scenario for 2022-23, so what we anticipate is probably about £8.4 million of anticipated costs, and this includes £2.4 million from April to November, and that's the additional meds that we've kept open. We would normally be able to close them because of the surge experience that we couldn't, and around about £6 million over winter, because that's our usual cost. That gives us a total of about £8.4 million, and around about £2.2 million we anticipate getting from SG, and that leaves a figure for the board of £6.2 million to fund. That's probably most years that we have to do that, and we put that into our financial plan going forward. The key for GG&C is that you have to fund winter, as you know. You do have to fund additional meds, you do have to fund staff, you do have to do it right across the board and not buying mitigates as much as you can. So that's the rough, not rough, that's the calculations that the director of finance has done, and that's what we're thinking about. Thank you, and over to Geoff. Thank you. I'm very brief, the convener. I think that the key thing is to look at boards underlying financial positions at the moment, and it is really hard to see from my perspective. It's really hard to see us in sustained financial balance at the moment, so it's probably unhelpful to look at different allocations and say, what's for winter and what's for other things. If you look at the entirety of our funding against the entirety of our projected costs at the moment, I've probably got a bigger gap than I've seen in my time as chief exec, so as well as an urgency of planning as to how we get through this winter in reasonable shape, keeping our elective flows going, keeping our non-elective patients safe, we've got to do a major piece of forward planning as to how do we reconstruct the health service to live within that overall allocation. That's going to mean a service that's redesigned with £20 million, £30 million less cost from my perspective, which on an overall turnover of barely over £350 million is a big reduction. So it's almost as if we're in two tracks at the moment, where how do we survive this year as a safe service and a service that can meet its targets, and then how do we reconstruct ourselves into a service that is sustainable in workforce and financial terms? That's the real difficult trick that we're trying to pull off at the moment. David, did you get any follow-up, or can I move to the next question? Can I ask, where would you consider that any additional investment could have the most impact on winter pressures? We'll go back to Jeff Ace on that. Yes. I think it'll probably be different in each of our boards. For us, I think the ability to discharge safely from hospital would have the most significant and immediate impact, and for that to happen, we'd need very large increases in care capacity. I don't think it's primarily or it's not solely a money problem. It is our ability to recruit and retain to those sectors. Yes, money would be enormously welcome, and that's where I'd direct it to, but I'm not sure I can rapidly solve the problem because it will require recruitment campaigns having greater success than we're having at the moment. Can I go to Adam first of all? I imagine you'll say similar things with regard to the care capacity since you've mentioned it already, but I don't want to pre-empt what your answer is. No, absolutely. Very similar to Jeff Ace, the key place that we would spend it would be on staff, whether that's in community settings, care settings, right through to hospital. Very much like Jeff Ace said, our really big challenge is actually recruiting people, so we definitely struggle to recruit across the whole spectrum of people that make health and care works successfully. Money absolutely is a worry this year again. I think Jeff set the context really, really well. Our overall financial position is definitely a worry for us, and trying to think how we redesign the system or a different financial envelope certainly adds to the pressure. I think the speed at which we can do that, again, is one of the concerns in planning terms my fairly bread and butter. That's a real challenge for us going forward. I'll go to Jennifer for her perspective. When you're coming to plan for winter, what you've got to try and do is balance the impact that you're absolutely right of funding that you've got available to you, as well as, just to give an example, we might come to talk about this. We have 300 daily discharge patients within our hospitals at the moment, and that's gone up from 50 last year. For those patients, it would be far better for many of them to be in an intermediate facility where you get rehabilitation. It's a much more homely environment in acute hospital sites. At the same time, those are 300 beds—that's about two floors of the Queen Elizabeth—where we put our staffed doctors and nurses and are actually for acute care patients. Certainly, within social care, that would be extremely helpful, but it's about staffing to try and improve patient safety as much as we possibly can. There are certain things like OPAT, I think that you've heard about, which is the outpatient antibiotic. We're looking at that, and actually that's extremely good. It's saving us about 50 beds per day, and it's giving patients a far better experience. As we roll it out across Clyde now in the RAH, that could go up to 100 beds a day. Other initiatives are good, but they're saving hardly any beds a day. Some of those things, what we do is we ask the clinicians, a view on that and the managers, and they come back and they do an impact assessment on each of the different features. One of the debates that we were having recently with the advanced the AHPs was putting additional allot health professionals into an acute sector, so that we could rehabilitate patients more quickly and get them out. However, what you're always trying to do, I think, is to maximise the impact on patient safety, as well as help staff as much as possible, because it's going to be a tough winter, and all of those things come into the mix when you're making decisions. What Gigi Cian has said before, we accept that we have to spend a lot of money in winter to try and keep patients safe, and that's why we put that into our financial plan. On a similar vein about managing cost increases, Emma Harper, you have some questions. Thanks, convener. Good morning to the panel. It's on a similar theme, I suppose. The juggling of all those plates in the air and the financial costs are now compounded by energy supply, the increase in that as well. If I'm thinking about how the facility costs are anticipated to be increased over the winter as part of the plan, I'm aware that health boards have a climate change or net zero group to help to look at where cost savings can be made. I know NHS Dumfries and Galloway. I think that Geoff will probably confirm that NHS Dumfries and Galloway has a climate change or net zero group. I'm interested in what impact the rising energy and facility costs that you have anticipated on the finances as we move into winter. Thanks. It's certainly increasing the gap. I spent the time before this meeting this morning in a meeting with my estate leads looking at potential options for different fuel solutions for CSSD, for example, for instrument sterilisation to try to reduce costs. It's a constant, I guess, double pressure in terms of cost reduction through reducing activity or finding a cheaper means of energy production. Also, we've got that carbon target. You're exactly right. Each board will have a carbon reduction group. Each board has an executive lead and a champion that is looking at how we achieve the net zero target over the coming decades. Fortunately, that does come together with cost reduction. It is a mutual good that we can link those two things in a lot of cases. The big challenge is hospital heating. That's the one where the intensity of energy generation is such that gas is a perfect solution and everything else is less good at the moment where technology is. Hospital heating is giving us a long-term worry as to how we reduce costs and carbon. Much of the rest of our energy bills and our carbon usage can be aligned so that we spend less and we emit less. Hospital heating is the real one to crack. As I suppose, if Donna Bell had been on this panel, she would say that there were real challenges with care homes as far as maintaining heating as well. I suppose that long-term sustainable solutions. I know that Orkney has got solar panels on the hospital there. Is that something that is being planned for the estates across other hospitals, whether it's Dumfries and Galloway or whether it's NHS Grampian? I bring in Dr Colville to talk to what NHS Grampian is doing to manage those solar energy costs. In the very short term, as in what happens this month and next month and the month after, we are very limited in what we can do and we are facing enormous rises in cost. I want to say a figure, but I might not have it quite right in my head. I'm not going to say that out loud, but it's many, many, many millions in the year of increase that we're facing in the energy bill. Our environmental group, I absolutely agree with everything that Geoff said, is the same. I guess the other bit that we're looking at very much in the environmental group, two things. There's the single use item, so again we use enormous amounts of single use items and the group are absolutely exploring that to see what we can do differently to improve our green footprint. The other bit that was mentioned this morning, during the pandemic, when we went to largely digital clinics, we saved 13 million miles of travel. Again, in terms of the carbon footprint rather than the heating, so I've slightly gone off your question, but in the green space, there was a huge carbon dioxide reduction just from patients travelling to and from clinics right across a big patch. Again, the more we can ensure that we stick with the digital approach, where it's appropriate and where it works with people's choice and things, then actually we support a big carbon reduction there as well as all the work that we need to do with heating. I think that one of the challenges that we've got with solar is actually the priority of the capital funding, so we need quite large sums of capital funding to be able to do it. And our whole estate, we have huge pressure on our capital allocation to prioritise that against what we need to spend money on in the here and now in quite all the state compared to what we can do in investment. So again, a real tension there between the direction you'd like to go and some of what you're forced to do in an annual cycle of capital spend. Thank you. I think that the additional energy costs in Great Glasgow and Clyde are something like £19 million that we're expecting over and above what we currently pay for energy, and my director of finance has given me that figure, but I can check it for you later. Just to, from Adam's point, Great Glasgow and Clyde, we do have a strategy for net zero target, and it's a very active strategy, and there's a lot of clinical involvement in it as well. However, with oldest state, there is a need for capital investment to change from fossil fuel boilers to something more green. We can do it in our newer hospitals, and we have got it in our newer hospitals. As we build new state going forward, we need to make sure that the energy is efficient. However, with a lot of older hospitals, change to net zero without additional capital investment is going to be challenging. The other thing is the sort of capability and capacity that you need within boards in the state departments to do things like that. We need to look at that as well as across Scotland to make sure that we've got that capability. Thank you. I'm able to move on to the effect of the cost of living and fuel poverty on people's health, which is awesome, and you'll need to be factoring in. Can I go to Stephanie Callaghan? Thank you very much, convener. Two questions that I have, and I'll ask them both together, and hopefully that will speed things up a little for us. In our earlier session today, Caroline Lam highlighted the negative impacts of the current cost of living and fuel poverty on wellbeing and on mental health in particular. My first question is about patients. What increases in demand are you expecting to see for mental health support and primary care services over winter, and how do your board plan to manage those? Secondly, about staff, what impact will increases in living costs and fuel have on NHS staff, and what actions are your board considering to support employees over the winter months? If I could start with Dr Armstrong and, of course, Jeff Eason and Dr Coldwells, I welcome to add anything too. I think that those are very good questions, and they are absolutely relevant. If I look at Glasgow and Clyde, we already have a deprived population, and I have seen some modelling, but I have not yet clarified it to share it. We are expecting with the fuel poverty and food poverty, because we have seen an increase in food banks, and we have seen an increase in mental health issues across the population. We are expecting that to have a significant impact on our population, particularly within Glasgow and Clyde, as more families are pushed into fuel and food poverty. That has an impact on chronic illness. If you are in a cold house—we all know that—and if you are in a cold house and you have asthma, COPD, young children or dampness, that will increase the amount of morbidity in the population. In addition to that, you then have—there were good surveys done by the Royal College of Physicians, and they show very clearly that, if you are in debt, your mental health is far worse, and that those are things that are obvious. In terms of trying to support that, and with staff as well, we have also thought about how we could do that. In terms of trying to support that, we are trying to increase our mental health support. We have a mental health framework that we did as part of our recovery planning, as well as our public health colleagues are looking particularly around child poverty and what we can do to alleviate that, and how we can get benefits out to people, and how we can use all the NHS interactions to do that. With primary care, we offer around 110,000 appointments per week in Glasgow Clyde. Around 46 per cent are face-to-face and 55 per cent telephone. What we are trying to do is prioritise those patients who really require our support by working with third sector colleagues. There is a whole plan around that for us to try to mitigate the impact of that. In terms of staffing, we have got staff concerned and worried about that. We are trying to ensure that they have access to financial support, all of our staff are living wage, but we know that there may well be further industrial action over the winter and we will wait and see what the output of that is. With staff mental health support generally, we have a whole programme of that, which we put in place for Covid. Things like peer-to-peer support, helplines, psychology support, rest and relaxation hubs, us trying to support people individually, mental health check-ins, and a whole series of things that we have done to try to alleviate that as much as we possibly can. We will try our best. We will have an NHS side of it, which is the patients and their families and the communities that we serve in Glasgow and Clyde, and we are trying to ensure that we support them as best we can right across all the services, as well as our staff who are trying to set up services, for example financial support, financial advice services to them. I probably do not have much to add to what Jennifer said. I would like to emphasise her point about child vulnerability. If you think of the experience in Scotland over the last three or so years for our children, that has been incredibly tough for them, I think, in terms of disrupted schooling, lockdown and now a period of potential austerity and poverty. That really fits with all our understanding of adverse childhood events. We have got good recognition now of what that can mean to health needs, both mental and physical health, as the child progresses. We have a real risk situation here with our childhood population health, so we need to make sure that our understanding and our mental and physical health services are adapting and expanding where appropriate to meet that. I am really quite concerned about the most vulnerable of our children. We have just had an extraordinarily difficult three years, and that has to be a focus for us as key agencies in trying to keep them safe, but it is a big problem, I think. I do not think of anything to add, convener. I think that Jennifer and Jennifer covered very well. Those are all universal issues. Thank you very much, convener. I think that I just wanted to explore that mental health point a little further, if I can, and really just about crisis and people who are going to inevitably end up in crisis due to pressures of cost of living. I am keen to understand, because this obviously ties into us trying to reduce attendances at the wrong place, if you like, and the wrong door, what work has been done with third sector providers by the boards in terms of the support that they can give to deal with crisis. I am thinking about organisations such as local mental health associations that have already run some of those services, and I am giving my local interests a might start in Greater Glasgow and Clyde with Dr Armstrong. I think that, with the crisis support, one of the key things that we have done—and I know that that is not quite what you were asking—one of the key things that we did at the beginning of the pandemic, and it has worked extremely well, is to put in the mental health assessment unit, so that is one base at Lavendella and Stockhill, and they run 24-7. I think that they have been a huge impact into how we have dealt with people in really severe mental health crisis, because before they used to be picked up often by the police, they would have to go to ED, they would face long waiting times, and I saw cases whereby people were really distressed. You do not want to be in a loud environment at that point. We brought the crisis support services together, and we have advanced nurses, and they will support people. I visited the sites and watched them, and they are absolutely excellent, so they will assess people in the mental health crisis. We see around 300 patients a week in the mental health advice centres, so that has been a huge impact. We have done a safety evaluation of that, and they look pretty good. As well as that, we can do about 60 per cent of the patients that are already known through the service. We have developed much stronger links between the GP and the mental health assessment units, so that GP's can now refer direct to the assessment units. That is a much better way of dealing with people there. There has been a lot of work done with the third sector in terms of things such as suicide prevention and ensuring that people get access to that. That is extremely important in terms of peer support work. We can certainly give you more of the detail around that, and we are working with various third sector groups to do that. The way that we do it among the mental health services is that we do a red amber green pathway, and we try to prioritise those patients that we believe really require support. There has been quite a bit of work done. We are also doing work within schools, and it is at Geoff's Point as well. In parts of our HSCPs, there are more advance than others, so it is things like giving children support within schools, while they might be waiting for other appointments and trying to prevent things more than we have before. There is a mental health strategy that Grace Giles and Clyde are implementing, and what we are trying to do is to develop the primary care teams, the primary care community teams, who are working with GPs and schools in order to support mental health. We can give you more detail on that later. If any of our other panellists want to come in on anything that they are doing locally, they are most welcome. Otherwise, I will maybe just take our next question and move things along. We have our next topic of conversation, which is accident and emergency waiting times. Emma, you have some questions on that. In the previous panel, I asked about the challenges that we are having right now for accident and emergency. It is really complicated to move people through the system. I know that whether you bring them into accident and emergency and then discharge them if possible, or get them moving into acute beds or whatever. I am interested to hear about what is driving the increased delays in the A&E services. It would be good to hear your thoughts about that compared to the previous panel. I suppose that we could start with the Jeffys. I think that for us, occupancy remains the biggest challenge in terms of our A&E activity. You cannot see a huge step up in our current levels of activity to the pre-COVID levels. It is a fairly consistent pattern. What we are seeing is an increase in acuity and a slight increase in age of patients. That requires patients to require more acute intervention and an admission. It is there where the blockage comes because of our consistently high occupancy. Traditionally, in rural boards such as mine, our highest numbers of A&E attendances are in the summer because we see a tourist influx, but they do not generate significant numbers of admissions because it is largely low-level injuries and young people-type incidents. This summer, we have seen a high level of activity sustained but a much higher level of admission into an already hot system or a system already facing very high occupancy. That is what has caused our traditionally very good in Dumfries and Galloway, four-hour performance, to dip down. We would normally be 90 per cent baseline and achieve the 95 per cent occasionally. We have been much closer to an 80 per cent baseline and, at times, we have been below that figure. Certainly last weekend, the weekend before the Queen's funeral, was probably our worst performance on record in DNG. It was just that consistent level of individuals presenting who required significant treatment in A&E, and then onward admission and our ability to admit those to a system that was already close to 100 per cent occupancy. Again, if you were doing the full diagnosis, you would again get back to capacity out of the hospital and capacity in our ability to discharge effectively as being one of the key drivers of that A&E performance. It is really important that, when you see the A&E headline figure, we sometimes fall into the trap of seeing it as a problem to be solved, when in reality it is a symptom of a multitude of problems that need to be solved. It is really important that we do that consistent systemic work to make sure that the safe flow of patients right through the system back to their home is operating effectively. Otherwise, A&E will always become that point of log jam where patients can have really long waits, really poor experiences, and for our staff it feels just an astonishingly consistent level of pressure. There is a key metric for us to the health of the system, but it is one that you cannot fix in A&E. You actually have to fix that whole systemic journey of the patient right the way back to their home. Come in in their particular areas, or if I can go back to Emma. Emma, have you got a supplementary question? Yeah, sometimes it's difficult to see if there's going to be light at the end of the tunnel, or if we just accept that the levels of attendance are really high right now, and that's going to happen all over or all through winter. The whole getting people out is part of the working with our social care teams as well, looking at falls assessment and then prevention and things that we can do to support people to get back to their own home. I suppose that I'm thinking about just the pressure and the demand and then the impact that will have on everybody across the whole service as well, and just about any other mitigation measures that you think that can be done. I'm going to talk to Armstrong, since she's nodding. Yeah, I think that what Jeff was saying, what you were saying, there was absolutely correct. I think that at the moment there's a logjam at ED and having spoken to many ED consultants and nurses, the pressure on them is absolutely enormous, and their ability to deliver patient care that's safe and they want to deliver is compromised. I would maybe point out a few things. In Glasgow and Clyde, we've roughly got about 6,500 people that attend ED every week. Now, if I compare that with the flow navigation centre, where it's about 300 patients that we deal with every week there, and what we've got to do is split that round because of the 6,600 patients, around a third of them are what we call flow 1s, so they're minor injuries and minor illness. We need to give patients a better service, and I've seen the probabilistic campaign about, can we triage patients before they even come to us, because that's far better for patients and it's far better for the hospital services, because we can, through the FNC and it goes through NHS 111, data them, come up to Stop Hill, ACAD at one o'clock, and you'll be seeing that away, and it's a much better service, or minor illness services should really be dealt with probably primary care, but because patients are trying to get treatment, we need to get far better, and that's going to take time for us to develop those services. Things like in Glasgow and Clyde, we know that there's a high convincing rate for falls and for patients who are nursing homes, and we're doing a lot of work with the Ambulance Service and the Flow Navigation Centre to give clinical advice to make sure that these patients come to hospital when they need to, but don't come when they don't need to. So there's a whole range of things that we can do prior to patients coming in, and once they're at the front door, we've got frailty assessment services where you have expert teams who work directly with the community teams, because what you don't want is if you're 85 and you've had a fall, you may well be better off in your own home with rehabilities, people helping you get out of bed, get your muscles moving, and so all of the heart of this is what is best for the patients. The other thing is that the consultant connect, so consultant connect means that we've got a whole series of apps where GPs can contact consultants within half an hour and seek advice, and I spoke to the area medical committee about that last week, and they believe that that's working well, but it's going to take time to bed in because you've got to have outward things, and then as you come into the bed capacity, that is a real issue. As I said before, 300 patients who could be better managed elsewhere creates an exit block. John Burns talked to me about things that we have to do more rigorously, so that's things like before 12 o'clock discharges, because if patients are in bed and you've got a search coming in, you can see it if you look at that during the day, you can see what time patients come in, and all of that creates an exit block, an assessment block, and then an overcrowded department. I think that our ED staff and paramedic staff have been excellent because they do their best day in, day out under really extreme pressure to manage that. It's a complex problem. It's something that the NHS needs to change. I'm not sure that we can do it all for this winter, but over the coming years, so that we manage patients in a much better way, both crucial for their own states and patient safety, as well as to ensure—and it's back to John Burns' point, he's absolutely right about this—the right time, the right place, the right person. I know that that sounds very, but it is true. Publicity campaigns this winter and be helpful of Scottish Comfort to that as well is trying to encourage people to use some of these new pathways. We must move on. Tess, you have a question on A&E, and then we'll move on to talk about waiting times and the cancelled operations. Thank you, convener. Jeff Ice and Jennifer Armstrong pointed out about the A&E logjam. My question is for Dr Coldwells, please. Right now, there are reports of at least 10 ambulances waiting outside A&E department at ARI, and that is becoming a big logjam. This is a crisis right now. The public is being asked that only if it's life-threatening to actually come to A&E. So my question really is, that's now, what actions are we doing to address now? And as we face or about to face winter where it will exacerbate and the pipe is already bursting now, there'll be an explosion in winter unless we have immediate plans and then think about what are we going to put in place for ARI in now? Thank you. Dr Coldwells. Yeah, thanks very much. So really what Jeff and Jennifer have said described the challenge, so it's very much a flow challenge through the whole system. The tiny bit of context for the grand pain system, during the pandemic we reduced our bed based quite dramatically associated with many infection prevention control measures. So we're operating close to a maximum capacity in the bed base all the time, so the flow through the system, like any system that's very busy, everyone's familiar with the M25 analogy, things don't work anything like as well when a system's very full. The four key actions we're taking at the moment to try and improve the flow at ARI. And again, exactly as Jennifer said, when an A&E department gets busy and it gets this crowding, as it's commonly known, then the efficiency there also deteriorates, but it's really the whole system flow. We're looking at, we already have in place hot clinics, so for particular specialties where people come, can we move them to an urgent flow under a scheduled basis, so the next day or later that day to do it. So we're trying to expand those so that people have rapid access to something that may create a different route than admission. We're also looking at a very different multi-disciplinary triage and assessment, and this has come and gone over the years. Another go at trying to have that really strong multi-disciplinary team drawn from across the hospital to look at it. Again, this is one of the key things that's come from all the work that we're doing with a very wide clinical body to try and collectively think about what can happen differently. Again, that's very much about a front door bit and how that can change people's journey early in the system. The next thing that we're doing is trying to increase our hospital at home capacity. In the city, we're trying to increase by 100 spaces, our hospital at home, and that will have a very good impact on the flow of people through the system, so that's a really active bit of work at the moment to try and increase capacity rapidly. A very local issue is that we've got a real backlog in cath lab activity, and we've got an opportunity to increase the capacity in the cath labs, which again would get that flow through cardiology working much better. So again, there's a really targeted bit of work to do, a slightly different approach there, maybe a little bit of investment, slightly different staff group to help improve that, which would be one of the bits that's getting absolutely stuck at the moment with some background. It's not just cardiology, it's in pretty much every specialty there's this challenge, but it just looks like there's a real opportunity to potentially improve that. So those are four examples of actions that are happening, but we've got a really big multi-disciplinary clinical and managerial team trying to work together to explore what are the improvements that we can make to reduce people's waiting. As everyone said throughout the morning, it's just a really good indicator of the busyness of the whole system. You could look at things in primary care that will be busy right through secondary care and back into community. Thank you. Thank you. Gillian McHenryd, I would like to ask questions around waiting times and cancelled operations, Gillian. Thanks, convener. Those who were listening earlier will probably recognise the question from the first panel. During the most acute period of the pandemic, we had really good national level information about services and what people's care will look like and a lot of people valued that. Many will understand why operations have to be postponed, but some constituents feel that more information about next steps and other support while they wait for a new operation date is not what they would like it to be. What work is being done at a health board level to ensure that patients have information about how to keep themselves well and get support while waiting for an operation and communication about urgent care is to link to a question earlier by my colleague Emma Harper. Can I go to maybe Dr Armstrong, given the size of the health board in Greater Glasgow and Clyde? I think that for planned care for patients, and you're absolutely right, there are a large number of patients who have been waiting in considerable periods of time. What we've been trying to do with one of the anesthes is to develop much more information on how you can keep yourself well, so exercise diet. One of the anesthes is leading quite a lot of work around that, so we can signpost them to that. There is also an app that we're developing that we're doing with the Scottish Government, and it's a Scotland-wide app, so it's not yet ready. However, I think that if we can do something around an app, around where patients can access care, there's been a lot of work done on that. I'm not quite sure where that is yet, but it's trying to look at all the different pathways and signpost people to that care. At the moment, that's what we're doing. I think that John Burns mentioned patient-initiated contact things like that, to try and keep patients as well as we can. As I said before, we're trying to look at pre-op assessment so that we see patients early. What we are trying our best to do is to ensure that we do the P1, P2, or the urgent categories, but also to look at people who've been waiting a long time to bring, if you like, that tale of patients in. However, we're very, very conscious. One of the worst things that we have to do sometimes in the middle winter is to cancel patients, and everybody feels for them. You see it in the media or GCC cancelled or whatever, but you do feel for them because you know that these patients have waited a long time, and we try to boot them in as soon as we can. That's roughly what we're doing as a board to try and get people to exercise and diet and just put yourself in the best possible space that you can before you get that operation. Thank you, thank you, Gillian. Standesh, you wanted to ask a question on this specifically. Absolutely, thank you. I suppose that this is to Dr Armstrong mainly because you're the biggest board again. When it comes to waiting times, the BMA and Dr Ian Kennedy, the new chair, has suggested that figures that have been compiled suggest that patients are not getting a realistic picture of the delays with orthopedics and orthopedic surgeons saying that only the most urgent care is being prioritised while patients face languishing and waiting lists for years due to a lack of capacity. How do you respond to that, and what can you do to ensure that we get those waiting lists down? With Greater Glasgow and Clyde, we have developed a waiting list plan, and as you know, there are waiting list targets. There is no doubt that there is a huge backlog and, in particular, there is a backlog of orthopedics that you have just mentioned. The long race at Glasgow and Clyde has developed a waiting list plan with the Scottish Government and has also asked for additional support. We will ask for the Golden Jubilee support, we will ask for other support to try to mitigate and improve that backlog. The way that it works is that those patients are clinically prioritised. Recently, it changed a bit in Scottish Government. It was P1, P2 and P3, which were all college ones, and it has changed to a different process. We ask the clinicians to prioritise. We try to get as much capacity as we can. We have a theatre capacity plan where we try to allocate capacity first of all to cancer patients but also to other patients and allocate the theatre list and maximise the use as much as possible. That is our plan, and we are trying to stick to that plan. There is no doubt that, the same as every other board across the UK, we still have a big backlog of patients, and it is going to take us time to work through that. It has been mentioned by a lot of people so far, so we have given it a good aiding. Specific questions about staffing, retention and all the pressures on that are starting with Paul O'Cain. Paul O'Cain, I wonder if I have two questions on this, so I am happy to ask them together if that is helpful. I suppose firstly about how resilient our boards are in terms of the approach to winter for staffing numbers, given the challenges that we know have persisted last winter and certainly over the course of the Covid period, particularly around single staffing of wards and some of the data that we know exists around that. Secondly, in terms of resilience, it was alluded to by staff wellbeing, but I wonder to what degree innovations have been made around, for example, the provision of meals on night shift and rest areas and those sort of things as well. We will maybe take each health board in turn. If maybe we start with Jeff Ace. Jeff Ace is the key question in terms of our ability to successfully navigate winter. There is no doubt that we are under extraordinary pressure here. Our staff are under extraordinary pressure. We are currently not able to staff our co-functions. That is not just in the acute, but if you look at mental health services, for example. We have talked about social care but we are not at the moment able to guarantee that resilient level of staffing that allows us to deal with routine sickness, routine annual leave and so on. Staff have been dealing with gaps consistently now since the pandemic. That obviously has a knock-on effect on their wellbeing and their ability to remain resilient and keep themselves well. It is the key challenge for particularly rural boards, I think, is how do we maintain that staffing level that allows us to provide safe, high-quality care. That is not just about recruitment, that is about retention and how do we work with staff that are coming to the other end of their career? How do we introduce enough flexibility that allows them to feel that this is still a good place for them to work and they can still contribute as they would wish to contribute? I do not speak for NHS Dumfries and Galloway. I do not think that anywhere near where we need to be at that on this at the moment, we have to create a much more flexible environment for staff to ensure that our retention rates match what we need to make up for our difficulties in recruitment. That is something that we have better at, but we have a way to go before we are exemplar in that area. Your point about staff wellbeing is really important. I think that the pandemic saw some extraordinarily good stuff going on throughout Scotland in terms of how we were supporting staff. Jennifer mentioned psychology support, pro-social type models. We have kept those on through post the pandemic. However, the important thing that I would like to emphasise is that if staff are coming to work and there are not enough of their colleagues on the shift to provide the level of care that they would want, anything that we try to put around them to mitigate that stress is not good enough. What we need to do is to make sure that those staffing levels are right, and that is where we are really struggling at the moment. There should be a focus on what additional things we can do for staff wellbeing, but the most important thing that we can do for staff wellbeing is to reduce occupancy in our hospital environments and provide the right level of staffing in our community and social care environments and recruit effectively to support people towards the end of their careers so that they do not feel that they need to leave in the numbers that they are currently doing. That is the key bit to staff wellbeing that we have all got to get better at in this much more competitive environment for workforce. I do not know whether anyone else has any points to add to what Geoff is saying. As with many other things, it is probably similar issues across all health boards. Adam, do you want to come in? No, I just agree that Geoff framed that really well and exactly the same challenge that he said Thank you. Paul, are you happy with me to move on to your colleagues to ask some supplementary questions on this? Thank you, Tess. You do not need to press your button. I think that Geoff gave a very good answer to that as well, but my question is to Dr Caldwell's. Take NHS Grampian. It has recorded record numbers of staff levels, but there is a shortage of staff to keep the community hospitals open. We have a recent example of a boin. What is going wrong here? What can NHS Grampian do to improve the current situation? We know that in the rural areas there are issues with falls, and that will create further pressure on the local units. A really good area for us to explore and try to understand what is causing the challenge and then, as you have asked, what we can do about it. The first bit draws on lots of the narrative that, hopefully, I have said and Geoff has definitely said about rural areas. Having staff in rural areas—a boin hospital to use that example—is a rural area outside Aberdeen, so it is drawing on a different population that works there than if you are in the city centre. One of the things that we learned hugely through the pandemic was that we deployed people from one area to another. We had a reasonable scope to do that at the start, because we stepped down all sorts of services. The list of critical services was quite small in episode 1. By episode 4, so by Omicron, the list of critical services was pretty much everything. Because of the postponement of services over a period, things had to be kept going. The reason for restating that is that our scope to deploy people who have the right skills from one place to another is almost non-existent for your example. A nurse, for example, who can work in a ward environment to support the population that will be in a boin or in ankerie or in general medicine in ARI, is a very finite group. Our scope for deployment of people between areas is very small. The solution is immediate. That is very challenging. It is about how we do exactly what Geoff was saying in the previous answer—how do we get the staff numbers to be right, how do we have the resilience across it, so that the framing of the original question and creating that resilience group that we can do. We are exploring things like can we have teams that are there to support other teams as they do it, rather than in the 24-hour planning deployment of people. The other bit that was important to remember is that staff being deployed from one place to another, they really hate it. One of the things that has a really negative impact on people's wellbeing and their resilience of wellbeing is being moved to other bits. You are in a team of people that you do not typically know. Without good planning, you have not had an induction there—all those sorts of things. Those are all things that we are trying to plan and make that terrible bit of deployment better, but it is a really unpopular and really negative effect on the wellbeing. It is a real on-going challenge that you have framed, and I do not have a magic bullet for that, but those are all the things that we are worrying away at to try and improve and see how we get resilience services across all of our areas. As a GP for myself, I know the troubles that we are having recruiting GPs, especially in rural areas, which is why I want to have my question directed at Dr Caldwell. When you have an MDT, which we heard in our last session, the MDT is very good. In fact, I would suggest that there are a number of occasions where it is better to see a member of the MDT than it is myself as a GP. Patients feel as though they are being phobbed off. Patients do not feel that they are getting seen by primary care. What can you do to ensure that we take the patients with us, and how can you improve the messaging, because it is not getting out to the public? Dr Caldwell? I think that two things I would probably comment on around that. I agree, I think that the public confidence in general practice, exactly as you have described, is definitely challenged at the moment. One of the things that Aberdeensia has been incredibly successful at is an MDT that is called hospital at home, and it works as a multidispery team, identifying people at a risk of deterioration, potentially for admission, and it manages to wrap around that individual response that changes the trajectory of their illness. That sense of that has been extremely well evaluated, with very positive impacts in terms of outcome, but also a sense of patience and the inputs that they have had as a consequence of that MDT. That MDT that the patient is not present at, that is a planning MDT. The second thing, in terms of our rural populations, we have a GP in a role that is trying to look at the sustainability of general practice and trying to think about how we support that and create a better recruitment and make it better for the longer term. That has been an on-going challenge in both Morrie and Aberdeensia for a long period of time to do that and trying to make sure that we, again, we had a really big programme to try and move away from two seed practices to independent practices, because they seem to give a different dynamic. That was very successful over a number of years, building up to the pandemic, where you get that different ownership and that different relationship in the community. The longer term, but about public confidence in the approach, I think is something that we all need to work on collectively together, be that from a political level, a local board level, a health and social care partnership level, so that everyone is transmitting and giving the same messages, having the same interactions with people as they come to contact with the system and going on a journey of the very positive benefits that we can have by working that differently. We have a couple of questions from members on delayed discharges. I think that it is fair to say that we have discussed delayed discharges over many years and we acknowledge that things are still continuing to be bad and possibly even worse. I suppose that, in the last panel and your own, it has already been mentioned that that is how important delayed discharges are to resolving some of the issues that we have. You have talked yourself about the recruitment of staff, staff pay, intermediate beds and the role that HPs can do to help with that and the pay terms and conditions and recruitment of social care staff. I wonder if you would be able to give us some idea of what support you need from the Scottish Government to move that forward because there is a lot of urgency about it and it does not always feel that we are moving a pace forward with any of the ideas that are out there from your own selves, the staff and the Government's support. I think that we should go round everyone on that, please. If we can maybe take Jeff Ace first of all and then go to Dr Armstrong. Yes, this is absolutely key, convener. I think that we have talked about A and E waiting times, we have talked about elective care and general occupancy. Almost the answer to all of them, you could argue, would be increased social care capacity to allow us to flow patients back to their own homes. Delayed discharges, again, are only a fraction of that gap of social care capacity because there are far smaller numbers in any system than those people who are at home actually and are not getting the full package of care that keeps them securely and safely at home. There is a bigger demand gap there than we are seeing in delayed discharges. That is an enormous problem. For me locally, it is 100 full-time equivalent staff in social care, providing that seven-day-a-week service to get me back into an even keel. Government is very well-cited on that. The Scottish Government has been working with boards about their capacity plans, working with partnerships about what we are doing to address that. It is extraordinarily difficult to move the terms and conditions questions, the who employs questions and how we get that capacity looking attractive to people to move into the areas. It is very hard to get rapid solutions to those. We have actually been looking at overseas recruitment, almost as a last resort solution to the issue. We will see how successful we can be in bringing in people from outside the EU into work, into social care, just as we have been doing with nursing staff. I am also thoughtful about just that model that we have at the moment and how much of that capacity can sustainably be provided by the private sector and how much we will have to step in and become an employer of significant additional social care capacity throughout our partnership. That is not a magic bullet. It generally comes at a greater cost. We have talked about our long-term financial problems before, so we would have to find a way to model that successfully. Potentially, the way that the labour market is moving, particularly in rural areas, is that model of relatively small-scale private providers being able to staff themselves up and remain resilient and reliable. That may be becoming a smaller part of provision in the future than the council, the partnership and the health board employing those individuals and giving them the career pathway through our services. Again, it is not a magic bullet. It is not quick and it is certainly not easily achieved within our current cost to envelopes. I am not sure that anyone heard me there. Can we go to Dr Armstrong, please? I think that for patients who are ready to go home from hospital now, that term is better. I think that there is a series of things. We have a plan or a development plan for the HSCP to really try to push that forward. It is from getting patients as soon as they are ready to go home. That is not just because hospitals need the bed. The longer a patient is sitting in a bed, sitting in a chair, the more muscle mass they lose. They can go from being able to transfer from the bed to the toilet or being able to go to their own fridges and their own homes to becoming really incapacitated the longer they stay in bed or in a chair. Although the acute sector does extremely well in trying to care for those patients, when you are in the middle of a busy acute receiving ward when you have lots of patients moving in and out, it is not an ideal place. It is really preventing people from needing long-term care to begin with. That is much better. Rehab services with rehabilitative grant host when taking a patient home so that you are surrounded by your own neighbours and that you have a decent chance of regaining the muscle function that you lost. The second issue is a more controversial one. In Glasgow, about a third of our patients are adults with incapacity, and there is legal legislation in there that could only be changed by Parliament. The reason that I say that is because I think that many of those patients would be better in an intermediate care facility while they wait for their choice of nursing home or whatever, because they are much better there. I have had relatives in nursing homes that have been excellent and have a range of activities, a range of people who deal with you as if you are in your own home. That is not an acute ward. Unfortunately, we cannot move those patients, and a lot of the delay in those patients stay in longer than any other patients. They need legal processes, the power of attorney, if they do not have that, it is then going to be set up. All of those things can build in very long delays for patients. I go back to the thing. All doctors, nurses and clinical staff managers are trying to do the best for that individual. I am not sure that the legislation that says that you must keep them in an acute site is really helpful for us. It is not helpful for the patient, but, as we have talked a lot about today, that goes back to a front door to a patient waiting in ambulance for three or four hours while they are trying to get access to hospital. There needs to be some debate within the Scottish cross-party groups about what we are actually doing with those patients, what is the best way of dealing with them, which protects everybody's rights and gets the best clinical outcome for the patients. That means that people wait to get in, but also for those patients that they get into a decent environment, which people can get them up each day, you can watch your toilet, you can do all sorts of things while you plan your onward journey. At the moment, a lot of that is done within the acute sector, and that is hundreds of bed days in which we cannot access that bed. That bed is fully staffed with acute consultants and nurses, and it would be better used by a patient who is sitting down in the ED department. Meanwhile, the patients who are sitting in it would be far better off in a different facility while we sought out all the power of attorney, but I know that that would be difficult, but if you ask what you could do, that is one thing. Can I come back just for a bit of clarification, Dr Armstrong, because it is really interesting what you are saying. The issue, legislatively, is around power of attorney, did you say? Yes, you have to have a power of attorney, either it is in place or you have to seek it if it is not in place. That is why you have seen the subways in Glasgow sort out your power of attorney. There is legislative change and I am not an absolute expert because it is quite complex legislation, but it means that you cannot move people out into immediate care facilities and it does build a lot of delay into the process. It is something that the HSCPs are far more expert than me on that, but it needs some thought about when people are medically fit for discharge. What happens if there is not a clear home they want to go to? What happens then? Do they stay in the acute sector, which is what currently happens, or do we move people to somewhere? I go back here and I spoke to a nurse dealing with this. What we have got to do, no matter what we do, is build in the best outcome for the patients and I think that at the moment they are not best served by that. Thank you for clarifying that and this will be something that we want to look into in a wee bit more detail. I think that we have heard from Dr Coldwell on this and then we have got one final question from Tess White and then we must go on to our next item. Tess, not yet. We have not heard from Dr Coldwell yet and I will come to you. I will be very quick then at nothing to add to Jeffers and for very comprehensive about the actual delayed discharge, but I guess if there is something that the Scottish Government could do and you could do politically, it would be part of starting a very different discussion about ageing and old age in our society and philosophically how we think about it. I would guide everyone in your committee to perhaps look at the book by Atal Gwande, which is titled Being Mortal. That gives a really nice consideration about ageing and how we consider ageing and how we not just medicalise it but healthcareise it, as it were. I wonder if a conversation nationally about that, we will not fix it in this term of Parliament, but if we never start the conversation, we will never change it. I suspect that delayed discharge is such a pernicious issue. We will still be having this conversation another decade if we do not start a different conversation alongside all those absolute tangible actions that Jeff and Jennifer set out. Thank you very much. Tess, you have a final question before we let our panel go. Thank you, convener. A very quick question. We've been looking at today at winter planning, so NHS Grampian is doing a primary care redesign pilot programme in Aberdeen city, and this is exploring about doing things differently to help to move things before we go on to the winter planning. Any comment on that? Most obviously, go to Adam Cole-wells, please. Thank you very much. As we've heard today, there isn't a magic bullet for any of this, so the more we can get schemes, exploratory options to try things differently from as many aspects as possible, that's absolutely the right thing to do. Will this bit of work in the city suddenly fix it and it will all be fine? Absolutely not. Will it contribute positively? Absolutely, I hope so, and I think that it will be really good. I think that it's trying to make sure that we consider everything that we can and bring all of the things in, because there are all probably small incremental changes. I don't think that there's anything that's going to suddenly solve it in a miraculous manner at all. I want to thank all members of the panel, particularly with the amount of ideas that you've put forward. Flag is some of the things that you're doing that's trying to make a difference. It's all given us a lot of food for thought and thank you for your time this morning. We must move on to the final item on our agenda, which is consideration of two negative instruments. The first instrument is the Sports Grounds and Sporting Events Designations Scotland amendment 2, order 2022. The Delegated Powers and Law Reform Committee considered this instrument its meeting on 20 September and made no recommendations. The purpose of the instrument is to update the list of home grounds for Scottish football clubs for purposes of schedule 1 of the Sports Grounds and Sporting Events Designations Scotland, order 2014, as amended in 2022. Those changes are required in the light of promotions and relegations from the Scottish football pyramid and to ensure consistency of approach over the application of the alcohol and other controls by a work set out in the Criminal Law Consolidation Scotland Act 1995, also known as the 1995 act. Part 2 of the 1995 act imposes certain restrictions on the sale and consumption of alcohol at designated grounds for designated sporting events. No motion to a null has been received in relation to this instrument. Do any members have any comments in relation to it? We don't propose therefore that the committee does not make any recommendations in relation to this negative instrument. Any member disagree? Thank you, we're all agreed. Excuse me. The second instrument is the Food Information Transitional Provision's Miscellaneous Amendment's Scotland Regulations 2022. The Delegated Powers and Law Reform Committee considered this at their meeting on 20 September and agreed to draw this instrument to the attention of the Parliament under reporting ground for the failure to comply with the laying requirements in section 28, two of the Interpretation and Legislative Reform Scotland Act 2010. The committee also reported that it was content with the explanations provided by the Scottish Government for failure to comply with the laying requirements. The purpose of the instrument is to make amendments to consisting existing transitional provisions contained in subordinate legislation and in retained EU legislation, which relate to food labelling requirements. The amendments that only apply in Scotland extend previous transitional arrangements, which were due to expire at the end of September 2022, and they continue to apply until the end of 2023. No motion to a null has been received in relation to this instrument. I propose that we do not, as a committee, make any recommendations in relation to the negative instrument. I agree on that. Thank you. We are all agreed. It just reminds me to say that our next meeting, the committee, will take evidence on the recently published independent review into racism in Scottish cricket and from representatives of integration joint boards on their experience today of health and social care integration in Scotland, but that concludes the public part of our meeting today. Tess, you have a point that you want to make. It is the inquiry into female participation in sport. Can we mention that before we close? That is for our private discussion. That concludes the public part of our meeting today.