 Welcome to the seventh meeting of the Health and Sport Committee in 2018. Can I ask everyone in the room to ensure that their mobile phones are set to silent and ask people please not to record our photograph proceedings as we will do that for you? We will start today with agenda item one on subordinate legislation, where, as colleagues will be aware, we have three instruments to consider. The first instrument is the community care provision of residential accommodation out with Scotland's Scotland amendment regulations 2018, and the second instrument is the community care provision of residential accommodation out with Scotland's Scotland amendment number two regulations 2018. It is no coincidence that they have such similar names because, in fact, the first of those has been, there is no motion to annul either of these instruments, but on the first of those, the Delegated Powers and Law Reform Committee made a comment because of the drafting error in the regulations. The regulations are being introduced because of a change in legislation elsewhere, and unfortunately, in the first instrument, the date that has been put in is 24 hours too late, and therefore there would be a gap in provision. The DPLR Committee pointed that out to the Scottish Government. The Scottish Government has therefore tabled the second instrument that I referred to in order to correct that error. Unfortunately, I think that this is the second time in a very short number of weeks that we have had a drafting error of this kind in an instrument before us. I am sure that that point will be well understood by those responsible for drafting such instruments, but can I ask colleagues if they have any comments on either of these instruments before us? If not, do we therefore agree to make no recommendations on either of these? That is very helpful. Thank you very much, colleague. That means that both instruments are now approved. The second one will immediately revoke the first, and therefore that will be the one that will have effect. The third instrument is the functions of health boards and special health boards Scotland, miscellaneous amendments order 2018. There has been no motion to annul and the Delegated Powers and Law Reform Committee has made no comments on those instruments. Do any members have any comments on those instruments? If not, do the committee agree to make no recommendations on those instruments? Thank you very much. We now come to the second item on our agenda, which is two evidence sessions on NHS corporate governance. We start this morning with evidence from members of health boards. Can I welcome to the committee our witnesses for this panel and introduce Linda Dunion, non-executive board member NHS Tayside, Christine Lester, non-executive board member NHS Grampian and Dr Graham Foster, director of public health and strategic planning at NHS Forth Valley? I invite colleagues to ask questions. I am very grateful, I should say, in introduction to all three witnesses but also to the other NHS board members who very helpfully responded to our survey in recent weeks. It is on that basis that we are very interested to hear directly from you from your own different perspectives. Can I start the questions with Jenny Gilruth? I would like to begin today by looking at board diversity. This is something that we considered in last week's evidence session. In the responses to our survey, 64 per cent of board members were 55 or over and there was nobody in the 18 to 24 age bracket. This is something that I raised last week in the context of this year being the year of young people in Scotland. It was not just age though that was highlighted as a factor. Bill Scott from Inclusion Scotland said that there is also desperate underrepresentation of disabled people on all public boards, including NHS boards. Do you think, then, that we have an issue in terms of our representation at the moment? Can you perhaps talk us through how those positions are advertised in your local context? Is there something around the advertising of those positions that we maybe need to consider in greater detail? I was appointed through a process that was part of the alternative pilot whereby people were either appointed by being elected on NHS boards or lay members of the public. I was a lay member of the public, so I answered an advert that was in the press and journal. That is how I came to this role. I am getting to the end of my two four-year terms now. It has only been in the past two or four years that I have felt able to be as well informed as I needed to be. From that perspective, if you want to get somebody on NHS boards, that is all I have been doing. I was widowed shortly before that. I was a carer for my husband. That has taken over my life. There is so much to learn if you come at it as a lay person, I would say. From an age perspective, I think that the remuneration that is given to people does not allow you to do a full-time or even a part-time role. It is not versatile enough for you to hold down another job at the same time. I suspect that, if you are on welfare benefits, that small salary would have a massive impact on how you get your welfare benefits. NHS Grampain is well-represented from the disabled perspective, but not from the aged perspective. I think that we need to be clear about why we want diverse boards. I would take it back a step. I read the note of the evidence session of last week, and I have to say that I was really quite concerned at some of what I was reading, because it seemed to me that—I might be misinterpreting, but it did seem to me that at points—diversity was perhaps being seen as, if not a substitute, but perhaps a way of ensuring that certain voices are heard at the board table in a way that is representative. That is counter to the code of conduct. We cannot represent anybody. This is an issue that I have had to deal with at our own IJB—Chairperson, Ross and IJB. I think that that is a source of confusion that needs to be addressed. We need to distinguish between having diverse boards—which I am not arguing against—and putting in place effective mechanisms by which the huge variety of different perspectives can be brought to bear on the decision making, on the strategy, and on the implementation of strategic direction by boards. I think that there are two different things here. In terms of the way in which board positions are advertised, it is very misleading to suggest that you can be an effective non-executive member—I am also a lay member—have come through the public appointments process. You cannot do it in eight hours. Nobody can do it in eight hours a week. That is misleading. In NHS Tayside about three years ago, there was a recruitment process. We did recruit a much-needed female member of the board. She did not last. That was because she had come in with an expectation of committing eight hours. When she could not do it, she was very unhappy for quite a long period of time. It felt like she was failing, which she was not. She was trying to do something that simply was not doable. I think that there is an issue there. For me, there is also an issue with the process by which people come to the board. Christine has talked about how long it takes to get to grips with the health board. When I joined Tayside, a chair elsewhere said to me, I do not expect to know what you are talking about until you have been on the board for two years. That was really helpful advice. It made me feel a lot better. It is something that everybody talks about. I think that there is a place for nurturing people, for being more creative about how we attract people to boards. I think that we have a responsibility to ensure that below the board, there are mechanisms in place whereby there is genuine engagement, participation and meaningful contribution to the business of the board. I think that it is important to think about form and values function and what is the function of the different members of boards. Boards are made up of a variety of different individuals doing different roles. For me, I am an executive director of a board, so it is a professional role. Like the other executive directors on the board, we have trained for a very long time to get to that. I would say that it took probably 20 years of training to get me to the stage where I was appointed as a board member and I was able to sit on a board and take on what is a very important responsibility. For non-exec directors to come on to boards, it is important to think about what we are asking those non-exec directors to do. I have the hugest respect for the non-execs that we have on our board. I see them working incredibly hard getting to grips with complex and difficult challenges in a world that is often not one that they are used to. Traditionally, the role of a non-executive board member was very much about holding to account. If that is the role of a board member, then there is huge potential to have a very diverse board because it is about asking questions and asking difficult questions, so it might be about saying, why are not you doing this for young people? I know from experience with one of our local authorities that uses a young person's panel that it is hugely valuable because you get those questions. Equally, we are representing the interests of various different groups in our community and the expertise to be on our board and the willingness to stand up and ask those questions is really important for us, so that is hugely valuable. What I see happening in recent years is the expectations on board members, and particularly non-executive board members have both increased and changed. I absolutely agree with what Linda said. Anyone who thinks that they are going to be a non-executive board member on a part-time basis is probably kidding themselves now. The further emphasis that we have put on community planning—in our board, for example, we now have non-executive directors participating in community planning, which is a significant role. We also have a huge expectation on feagleding non-executive board members to take part in integration joint boards, and those are quite different roles to the holding to account role that we have traditionally asked of non-execs. I am not sure that we have had sufficient thought about what training and support those individuals need to fulfil those roles. I particularly see the work on integration joint boards as challenging, because it is a very different environment. An integration joint board is balanced non-executive board members and local authority councillors. You will be very aware that local authority councillors have a very different background experience and expectation of a structure in a process than a non-executive board member who might be a young person who signed up to do eight hours a week to provide some scrutiny of the board and ask difficult questions. Diversity, to answer your original question, would be a really, really good thing, but if we are going to land that and make it possible for non-executive board members to deliver what we are looking for, we would really need to stop and reflect on what we are asking of our non-execs directors and non-execs board members. Perhaps there are alternative ways to achieve that diversity, so having panels and advisory boards and so on might be a different way to make it more possible for those individuals to step forward. If we want individuals from all sorts of different backgrounds to participate, we need to make it possible for them to participate. At the moment, I would suggest being a non-executive board member is a pretty scary concept to take on and not a difficult job. I appreciate what you are saying, Dr Foster. I imagine that it would be a pretty scary concept becoming a non-executive board member if you do not have that background, particularly in the medical sector. However, you could apply the same logic to becoming a politician. Obviously, this Parliament is legislated for gender representation on public boards, so, perhaps in the past, people could have argued that becoming a politician might have been too scary for women. We have moved on, I suppose, the argument on, but, going back to that argument in terms of training and support, I suppose that what was coming through from all of your answers there and Linda Dunion said that no one can do it in eight hours a week. Christine Lister said that in the last three to four years, you have got to grips with the process more so, and you yourself, Dr Foster, said that getting to grips with this complex role could put some people off. As opposed to giving adequate training, do we then need to look at the current system as it is and make it more accessible for everybody? Look at how we use plain English, for example, in board meetings and how we make the language used by the NHS much more accessible for all groups in society. Never mind looking at gender or disability, for example. Use the language to engage more people in that process itself so that it does not take more than eight hours a week, for example, so that it is a more accessible system. Is there something that we need to look at there in terms of making the board membership role more accessible to everybody? I would absolutely agree that it is something that we have talked a lot about in NHS Tayside and have made a lot of changes, in fact, since John Connell, our new-ish chair, came in, in particular. You have just said that in terms of the density of the language that is used, the number of technical terms that are used, that is a real barrier. I think that the NHS traditionally has been very poor at talking in plain English. I think that there has not been a culture of transparency. There is a bit of a vicious circle there, if you like. That therefore does not always deliberately but inadvertently excludes. That is an important issue, but the way in which we do our business is not helpful. For example, last week I was in a meeting for five hours. Who can you ask to do that during the week, during the day, as a formal board? Yes, there needs to be a high degree of formality around a lot of the issues that we are discussing. We are receiving reports on clinical care and governance and finance. You do need formality to deal with those issues effectively, but, having said that, if you think about the different circumstances that we have, it is really no surprise that it is people who are retired or semi-retired or have very flexible employers who are able to sit on a board and fulfil all the functions that are expected of a non-exec, because it is not just about board or committee meetings. The whole process of getting a public appointment, I went through answering a press and journal advert. If you go on the public appointments website for board members in Scotland, it is very competency-based. It is a very technical way of applying for a role. I would struggle doing that. I really would. I have looked at them recently because I am coming to the end of the term that I am in. It is a real struggle to do that. If you want an ordinary young person to do that, you are really looking for an extraordinary young person to even get through that part of the process. From my point, I would absolutely agree with you. We need to change. If we want diversity, we just need to move with the times. I would be absolutely up for that. We need to make sure that our boards are speaking in plain English. Often, as a non-exec board member, my role is to say, hang on a minute, can we just explain what that means? We need to make sure that we are speaking in a language that is entirely intelligible. We are not descended into professional gobbledy cook. That is really important. Our meetings tend to be very formal. It inhibits some of the structure and it limits people to asking the questions that they want to ask. Again, we can be much more flexible about the way that we meet. We can have less formal meetings. We have board seminars, for example, in between meetings that are not taking place in public, which allows people to be more comfortable at asking questions and all sorts of different settings. We need to be sensible at the length of meetings that we have. It is no longer acceptable to expect people to sit for three hours in a meeting because that is the way that we have always done it. We need to take regular breaks and be accommodating. There are all sorts of different things that boards can do to be more accommodating. We need to absolutely do that. I go back to stressing that we need to think about what we are asking people to do as well. Your analogy is absolutely right. We can elect politicians at any age and adult, but we do not ask them to be the First Minister straight off. We need to make sure that we are sensible in what we are asking people and that we use them for what they are actually asked to do, which is holding us to account. The bigger and wider range of people we can get to do that, the better. The more we can encourage them to ask those questions, the better system that we will have in the end. What you are explaining in a number of the population would actually be put off quite frightened to go ahead, but the one that I wanted to pick up on was the fact that it affects people's benefits. Obviously, people who are working are on benefits also, so it is not just people who are not working. That could be near enough half the population that are being stopped. It is something that we really need to look at in the committee. I did not realise that, but I thank you so much for raising that point. My big worry is that half the population is being excluded, one, because they are on benefits, and two, because it seems so formal that people are frightened off, even once they get there. I came to that rule, so that is why I am aware of it. My jobseekers allowance was stopped when I got my—luckily, I had a small widows pension. That enabled me to continue, but other people would not have been so lucky. Thank you, convener, for coming along to talk to us this morning. I am particularly taken by what you said, Dr Foster, about form follows function, because it is important to understand what the purpose of the non-execs is. I can get all the points about yet it is difficult and it is scary, but at the end of the day, you are asking people to hold an organisation account that is spending £13 billion of taxpayers' money in response to the lives and wellbeing of hundreds of thousands of people. If it was not a big scary job, there would be something wrong. I suppose that the clarity on what the role is is that job description written down somewhere, and is what is written down what you think it should be, or should it be something different? The job description is, when you apply for the public appointment, it is set out. I cannot remember what it is called, it is a role description. It is set out, but without having spoken to somebody who is an existing non-exec, you do not really know exactly what that means. I was previously on the board of what was in the care commission and I would say that that probably was a closer fit to the description and the expectation. I think that the territorial boards, I have never spoken to a non-exec that would not say the same as we are sitting here saying today. I think that it is the expectation that is the issue. The description in terms of the role of the board member concentrates on strictly the governance role. In some respects, that is the most important part of your role. You are a board member. As I said before, it is something that I have really had to work very hard with IJB members on to get them to appreciate that it is also abhorred and with that goes certain responsibilities, if it is signed to code of conduct. There is a lot flows from that and that would be true to anybody coming on a board. It is the additional expectations that I think is where the lack of information is. It is a real opportunity to do other things. I am a member of the community planning partnership board in person, Ken Ross, obviously the IJB. I have done other things as a board member, but it does not fit into the time. A practical suggestion that I have certainly made in the past within our board is that we should look to create opportunities for people to buddy or shadow existing non-execs, particularly when we know that their vacancy is going to come up. Likewise, when new people are appointed, I think that there could be a system whereby their remuneration kicks in before they come on the board so that they would be able to come in for a pre-induction, if you like. Marrying up with not just non-exec board members but with some of the executives to get a sense of the language, the culture, the issues before they sit down at a board table. That would help everybody, not just people who are currently underrepresented. I think that one of the other big issues, and you mentioned language and accessibility of language, is just the amount of reading that you have to do. I live in rural Murray, so if I come down to Edinburgh, I have to come down the day before. I have a big pile of stuff to read, which I can do sat at home at the kitchen table, but if I come down to Edinburgh, as I did on Sunday because there was a masterclass yesterday for board members and then this meeting today, I've still got to go back. I've got a board meeting on Thursday. I've got a pile of stuff that's literally that thick that arrived on Friday to my house that I'm going to read through. You do get better at that, but there's no doubt about it. Those papers could be so much better and concise. You just have to look at, for instance, Audit Scotland reports, which are really clear, concise paperwork. It can be done and you challenge it and it gets a wee bit better for a while and then it just creeps up again. That part of it is a nightmare, really, and it could be so much better. Just specifically on that point, and it ties on to something else, round about if the job is to hold the execs to account, then how effective are non-execs at that? As I've supplemented to that, do you think that the reason the papers are so big and complicated in the language is so difficult is to, in some ways, perhaps make it more difficult for non-execs to account? There, I say it deliberately. I wouldn't say that it's done deliberately. I think that the landscape is so complicated that when you come to talk about something, there's so much background to it. It's all done in appendices. For executive colleagues, that's their bread and butter, that's what they live and breathe, so it's an attempt to put all the information on the table in my experience. I don't live and breathe it as executive colleagues do, so I don't think that's the case at all, but there's no doubt about it. It could be clearer, and it could come in bits before the meeting. It doesn't have to come in the week before. We have quite a good way of doing things in NHS Gramp Hoods. We have seminars, but I would say that those are informal briefings almost, where you have that opportunity to all work together. That was a good thing when it started seven years ago, when I started doing it, with the integration landscape and everything changing. There's now so much more with regional development integration that those seminars are taken up with other things, almost as well as the board business itself, so it just becomes very difficult to do within the time that you've got to do it. Up to that question, how effective do you think non-execs are at holding execs to account? Personally, I hold the chief executive to account, but I think that we are quite good at doing that. I could perhaps come in on the question of the volume of papers. This is something that, in Tayside, we've done a lot of work on over the last few years, and we have vastly reduced the number of papers because we were getting hundreds and hundreds of pages, and you couldn't possibly read them. A lot of work was done to revise the committee structure, to delegate responsibility to the committees, but at each board meeting we received a chairs assurance report from each of the standing committees, and that brings out any of the issues that need to come to the board's attention. The board has an opportunity to request further information, or if the board needs to actually take a decision, that will come by that route. We've also streamlined the reporting around performance, so there's been a lot of work done to try and change the systems to reduce that side of the workload for the non-execs. It enables you to be more effective. I think that there's been also a lot of work done around listening to the non-execs and what we need in order to fulfil our role more effectively, and that's covered things like plain English that we talked about before. If I could confess that, as an executive director, I dread those piles of papers, just the same as my colleagues do. They're equally daunting and difficult to get through, and often it's to be small hours by the time that you've read through all the papers for the next meeting, and they are frequent, and we have a lot of those meetings. The difficulty that we face is that there is a culture within the NHS that feels that in order to deliver governance, in order to deliver accountability and in order to be open, all those papers need to be produced and entered into the public record. It would be refreshing to get some guidance or help to say that you don't need to produce that many papers for every board meeting to be a public body and to be held to account, and that would be quite helpful. In our own board, we've reduced the number of papers, as it has been described, quite considerably in recent times, largely by expediency more than anything, because we simply don't have the number of people to produce that paper any more, and we have a smaller exec team, so we can't manage it. I think that it is important that we try to reduce those papers. Equally, if you produce something that's that thick, you're absolutely right that you're burying the facts in a mountain of paper. If you can make the key points in a couple of pages of A4, that would be absolutely fine, but I think that, as officials within the NHS, we'd need to be clear that that was good enough and that we weren't failing the public by not being sufficiently open and not producing sufficient information. However, if that balance was there, there could actually be a revolution in some of those board papers. The other thing that I think is important to say is to check that everyone is familiar with the structure of boards, because NHS boards are structured differently to other public organisations in that the chief executive is the principal accountable officer and is appointed directly by the cabinet secretary. The executive directors like myself are also appointed directly by the cabinet secretary and the non-execs are also appointed, so the board is comprised of a group of individuals who share responsibility for running that large public organisation. You're right that it's a huge amount of public money that we're in control of. In our case, it's £550 million. That's quite a lot for me to take on, and I do feel personally accountable for that spend and for not overspending that money. We absolutely follow that. That's different to the other agencies that we deal with. In a local authority, for example, the councillors effectively are in control and the staff work for the councillors, and that's a different model to the way that the NHS currently runs. Again, other public bodies run in a different way, so it's important to be careful that we're familiar with the structure and how it works and thinking about how that function is delivered. Excellent. I'd like to move on to questions around involving staff and the public and start with Alison Johnstone. Thank you, convener, and good morning. I think that your evidence so far has helped us to understand how challenging a role is and what a responsibility you have, even in terms of getting your head round the facts and figures. There's a lot of information that you have to scrutinise, but during last week's session, some of the witnesses felt that the lack of public trust sometimes in boards is because of a tendency to inform and perhaps consult in a way that sometimes appears less than meaningful, so I'd just like to get your views on whether or not the correct mechanisms are in place to enable the public staff and the third sector to get involved in the NHS decision-making on an on-going basis. If you think that public engagement is hardwired into the process in the way that I think we'd all feel it should be. I think that public engagement is really important. We take it very seriously. We work hard to get public engagement. That is in a whole different range of ways. Starting with communications and trying to keep the public informed through our relationship with the media and the information that we send out, we probably get down to things such as the fact that we have our meetings in public, we publish all our minutes and so on. We then have active involvement of members of the public or patient representatives in various different groups, in most of our planning groups. In our clinical governance committee, for example, you'll find a member of the public watching what we're doing and asking challenging questions again, so that really helps us to focus on the fact that we're actually serving our public and remembering what we're about. We also have a number of different public panels that we ask questions of, and that helps us to be informed. I forgot the name of the website, but there's a public website where individuals can ask questions of the NHS, and we're very energetic in following that and responding very quickly. If you post a question on that website or a concern about care that you've received in our health board, you'll have a care opinion. That's one. Thank you very much. We use care opinion a lot. If a member of the public posts something on care opinion, I'd be surprised if he doesn't get a response within 48 hours, possibly a lot quicker. Often, on the same day, you'll get someone saying, really sorry that you've had that challenge. Can we direct you to how you can access that service? That's been very successful for us, and it's using technology, so that's helped enormously. We need to make sure that we are responding to public opinion in a realistic way, because we get the people that we get. We will get people who have a particular specialist interest on a committee. Those individuals, again, are very hard-working, very committed, but they tend to stay with us for quite a long time, so we don't get a lot of turnover. Reflecting on those individuals, it's probably the case that we don't get a real cross-section of our local society, and that would be something that would be better. The panels are obviously much better at that, but you don't necessarily get that. It's something that we're really committed to, and we want to try to get that public engagement, and it's important to us. I think that that is important. We're also embracing some of the new ways of doing things, social media, Facebook and Twitter. I think that, certainly over the winter period, NHS Grampian, we had a very successful saying that this is how many people have fallen over, the pavements are slippy, that sort of being aware, go to your pharmacist. That was really successful. The Twitter was shared and shared again, we've got loads of Facebook lights. That's a really good way of doing it. I think that the other thing is, don't forget, it's an honest conversation that we need to be having with the public. It's not just when it's winter, and it's not just when we've got good news. The changing landscape means that we should really be engaging with them all the time. Part of the issue is that we are driven by media interests. We're almost a bit fearful about having that honest conversation, about saying what we can do and what we can't do, and why. I think that that is a real challenge going forward now for us. It has to be an honest conversation, absolutely. I think that I would draw distinction between information giving and communication, where I think that the NHS actually does quite a good job and some of the techniques that we've just heard about are effective in that. It's certainly easier to tell the NHS what you think, if you remember of the public, than it used to be. If we're talking about genuine engagement, we need to look further down. We need to be looking at the localities within the IJB structure, certainly under the community planning partnership. There are local action partnerships, and they are working very closely with the IJB localities. The strategic commissioning plan for the IJB was a huge public engagement exercise run by the local third sector interface, but with funding from the public sector. I see that as starting down here with individuals, neighbourhoods, communities and the involvement, not just of those who are explicitly about health, but looking at community development trusts, looking at those who are getting involved in issues that may lead to social prescribing, for example walking groups or whatever. Looking at what's happening at a community level and feeding that up through the system so that the boards, the NHS boards, have actually got a very robust, I hate that word, everyone uses it now, a very robust sounding board that really tells them what's happening on the ground. We had a model in Aberfeldy, which I think demonstrates something that, to me, is absolutely key to sharing the difficult information that we've just been talking about, which is giving communities ownership of the data, giving communities ownership of the complexity of the issues. If people are actually trusted with the information that we have at our disposal, they can really help, it can be a real joint effort to actually arrive at solutions, which people will support because they absolutely understand it. I remember sitting in a public meeting in Aberfeldy and the woman next to me, who I didn't know, turned round and she said, you do get awful wedded to bricks and mortar, don't you? My daughter was born in the hospital, I was born in the hospital, but actually it's got to go. Because she'd been part of the process, she concluded that. I think that we need to see more of that happening. I think that Michael The Question that I have has been covered by the answer to Alison Johnston's question. Thank you convener and good morning to the panel. I wanted to develop further Alison Johnston's point there. A piece of research that the Scottish Parliament's independent information centre provided us brought some results out, which I think surprised us all. It was actually suggesting that the majority of members of NHS health boards believed that they're not always honest with the public about their decisions. The survey had a response from half of all members. Total 59 per cent said that they are mostly, sometimes, hardly ever transparent on this. How do you think that can be improved in the future? I think that's where, just like we've heard, there is that disconnect sometimes between decisions being taken by boards and the public not feeling they're part of that decision making process. I didn't ask about culture change. If I could give you another example, which you may well be aware of, it was in our redesign of in-patient adult mental health and learning disability services in Tayside. About two and a half years ago or more, there had been the beginnings of a consultation process, but then it came to the board to ask us to take a decision. Myself and a councillor member of the board were very unhappy at being asked to do this because we felt that the process had been inadequate. We knew that would delay the decision. We knew that there was pressure on us, but we felt that the public had not actually had a chance to be involved meaningfully in the process, that people who used the service, the carers, the staff within the services, had not actually had the opportunity to be properly engaged in informing the decision, and as it turned out, helping with option appraisals and arriving at a preferred option. The process was pushed back. As I say, it wasn't a universally popular decision, but it was the right decision. That's where I think that non-execs actually need to be quite firm, draw on their own lived experience and professional experiences and change a decision that would otherwise have been made. If we're serious about being honest with the public, we need to recognise that that takes a certain skill set, investment and a certain amount of time, but it doesn't need to be an inordinate amount of time. The honest conversation just needed to start, because we're quite good at the good news or saying it in so many words that nobody else understands it. Clear, concise language, tell it like it is and just do it all the time because life's like that. The NHS is no different to anywhere else. It's challenging sometimes, challenging quite a lot. Talk about money, talk about how much it costs if you don't turn up to your GP surgery or your outpatient's appointment. I think that that's really important. We don't do that, we do the good news, we don't do it all together. When a bit of bad news or not so good news comes out, it's a big deal. Life is like that. The whole thing around language about telling it like it is, is something that we should be doing in the board meetings. That comes through the papers as well. I think that what you're talking about is public confidence in the system, really, isn't it? That's the issue that's at the heart of this. I do think that it's very challenging in the world that we live in to maintain public confidence in the service, because by the very nature of the world that we live in, people challenge everything that goes wrong. They challenge targets, they challenge things that they see that are not right, and we're not actually that good at celebrating success. We're in the 70th anniversary of the national health service this year, we started it in 1948. The national health service has never been better. There's absolutely no doubt about that. I challenge anyone to prove anything otherwise, it's never been better. It does spectacular things. Every day we're doing new interventions that were not possible before, we're saving lives, and it is free at point of delivery to everyone. It's the envy of the world, it really is. There's nowhere else that can do what we do in Scotland in terms of the national health service. We should be proud of it, and yet it belongs to us, and we want it to be great, and we spend an awful lot of time trying to solve little problems around the edges. It sounds like it's constantly in crisis, and there are challenges there. We're partly guilty of believing our own hype, in that we've started, even our non-execute board members believe, that we're constantly rolling from one crisis to the next. If you stop and think objectively about the quality of the service that we're delivering, about the fact that we've continued to sustain that delivery, despite all the financial pressures that we've faced in recent years on austerity and all the other things that we've had to do, you compare that with—in the past, we used to have NHS uplifts every year of 7, 8, 9 per cent financial uplift for the last decade. We've run almost flat cash or 1 per cent increases, because that's the way public finances are now, and it's the same for everyone in the public service, it's the same for government. We've continued to sustain a national health service that's free for everyone. We're not turning people away, we're delivering fantastic new services. I was just listening to the television this morning, watching the television this morning, and they were talking about 6,000 premature babies who are alive every year who wouldn't be alive if it wasn't for the national health service. We couldn't do any of that before we started out in 1948, but we do really struggle. If you actually go back to—I did a presentation at a conference last year—to do that, I went back to look at some of the original launch documents from the national health service. Within a few months of that launching, the national health service in 1948, the minister for health was already saying, we're going to struggle with this service because expectations are rising, technology is moving ahead and the population is getting bigger. Here we are 70 years later and we're still facing the same challenges, but we've done it. We continue to deliver this fantastic national health service, and sometimes we forget to celebrate that and forget to remember that it's a really good thing. Yes, all around the edges there are challenges and we need to get better and we need to work on that and it's tough and the money's tight, but sometimes we get wrapped up in it being constantly in crisis. If we say that, the public believes that and then they lose confidence in the service, and that's the challenge. There's a big thing about how we maintain public confidence, and when we say that we're not being honest with the public, that's part of the root of it. We're dealing with all those challenges and we're trying to battle against the idea that it's all in crisis. We're saying, no, no, it's all right, but we know that it's really difficult. I think that's where you get that tension between, are we being really honest with our public and telling them about what the challenge is at? Just a very brief supplementary to that. Part of the research pointed towards decision making which you take, they're not being able to feed in from what the Scottish Government or UK Government want to see. I was interested to find out from what we heard, do you feel there's political interference then around your decision making processes from central government? Do you have any examples of that where you felt that actually being able to take a decision and take the public with you is something you can't do because central government have either made it known that they would not like to see that happen. I'm not aware of any decisions. I mean, I know there were quite a lot of comments in the survey results about the fact that clearly, you know, the health boards have to meet Scottish Government, set targets and be accountable to government. I'm not aware of a specific instance in my time on the board where government has lent on NHS Tayside to make a decision that we didn't want to make or to not take a decision that we did want to take. I wish I could say similar. I think the timing of elections is quite often stymies discussion along that period of what's called perda. I think you can have a momentum going and then it all stops and then it all has to start again and it's a giant tanker. So if you're trying to turn it around and do things differently and change that whole cycle of local and then national elections, and boy, we've had a few of those recently, haven't we? It doesn't stop the discussion but it definitely holds things back because you can have a trajectory and you can have the public engaged, you can have your local politicians engaged, you can have your national politicians engaged and then you have to stop. You know, and then it takes time to get going again. That has been a real issue, I think, in fostering change, certainly within a rural community where we're wanting to do and change things differently. On the issue of public confidence that you just described, Graham Foster, and with public confidence or building public confidence, you need to manage expectations of service adequately. I can only really speak to NHS Lothian as an Edinburgh MSP, but I mean, I'm lost count now of the number of constituents who have come in to see me because of protracted waiting time delays where they have been led to believe that they were in one bracket of waiting times, whether that's a 12-week treatment guarantee or any sort of notional expectation which has been then blown out of the water subsequently, maybe halfway through that period by an indication they're going to have to wait significantly months longer than that. Can you give us an idea of how each of your boards deals with expectation around waiting times, particularly when you've got statutory targets to meet? As you say, it is about public confidence and the whole waiting times issue, I think, is one of the areas where we face challenges and expectations are very high. I think that we actually generate a lot of those expectations ourselves and it's perhaps because we are not realistic about what we can do. Related to the previous question, which I didn't answer, but the previous question was about challenges that we face and perhaps times when we're not able to make our own decisions, ultimately the boards are accountable for our own decisions and we're free to make those decisions, but we do face continual pressure to do ever more every year. One example of that is new technologies and new drugs and it is very difficult to explain to the public that the very latest new cancer treatment that perhaps costs hundreds of thousands of pounds is not as important as making sure that we clear that waiting list or we give everyone the core life-saving treatment that they need. We find it very difficult when we are challenged with what about this new technology that is being done in America or in England? Why can't we do it in Scotland? We must do it now and these things are expensive and difficult. It is actually quite hard to set our priorities locally because all of those things do come in from left field. There's a lot of discussion going on, particularly around the medical directors in Scotland, to try and bring some order to that and try and reduce those new expectations coming in and saying, stop, can we think about the cost of these new things that are constantly being added to the expectation? I could probably talk for a whole hour about different examples of decisions that are made out with the control of boards that suddenly increase our costs and those are quite challenging, so we have to manage those. An infection control thing that we were asked to do recently was asked of us by an infection control nurse in a national agency following an inspection and for us that collectively would cost between £60,000 and £100,000 to implement and I could find no evidence space for it whatsoever and I could see no benefit to patients from it but a national expert had thought it would be a good idea if we changed the way we cleaned from this way to that way and that doesn't get any governance, it doesn't get any checks, there's no cost impact assessment of that. Someone in a national agency says, change the guidance, add this new level, raise the bar and we just have to dig into our coffers and find a cost so that's really challenging and those are the realities of what a health board faces every day and so I think there are questions to be asked about all the different agencies that produce rules, some of them are entirely valid, some of them are less so and do they actually stop and think about the cost to the public purse of those decisions that they're taking and the impact of those decisions but to come back specifically to your question which was about waiting times I think it's really really important that we don't lead patients into believing they're going to get something and then not deliver so we need to be very realistic about what we can deliver and we are very guilty of currently putting people into pathways which drive them down a line which says you need an operation it'll be done in 12 weeks there's no other alternative and actually very often those individuals have a lot of other alternatives and we know if you ask doctors they wouldn't have that operation in the first place so they'd certainly delay it because they'd follow another pathway you take the example with someone we were talking about knee operations before we came in and you take the example of someone who's got a painful knee and they go to see their GP with a painful knee and the GP says I'll send you to an orthopedic surgeon the minute they see that orthopedic surgeon and the orthopedic surgeon says you could have a knee replacement the clock starts ticking you're on the clock you have to get your knee replacement and what we don't do is say you could you would benefit from a knee replacement but actually you will also benefit physiotherapy and that could keep you without any replacement for another four or five years possibly a decade you might benefit from this drug that might help you might choose to just keep what you're doing and change your behaviour what's important to you and we're really bad at stopping and saying what's actually important to you we're because we've got all these waiting times and things we we we we we slavishly follow the pathway and as soon as you're potentially a candidate for a knee replacement the clock's ticking and we shove you through that tube and we give you a knee replacement and you go home and you sometimes see people are sort of like well I went to the doctor with a sore knee and I have my knee replaced you know how did that happen and but that's because we're so obsessed with with that and so I think we need to be much more honest with our public about what we can do and what the alternatives are and if we're going to say to someone you need a replacement yes we should absolutely do it in good time but we also need to be a bit more sensible about when we put people into those pathways and give them the alternatives and make sure it's what's right for them at the time because I'm quite convinced we're doing a lot of things just now that are not actually in the best interest of the patients we're doing them because we think we ought to. It's funny that you said that about knee replacements I think one of the things I learned most recently about knees is that and we were talking about obesity strategies that actually if you if you lose one kilo in weight it actually for your knee it's eight kilos because of the way a knee works because of the mechanism which is fantastic you know one kilo is really achievable so if you've got a sore knee go home and lose a kilo first you know it's infinitely preferable to to waiting for weeks and weeks and then going into hospital so and I just thought I'd throw that in because that was fascinating for me because eight kilos looks unachievable one kilo I'm quite happy I'll go for that anyway going back to your question I think it's a real challenge that the waiting times in NHS Grampian we've chosen to clinically prioritise people so those people who need treatment will be seen quickly and first before anybody else those waiting times are published on our website but they're only published if you're in that pathway so if you're a member of the general public you wouldn't even be able to find that on our website so I'm back to what I'm talking about the honest conversation about what expectations are of the NHS and what it can provide for you when your knee gets sore so I think that that would be my point there I think you're also talking about this realistic medicine that we've all read about we've talked about in boards we've we're in but actually we're still shying away from having that public conversation about what realistic medicine actually means to you before you go to your GP surgery about what your expectations should be okay can I ask just I think we've touched on it to from a couple of different directions around seminars and around external advice is there a sense before I ask colleagues to ask directly about ijb's is there a sense that the development of ijb's and of a regional level of health health provision has reduced the strategic role of boards to board members feel that their strategic grip is less than it was say a couple of years ago so no and this is the kind of very front of mind at the moment I mean NHS Tayside has been developing a number of strategies surgical services and what have you primary care under the umbrella of our integrated clinical strategy and that's a really important part of the landscape for ijb's not just for ijb's but for community planning partnerships as well I think it's about people find sorry the organisations finding their place in the new environment and but given the responsibilities of certainly the health board and I can only speak for for Tayside in this regard I think it's actually really important that the health boards know what they are about in terms of their own strategy and then how that sits alongside regional strategies but also I would go back to what I said earlier on about ensuring that there is also a bottom-up approach and that the strategy is is informed by what's happening across the piece because if integration doesn't work if communities and individuals are not more knowledgeable and have more ownership of their own individual health if they don't have information and own the data, own the information about what's happening locally then that's to the detriment of the health board in determining its own strategies so I think it's about a new a new modus vivendi if you like but I don't see any diminution of the role of the health board in setting strategy Thank you very much, Brian Whittle You know just maybe moving on from the community morning panel obviously with the commencement of the IGBs and moving towards a sort of regional planning you'll there must be some kind of adaptation you're going to having to undertake to to take in those roles of the IGBs and I wonder if you're getting room to breathe within that environment you're getting room to adapt have you got the tools to adapt into that the boards into that role? Very busy world just now yeah so I yes you're right it's very busy just now it's a congested playing field if we use that analogy there's a lot of things going on and it is it's making life very difficult I think you'll actually find that boards are probably smaller now than they've been they've less staff of less resource and we've got a bigger more complicated structure that we're trying to set up and make work I agree with the previous answer in terms of strategy I think boards have strong strategic direction making responsibility and they're continuing to do that my own board we have a very clear healthcare strategy and a very clear health improvement strategy and we want to deliver those things we understand the principles of why regional planning is important but at the moment it's very much about establishing structures and processes and needs assessments and planning and so on and it's not actually doing the critical joining up of regional services that we probably need it to do and we've got a bit distracted from that because we're trying to set up this new structure and in the integration world as a board we're absolutely committed to integration if you go back to the original integration principles that are set out in the act that's what we want to deliver but again we're finding that really really challenging because we've got sidetracked into a discussion about structures and processes and who works for the iGB and who doesn't and what's their role and what's their responsibility and who line manages who and operational delivery issues and so on and actually we just want to get on with doing something at the front line for patients and that's really tricky because we've got sidetracked into all these different organisations and governance arrangements and so on at the moment and until those settle and settle down then it's a real it's a real struggle to make those things land and the core of the question is about strategic planning and I go back to the fact that my role is strategic planning and integration and the iGBs are meant to be about strategic planning and we're almost wondering when are we going to actually start doing strategic planning in the iGBs because we've spent so much time on governance and structures that we've never actually got round to that so at the moment I would say boards are still doing the strategic planning and we're waiting. I'm also the chair of Murray iGB, where I think we have a very different scenario. We've found, don't forget, that integration is quite new as well, it's not even two years old so we've been given a lot to do. Some of it is, from a Murray's perspective, we've been given things to deal with at the health, neither the health board nor the local authority has wanted to do up until that point so it doesn't come with any good news on the horizon for want of a better word but the opportunity is great. Murray was one of the first places to have a community health and social care partnership before an iGB, so we did have people working together in the same building, they were all sitting in different offices, now they're all in the same office, you know we have health people who are managed by local authority employees and vice versa. Murray is a small place, I think that's probably made it easier because it's all the same people at the end of the day, you know it's quite a small structured environment. I think the strategic planning side we've been able to do, I think we're between Highland and Grampian, we are part of Grampian but we're on that A96 corridor so strategically Murray is in a good place to be doing that planning so we are doing that. The regional side definitely not driven locally at the moment, that's been driven nationally and then through the health board structure I think from an iGB and a local authority perspective less input. Is there a danger of duplication of work through from the iGB and the board and how do we avoid that? From my perspective but I don't know about anybody else. I don't recognise that, I don't think there is a danger of duplicating, well there might be a danger but I don't see it in practice. I was up at Pitlockery with members of the iGB on Friday and we were extremely encouraged because you know there is a layer at which you would say integration is struggling and that's getting that kind of management structure in place but what's happening on the ground is people are just getting their sleeves rolled up and getting on with it and doing some fabulous work. So it's really important that we on the board of the iGB can get so wound up in thinking always about the finance, the heavy papers that we have in front of us but it's actually good sometimes just to be reminded that people have embraced integration and are getting on and making it happen and we were sitting with people from health, people from the council, people from third sector community organisations so I'm very encouraged by what's happening on the ground. We just need to crack the structures and get to integrated budgets because I think that's key to making it happen properly. A lot of that. The question was is there a danger of duplication? My initial answer would be absolutely not because it's the same people doing the work actually you know the iGB is a new planning committee effectively it's not a huge great new organisation that's going to take over a lot of the work so it's always the same people and therefore there shouldn't be a danger of duplication however I am just minded that the topic of the conversation this morning is corporate governance and the bit where there is duplication is we you know we were talking earlier about those piles of papers and big big meetings and all that administrative burden and there's definitely a duplication of that now because we've a lot more meetings and you won't see the size of board meetings decreasing by the corresponding number of new papers that you'll see at iGB meetings and for a small board like 4th valley it's certainly a struggle for our non-execs and execs to support the sheer number of meetings that we've got because we've got a number of iGBs to support with a number of community planning partnerships to support and a board where previously we just had the one structure so there's a lot of duplication of the admin and the governance but not of the actual work. A supplementary to that obviously Audit Scotland did a report in 2015 talking about governance accountability and I'm pleased to say that here you say that basically you feel that you know the integrated joint boards etc are moving in the right direction do you think excuse me for sniffing do you think that the governance has improved you know since you know the integration boards were actually introduced obviously there's lots of layers as you say councillors etc being their regional boards as well because some people seem to feel that local boards and accountability in regional boards they're a bit kind of blurred I just wondered what you would feel about that you know is it much easier now possibly not but it will it be much easier is there a timescale for that can I say something if you look at the legislation and the role of an integration joint board and that of an NHS board it's really very clear what the governance and the accountability structure is there is quite a lot of talk about it being unclear and my personal view is a lot of people don't like it so actually it's easy for them to say that's not very clear to me as opposed to I don't like it and that is from both the local authority and the NHS boards you know because it's a lot it's a lot a loss of control for want of really it's human nature so I think they throw these things in the red herrings I think if you really look at the structure the accountability pathways these are legislated bodies you know the professional people they are doing a really really good job the chief officers are fantastic at what they do and we have three very good chief officers in fact one of them is leaving Aberdeen actually to come to Edinburgh shortly under the NHS Grampian within the integration joint boards so I think a lot of it is it's just in the wind it's it's not liked so we'll throw in the thing about governance that's my own personal view like cultural change it's needed within there's a definite cultural change that's needed and that goes across the regional planning environment as well you know that kind of power and control you know health would like it done that way local authorities like it done igb's actually of where you actually want that done because actually it's down to the communities where people want to go for their healthcare as witnesses we haven't met beforehand we don't actually know each other so I had no idea christine was going to say that but I just want to say I absolutely agree I think if you go back to the original legislation and you go back to the integration principles it's absolutely clear what we're trying to achieve and it's absolutely clear how we're meant to go about it I think what you've got is a complex environment in Scotland you've got 32 local authorities 31 igb's 14 health boards territorial boards and everyone's trying to kind of twist it to the way they want it to be and that's caused a lot of difficulty because people are looking for local solutions and some people have one vision and others have another and if one is to be critical I don't think the guidance has been that clear in terms of sticking to the original act and saying this is what we expect and that's to allow people a bit of room to to move and a bit and to develop and you know have different solutions to the same problems but if we just go on with doing what the act told us to do in the first place I think christine's absolutely right it's very clear what we're meant to be doing thank you Emma Harper did you still have a question in this area it's similar to what Sandra White has asked but i'm really encouraged to hear what you're saying about targets time frames Sir Harry Burns mentioned targets and time frames and looking at we shouldn't just be looking at 12 weeks 16 weeks whatever it is about what matters to the person and realistic medicine and maybe you need pulmonary rehab before you go for a knee replacement or a weight loss package for that one kilo so i'm really encouraged to hear about that and the fact that the ijb's are about integrating in the community so i'm just wondering if there are some difficulties in scrutinising when regional boards might deliver cancer care for instance nhs of recent galloway send patients to greater Glasgow nhs Lothian and Dearshire and Arran for urology and cancer services so is it difficult to scrutinise when things are measured that are regional wide rather than just simply board wide difficult to scrutinise it does introduce challenges i think in scotland we're we're guilty of trying to compare 14 health boards and assume we tend to assume all 14 health boards are exactly the same and actually we can compare them by just creating a league table and say who's best and who's worst and often the boards are very very different and you know that the challenges that highland has and the pathway that they have into care is quite different to the pathway that Orkney has which is different to Dumfries and Galloway which is different to Glasgow and has everyone very close and and that leads to challenges so actually i think in some ways the regions will help because as an exact director i quite often get involved in trying to address issues and challenges but people have been delayed in their treatment or i quite often get approached by other boards who are looking after our patients saying here's a list of all the patients you've sent us in the last six months can you just review them and make sure that you still need them seen and i'm thinking hang on a minute they've been on a waiting list you know for six months i can't stop now and and send them somewhere else you just have to see them don't be ridiculous but we move people around and we do these things between boards which are not helpful so so actual regions should so actually regions should get us away from that and get more towards the idea of we're looking after our patients and it doesn't actually matter if they're on a waiting list in Glasgow or a waiting list in fourth valley or a waiting list in Lanarkshire and it's not a competition it's about making sure that patient gets the service they need as quickly as they possibly can and at the moment the service would tend you know there's no there's no gain to Glasgow for treating my patients quickly because it's my waiting list not their waiting list you know and and it's unhealthy that competition and actually regions might help us to do better by the patients ultimately so that's the big hope of doing it in a more joined up way okay into our final area of questioning thank you convener i'm interested in having your views on sharing and learning from other boards as you may know we had some interesting feedback from our survey results on that could you tell the committee how much what some good examples of where you've learned from other boards maybe adjacent to our other parts of Scotland requires a bit of thought whilst my colleagues are thinking i'll just say that one one example is is that i think two of two of the three of us were at a collective event yesterday so all of the board execs and non execs were together our health improvement quality improvement event yesterday where we shared good practice and and then had we finished off with individual sessions in boards where we set action plans for what we would do locally but three quarters of the day was a collective thing where we networked we talked we listened to experts and we thought about how we could do things and we looked at what other boards have done so we had presentations for example from NHS Lothian and what they've done about quality improvement and their quality improvement academy so we've drawn lessons from that and we're going to go back to our board and think about that so that in itself was a good example that was taken place just just yesterday i think probably the sharing and learning is much more something that executive colleagues do than non executives i think it's not that non executives can't learn and share amongst themselves they certainly can but i think it's a different conversation that we would have around you know challenge scrutiny supporting each other through especially when you first started in the role so i think definitely we as a board i know of sharing and learning but it's come through executive colleagues medical directors nursing directors who are all working together nationally and then coming back to the board in that way i would agree with with christine that i think it's more ad hoc for non execs i would also say just christine and graham have both mentioned you know the national events and opportunities for networking for me that's just a step too far you know it if you're doing already spending some time of each day on board business whether it'd be the iJB or NHS Tayside actually taking a whole day out to do a national event i find them valuable when i've been at them but i just can't prioritise them so i think you know there is there is merit but it's difficult as i hinted at the our survey responses expressed some concerns that end-us-s is quite poor at sharing knowledge and learnings maybe a question for graham is there any particular barriers to sharing and learning from from other boards in your professional experience i think there's a will i think people would like to do it i think there are challenges around time i think we we by our very nature are quite internally focused as board members we're trying to deliver our own targets and our own performance so my priority will always be to make sure i'm at the board meeting in fourth valley not in Glasgow helping Glasgow improve their performance that said i don't think there's any lack of will i think we get great help when we ask for it if we if i take the example of our local A&E department where we've had some challenges around the four hour target we've had the academy of rural colleges have been in to help us we've had visitors from other boards we've looked around we've asked you know we've taken lots of advice on is there anything different we could do while we're getting something wrong is there another model and people have been very willing to help us and very willing to give up time to do that so i do think there's a willingness there but i think at the end of the day it's you know we we do tend to focus on 14 separate health boards in terms of the way our service is it's the way it's traditionally been run and the natural focus is to is to worry about our own challenges and our own budget not to not to necessarily spend a lot of time reaching out to others so that's probably the impression that leads to the answer that you're describing but given given time i think we could come up with lots and lots of great examples of how boards do learn from each other and we do share learning and staff move between boards and so on so it's not that we have you know 14 boards that don't speak to each other but we do have a system that is focused on 14 separate boards rather than one collective whole. My final point here is looking at the wider view in this healthcare improvement Scotland has as you know an excellent website i looked at the i hub recently at some good examples i'm interested in diabetes for example and i had some good examples of best practice is that something from your professional point of view that you find is a good development so this is obviously centrally held giving best practice for all boards is that something in your experience is extremely useful and something that could be developed yes it is very helpful and for example in diabetes we have diabetes networks as well and the networks are very useful as well and we that's a very good way of trying to share best practice and learn and develop i'm just slightly wary of your question because i think we we are guilty in Scotland of having spent the last decade moving our expertise from front line boards and international agencies so we've lots and lots of experts we've lots and lots of inspectors we've a very inspection focused environment we've lots of national agencies and we've created a system where the natural career progression if you're successful in your specialism is to leave your territorial board and leave the front line and become a national expert running a some sort of national advice service which is a you know great for an academic but actually it's a bit like the story we had in education a few years ago i'd you know quite like to see a system actually where we reverse that trend and there was greater reward for staying in your board and supporting front line services and a bit less focus on lots of national agencies because you know and so that would be my fear is that if i say actually yeah that's a great idea we lose yet more of our you know our skilled staff to go and sit in Edinburgh and Glasgow and send us advice no indeed well i'm absolutely committed to fourth valley and i'm staying there because i think it's the place to make a difference as a director of public health your basic answers look is your basic message for us is to look at best practice but to decentralise as much as possible yes yes i think we need the we need the staff in the boards the one thing boards are struggling for just now is staff actually we do not have the expert staff to deliver the demands that the service is facing so thank you it's very helpful thank you very much can i thank all of our witnesses for the evidence they've given this morning it's extremely helpful to us in our proceedings we will be hearing next from the cabinet secretary where we will be putting to her some of the points raised today as some as well as evidence from previous evidence sessions thank you very much we'll now suspend briefly to allow for a change of witnesses we will reconvene can i thank the next panel of witnesses for your patience and welcome to the committee to our second panel of the morning on NHS governance and welcome Shona Robison the cabinet secretary for health and sport accompanied by Dr Catherine Calderwood chief medical officer by Christine McLaughlin director of health finance and by Charlie Rogers director of health workforce and strategic change and can i invite the cabinet secretary to make an opening statement thanks convener grateful to the committee for the invitation to appear today and to welcome the work on governance that the committee is undertaking our nhs boards are responsible for providing the vision and strategic direction through which they deliver high quality safe and effective care to our communities effective governance is essential and ensuring that our health and care system functions efficiently and effectively the corporate governance of our nhs is underpinned by legislation and a range of guidance but we don't simply rely on these documents to ensure that governance is in place the governance of nhs Scotland is delivered by all those who serve on our health boards our boards are unique mix of non execs drawn through an appointment system regulated by the commissioner for ethical standards in public life's office executive directors who bring a range of skills and experience and stakeholder members who represent our partnership with local authorities workforce and the clinical community i recognise this unique mix of members and the strengths that it brings to the governance and assurance arrangements of our health and care system but i also recognise that we must continue to keep the makeup of boards under review to ensure that we are diverse as Scotland is diverse but also capable of delivering the vital governance functions that the nhs and our communities rely on with that in mind like we restate my commitment to delivering diversity to our boards we're committed to the Scottish government's gender balance 50 50 by 2020 pledge more than that we're also committed to moving away from the traditional competency based approach to making public appointments that can act as a barrier to people applying working with the commissioner for ethical standards we've now begun to appoint non executive members not just on their skills and experience but also on how their values match with those of the nhs paul gray recently chaired an appointment panel to deliver four new chairs for our health boards and at the heart of that process where our values of care and compassion dignity and respect openness honesty and responsibility and quality and teamwork over the coming months we'll begin work with all of our health boards to ensure a similar values based approach to the selection of their senior executive directors similarly in an evolving health and care system the processes and machinery of governance must also continue to change and evolve traditionally corporate governance is focused on direction control and the establishment of rules and procedures in our nhs we recognise it's not enough and that we must respond quickly and robustly to emerging issues and importantly ensure that open and constructive engagement exists for nhs Scotland this involves an open and transparent approach to governance including annual reviews are held in public board papers and minutes that are published audits both internal and external certificates of assurance submitted from boards to the director general of health and social care and the ladder of escalation providing a framework for intervention where there are concerns this is underpinned by regular dialogue between the Scottish government and nhs boards both on developing strategy and on emerging issues this regular dialogue includes meetings between myself and the chairs of nhs boards as well as regular meetings between chief execs and paul gray and his directors similarly senior officials also remain in close contact with the range of professional groups such as the Scottish partnership forum medical directors and finance directors i believe the mix of legislation and guidance that is in place along with the regular open and constructive dialogue we have with senior executive and non executive board members gives me sufficient assurance around the performance of nhs Scotland but i'm certainly not complacent and as we seek to improve services and drive up quality so must we develop and improve our corporate governance arrangements the introduction in 2015 of the integration of health and social care changed our landscape forever in 2016 the publication of the health and social care delivery plan set out a vision for government and local health and care services to deliver better patient care and better population health including greater regional cooperation we continue to seek new ways to improve and strengthen our governance of the nhs and we do this with our partners and in the light of best practice so we are building from a strong existing foundation of corporate governance in the nhs but our intention is to continue to develop our approach in recognition of the vital role played by good governance finally i welcome the work that the committee has undertaken around corporate governance and the survey that was commissioned from health board members this provides a level of assurance around how board members perceive themselves and their role importantly it provides further confirmation that the developments around corporate governance now underway are the right things to do thank you very much cabinet secretary that's very helpful and clearly we've had a wide-ranging inquiry and we have a number of areas we will want to raise questions on can i start perhaps with the area of staff governance with the replacement of the former nhs staff survey with iMatters and the expectation that that would be fully implemented by the end of 2017 and i think you'd previously informed us that you expected this month to have a health and social care staff experience report published on the basis of that can you tell us about the publication of the health and social care staff experience report and what action you anticipate will be taken as a result of the report's findings okay so the national health and social care staff experience report covering the full results of iMatter and dignity at work will be published on Friday the second of March which is this Friday the timescales for producing this report i think have been challenging it's fair to say given that this is the first report of its type and the complexities of the data gathering and the analysis have been have been complex and the independent company that was contracted to undertake this work has been working very closely with officials to ensure the robustness and accuracy of the the data the report will present so i think it is probably right that it was it was got right if you like before publication so taken a little bit more time to make sure that was the case the iMatter staff experience continuous improvement model has been developed and provides a new mechanism for measuring employee engagement levels across all 22 health boards so we're keen to make sure that there is a growing participation in iMatter and you know i think if we want to get a bit more detail surely do you want to say a little bit more thanks thanks very much so the committee will be aware that iMatter is a very different kind of tool than the staff survey which was a paper-based set of correspondence with some tick boxes about how people were feeling iMatter sits more closely alongside some of our od initiatives and it allows teams and individuals to talk about the individual set of circumstances that they see in their part of the organisation and to develop their own plans for how they want to tackle some of those initiatives iMatter has given us a significantly larger return so in 2017 the questionnaire achieved a 63% return response rate with 108,000 respondents out of 172,000 staff thereabouts including 23 nearly 24,000 staff from 23 health and social care partnerships so it's not something that is only to be used within the NHS it has a wider reach into iJBs that compares with previous staff survey completion rates that varied from 28 to 38% of the preceding three attempts so it's giving us a much larger sample size it's giving us something quite different alongside of that we ran the complementary dignity at work survey in November of last year and achieved a response rate of 36,000 sorry 36 percent which is 63,000 respondents so we anticipate having a very good platform to make conclusions about how it feels to work in health and social care across that piece and be able to encourage boards and support boards to be able to do whatever it is locally to improve those levels of engagement clearly the publication on the 2 March is very close to your initial intention of February and I'm very welcome can quite clearly you won't want to preempt the publication but can you tell us a little bit about what responses iMatter reflects in other words you've talked about the level of participation which is clearly very welcome what does it tell us about the standards of staff governance in the individual boards and across the country the first thing it tells us which I think is really important is that staff governance is taken very seriously so the particular pleasure that I've had is in seeing the way in which the staff side have contributed to that and the importance that the staff side have placed on iMatter and that analysis from from the boards it tells us an awful lot about the pride and engagement that people feel working in health and social care it also talks to us a little bit about some of the challenges that sometimes arise from from the experiences of working in health and social care so so it gives us that richness but if I can if I can say that for me perhaps I can make reference to a quote here from the RCN which said health trade unions as well as employers and the Scottish Government are committed to implementing the new approach in 2017 ensuring that staff concerns are better recorded and listened to it's simply not the case that NHS staff are being silenced rather staff representatives have worked in partnership with employees and Scottish Government to strengthen the process by which staff can have their say it actually emerged didn't know out of the Scottish workforce and staff governance committee as a concept in the first place so it was very much driven by staff side which is post yes indeed thank you very much i wonder if i can turn to Emma Harper thank you convener good morning everybody i'm interested in aspects around whistleblowing and the information we have is that you know the committee took evidence previously about whistleblowing and some of the items expressed or concerns expressed were around the independence of whistleblowing investigations allegations of mistreatment of whistleblowers and the independence of whistleblowing champions as non-executive directors of a board so i'd like to ask the cabinet secretary in the panel to tell us a little bit more about the role of whistleblower like the investigation part and i'd like to ask your view cabinet secretary and how the Scottish Government will assess the effectiveness of the new role and then what changes would you expect to see around that because of the non-executive whistleblowing champions so the non-exec whistleblowing champions have been in place in each board since 2015 and boards have allocated the role to existing non-executive directors and it was really intended to provide a level of local scrutiny and assurance independent of the direct management or handling of whistleblowing concerns so it was a go-to person that was separate from potentially someone's line manager for example so it was seen to be somebody who would be a go-to person but also someone who could promote and champion whistleblowing as a concept in its own right so each board also has a designated and trained named contact outlined in their whistleblowing policy who staff may contact directly for advice and to raise concerns outwith line management and i guess the whistleblowing champions are also there to ensure that internal mechanisms within boards are working effectively in line with whistleblowing policy and to support staff in raising concerns trainings being provided and guidance has been developed to support the the champions in their role and of course some of the whistleblowing champions may themselves have been whistleblowers previously in terms of their interest in the role i think the benefits of the role are emerging so in one of the boards the whistleblowing champion challenged the way in which the board gathered information about the number and nature of whistleblowing cases and that led to a piece of work being undertaken across the whole of the NHS to ensure that information is gathered and recorded consistently and those templates were then piloted in four boards and they're going to be rolled out following partnership agreement later in the year and there are other examples as well of of of good benefits flowing from the role that we can can certainly furnish the committee with if you'd find that helpful. Assuming that there'll be a continuous on-going review of the process and then updates and the evolution of the role as items are exposed. Yes absolutely I mean that there there've been stakeholder events which are important in terms of getting that that feedback and those have raised some important issues around training implementation and communication and we're going to reflect on on these issues as the policy develops further. Also we need to look at the role of whistleblowing champions and the relationship they're going to have with the independent national whistleblowing officer the INWO and the support available for whistleblowers at local and national levels so as that landscape develops with that national officer I think that it's important to look at the the development of and the relationship with the local champion so it's an evolution but I think it's important and has I think so far demonstrated it's it's worth. Okay thank you thank you. Brief supplementary is under work. Brief supplementary in regard to the INWO the international you know independent under the auspices of the Scottish public services ombusment it's going to be introduced this year sometime. Do we have a date for that and what you said previously cabset is you still have these whistleblowers as you might call it where people can go to them and then they will go to this new independence so there's a three step there is that correct? So so let me answer your first question. The legislation will be introduced in the first part of this year to allow the INWO role to be hosted within the SPSO and with a view to the INWO being introduced late in late 2018. Is that secondary legislation that you anticipate? Yes secondary legislation yes you'll be pleased to hear. So in terms of the relationship and roles I mean I think that's why it's important that we are clear and there's opportunities for further training and development of guidance around how does that role then relate to the local champions and that's I think work that we need to develop. Shirley do you want to just add to that the decision to cite the independent national whistleblowing officer within SPSO far too many initials in all of those sentences was taken after a fairly substantial bit of consultation and a proposal was developed which we're in the process of implementing. The arrangements by which people can raise whistleblowing concerns are many and designed to be many so they can use the independent helpline or whatever. The other important thing about the independent national whistleblowing officer is that that in gathering information in an appropriately anonymised way will help the system to learn and it's really important that above anything else in our approach to our own whistleblowing is to try and get the system to learn as a result of those concerns being raised. I can supplement and add to the cabinet secretary's examples if the committee would find that helpful but we're already getting examples of practice that's been changed and relationships that have been changed as a result. We're on to wider issues of workload and human resourcing and Alison Johnstone. Thank you convener. Good morning. We heard during the staff governance stand of our inquiry about the stress that some NHS employees are under currently really from under resourcing. There was a feeling that staff often work above and beyond their contracted hours from goodwill but that can leave to burnout which then leads to sick leave and puts pressure on colleagues. A key tenant of the GP contract is that primary care, as already happens, will free up GPs to focus on certain tasks and others will carry out some of the tasks that they're clearly carrying out already but I'd just like to understand what work has been done with those other professions to realise this vision for primary care? First of all, I think that we recognise that staff in the NHS work very very hard in all roles and they do go beyond the call of duty on many occasions. I think that this winter has demonstrated that staff go the extra mile to keep patients safe and I absolutely pay tribute to each and every one of them and I think that's why when we're looking at the development of for example safe staffing, putting the workload tools on a statutory footing and looking at how we make sure that we can use those tools to good effect and where they've been tested in for example Fourth Valley, they've actually shown a reduction in sickness absence because it's about having the right staff the right time in the right place and being able to flex the rotas to take account of high level of acuity of patients with dementia and so on and so forth. So just as a general point I think that's important in terms of the GP contract and the new model obviously the negotiation was very much a bilateral negotiation between the Scottish Government and the BMA to secure the GP contract but what's important in building that multidisciplinary team is the engagement of those other staff and that has certainly been picking up a pace particularly with other organisations representing other staff to make sure that that multidisciplinary model has not just the support of those other staff groups but the way it's going to work in practice is worked through so there's been a lot of work particularly post contract agreement to expedite that in anticipation of the changes that are going to take place. I think that you'll appreciate that when you have a bilateral agreement and then a vote on a contract you've got to vote on what's in the contract and that has been quite tricky because the delivery of the model will rely and require the engagement of those other staff groups so it has been quite a complex thing to take forward but I hope certainly that those other staff groups feel there's been a lot of effort put into engaging them. I just ask it, are we confident that phase 3 of the workforce plan will look at this and are we confident that those other groups have the capacity to be as fully involved as we'd want them to be? Yep, so part 3 of the workforce plan which is due to be published imminently is going to be important to set out the you know it's not just about increasing the number of GPs albeit we made a commitment to do that and that's important it's absolutely about growing those other elements of the workforce now we've already made some very substantial announcements in that direction so for example for nursing and midwifery training posts the commitment to 2600 additional training posts by in the next four years by the end of this parliament has been a big commitment it's a big uplift in that core workforce and of course that's with a view to many of them working within the community as we shift the balance of care that community nursing role practice nurses hugely important part of that multidisciplinary model but as are AHPs as are the mental health workers and of course there's the commitment to the 800 additional mental health workers within that financial commitment and commitment was given in the programme for government so it's about bringing all of that together and shifting the resources as well I mean the resources going in in 2018-19 into primary care and delivering the GP contract are substantial I mean 110 million pounds of additional investment is a game changer and that commitment to continue to invest in primary care will help to deliver the workforce that we need to build but it's going to take time I mean I can't say like two weeks on Tuesday we're going to have all those people in place it's going to take time to build that that workforce and that's recognised in the way the GP contract is a is a build-up if you like of that that model it's not going to happen overnight but it is a direction of travel that we have embarked upon that I think will deliver better patient care thank you thank you thank you very much I was looking at Charlie Rogers who I think wanted to offer us some additional it was really going back to your first question about how people are supported and just to to advise the committee that there is a battery of resources available to the NHS workforce of whom I'm a proud member who involving occupational health support stuff support generally welfare support and so on we're working very closely with the colleges in respect of the way that we can support people in what are sometimes quite pressurised roles as the committee will understand we work very closely with the RCN we have quite a programme of work at the moment looking at staff well-being because clearly the NHS and health and social care employ a lot of people so if we can improve the start the well-being of our own staff we're doing quite a lot to improve the well-being of the population so there's a there's a battery of things that are available to to NHS and other staff to help them and support them in in that process and the final point I wanted to pick up on was was one that cabinet secretary has just touched on the sustainability of of the health service requires us to think ever more closely about multidisciplinary multi professional teams so the importance in part three of the workforce plan around things like pharmacy services the kind of support that's required for paramedicine the kind of support that's required through the AHPs generally has allowed us to engage quite heavily in that space as the cabinet secretary has already said part three will obviously speak quite a lot about what we've found from the GP contract but it won't speak only of that it will talk about what that primary care team looks like and what it will continue to look more like as we go forward it's just to Alison's point about stress and burnout in staff my next chief medical officers annual report which will be published in mid April has a chapter on valuing our NHS healthcare staff that's distributed to all doctors and nurses and AHPs in scotland so it will raise awareness of some of the support that charlie has alluded to but it also is has a lot of information within it about the research that's been done about the impact on not only those staff but on the care that they provide and we know for example that staff who are under pressure may become very risk averse and they actually don't make good decisions regarding risk and that probably leads to over treatment and over investigation so that the staff's stress is actually having an impact on patient care so i explore that in the report but i'm also doing that in order to raise awareness among those staff groups that actually they need to look after themselves and we have a duty to to look after them very much that's very helpful can we move on to clinical governance and start with good morning panel and i'm really interested in how we measure adverse events what constitutes an adverse event because it's been explored quite a lot within within this committee and there's been quite a lot of conflicting conflicting evidence from a number of people so i'm interested in what constitutes an adverse events what guidance is given who monitors and who responds to to changes in adverse events within within the health board i'll kick off and then i'll be Catherine you want to come in male his as you know is the lead organisation for adverse events and back in 2012 we instructed his to develop a national framework and a programme of reviews for adverse events that national framework was published in september 2013 following extensive consultation it was then refreshed in april 2015 to reflect changes in best practice and to ensure ensure consistency of approach when changes in patterns or of incidents or concerns occur on an individual board the adverse events adverse national adverse events framework is clear that boards undertake trend analysis of adverse events data and as you'll be aware from the the experience in Ayrshire and Arran where there were concerns about the inconsistency of of the application of a significant adverse event review process that has been involved in addressing that and are monitoring those matters on a quarterly basis but also that Catherine as a CMO wrote to boards to remind them of the need for consistency in terms of what constituted a significant adverse event review and what should be handled in what way because it is really important that boards are consistent in that Catherine do you want to and i think your point is is well made that we have had inconsistency inconsistency is what's what's reported but also inconsistency in what our response has been and very much i know mr Whittle in your in your very interested in the involvement of people who've been harmed or who have had these adverse events occur to them or their families so so for the first time we are we are attempting to bring these into a much more standardized form of not only reporting but also reacting to reports and i know that you know very much about the national work in maternity services where we have found that it's inconsistency is not only across scotland but actually right across the UK so we're not alone in this being having been a problem in the past what we what we know is that we get a bit a standardized report but also that involves families patients themselves but also their families in in having some of that feedback to them if i could just to clarify the is it the responsibility of the board themselves to review that adverse event reviews or is there is there a level above that where the government are having an overview of that so i think what's really important here is it's not measuring adverse events against other you know we're not trying to penalize anybody here what we're trying to do is is create an environment where we can learn and for me adverse events or the significant adverse events gives us the opportunity to look at the system rather than the individual a healthcare professional so is there somewhere above the health board i mean if the health board are responsible for their own measurement of their own adverse events where does the government sit within that well if when the work of well you have the boards obviously looking at their own adverse events and looking at trend analysis so they should be looking whether there are trends emerging then you have the his overview of that and where his identify a serious concern with a board that so something is emerged from either that trend analysis or from his scrutiny work then his can escalate this to the board's accountable officer the the chief executive chair and to the Scottish government so if you look at for example an example of that back in august 2013 when the previous cabinet secretary commissioned his to undertake a rapid review of the the safety and quality of care for acute adult patients in NHS Lanarkshire that was prompted by a higher than predicted level of mortality in the first quarter of 2013 because obviously the the measurement of the hospital standardised mortality ratio gives us that ability to measure the review report then made recommendations including the need for stronger focus and leadership in implementing robust safety measures and then the redesign of services and and the recommendations were aimed at senior managers to really make the improvements you're talking about so i guess that's one example of an escalation because it was identified there was a trend there was something not right that was identified initially by NHS Lanarkshire themselves but also by his that was escalated to the Scottish government the cabinet secretary intervened and what flowed from that so that's one example of where we would expect that to work the duty of candor obviously which is coming into force from the first of april i think provides another level of reassurance in that it i guess it reminds everybody and and by by statute requires places of legal duty on organisations and the individuals who provide health and care services within those organizations to to report and publish annual reports on all incidents that have instigated the duty of candor procedure so that will bring a an extra layer of transparency i guess that the and not only reporting on the incident but what action was then taken in the learning from that so i think all of that amounts to a a system that you know i'm confident in is robust enough to pick up anything that needs to be picked up and it may be just worth mentioning that this you might have seen the reporting on the the fact that the patient safety programme has actually delivered and cut hospital mortality by over 10 across the period meeting a key aim 15 months early and i think the patient safety programme sits behind all of this as a way of making sure that where the learning isn't just learning for its own sake but it improves patient safety and there's evidence i think from that that it has over the 10 years of its operation has led to a safer system things still happen things still go wrong but overall i think it is a safer system than we had 10 years ago the evidence cabinet secretary we've had from health improvement scotland suggests that there isn't really a simple recording of adverse events and there isn't really access for them to all of that information is that something you recognise or well i think the duty of candor will because of all of the requirements for for those reports to be published the learning and the that's taken and the changes that would happen in the back of a report for that to be published brings a public transparency scrutiny to the public no not just not just the service and i think that's an important development on the back of duty of candor i mean we always keep these things under review but what what's the most important thing here and for me is that when something happens there is an openness about that and i think well there's i don't know there are concerns obviously with the garba case that although it was an english case we've got to make sure that the message goes out and we want to look at how we we re-emphasise this with the duty of candor from the first of april that the most important thing is openness and transparency around what has occurred and that's really really important because if we don't have that we'll have people retreating and not being open and transparent and therefore the learning and improvement in patient safety opportunity will be lost so it's really important that we re-emphasise that and so the most important thing is the openness and transparency learning from the incident that all of that is is clear and open and the reporting of that with the duty of candor i think will will bring a transparency to that and hopefully address some of the criticisms that there's been around whether boards are are open and transparent enough with the information that flows obviously patient confidentiality has to be protected but you know there is a lot of information that can be placed in the public domain the involvement and role of his beyond that provides that that scrutiny that is required and the clear escalation process to Scottish Government in cases where there is a trend and something systemic or systematic within a board it can be picked up on and acted upon and I think we you know used the the case of NHS Lanarkshire but also the fact that in the adverse event reporting itself in Ayrshire and Ireland we've been quite quick to I think we get or get improvements happening within that particular board and the way they record so we obviously you know if there are other things we can do we'll obviously always keep those under review but there are a lot of developments in this space not least the duty of candor that I think will add real value to. Thanks can I ask a little more generally about standards and variation in care and I know that chief medical officer has had some comments to make on that recently in in public and I guess the question is whether health professionals and I'm looking more widely than at adverse events but in general standards of care do health professionals need more guidance or support in delivering a consistent standard of care? I think that we are beginning to understand the amount of variation there is not only in practice but in the outcomes of that practice. My first annual report pointed out variations across Scotland and in fact in speaking to audiences so this isn't just doctors it's mixed healthcare professionals and from social care too that I really challenged them to say do you know how your practice compares with the next unit over or the next care home or the next health board and people aren't aware that there's variation in practice and variation in the procedures we're doing to people. There has been an awareness in England in an atlas of variation has been published for some years and so for the first time in Scotland we'll publish an atlas of variation this year. We're hoping to have that by the end of April and that will cover hip replacements, knee replacements and cataract surgery and that will be done by population level but also by health boards so that we at the moment then probably flag up more questions than answers so I personally don't know what the correct rate of hip replacements is but I do know that it shouldn't vary in a country like Scotland with one rate in one part of the country and three or four times the rate in a different part of the country so that the next part of this is then how to interrogate those data and how do we then examine whether some parts of the country there are too few procedures being done and arguably are we doing too much in other parts so we start with those three operative procedures those are chosen because they're very common and they're done all across Scotland in all of our areas and we will then build on that year on year so we plan to add public health measures childhood obesity again it may surprise you to hear various across Scotland and from less than 20 percent in some parts of Scotland to over a third in other parts of Scotland and the parts of Scotland that are the highest may not be where you would expect it isn't in our city Glasgow it's Stumfries and Galloway and NHS Shetland so again we need to understand that first of all that I can give you the those data but we need to then explore with those individual areas and this brings us back to the importance of local data for local interpretation and sometimes the government's top-down approach will not that will not help because local areas know their own issues and also are the right people to solve those we so we're determined to tackle variation because what I can't tolerate is that it that there are differing patient outcomes across a small country with a population of 5.4 million clearly a very important step can I ask how the evidence from that on you've identified the three disciplines that will be examined first how the evidence of that will feed into priority setting either through his or from the government directly to boards well it fits very well with the elective collaborative that has been led by Professor Derek Bell because that is very much about identifying best practice identifying wicked problems if you like and then being able to work with the the the best brains around and expertise around those issues and to then roll out the best practice so if you look at for example some of the the work done around orthopedics in Glasgow and GRI particularly with the virtual clinics so it was one example in one specialty where they have been doing groundbreaking work and some of that will help to address the variation but also to create the the best most effective and efficient use of resources and you know the twin track we're taking of investment and reform go together because if we can get the reform but right we can make sure that every pound spent is being spent in the most efficient way delivering the best outcomes and and it's unwarranted variation we're trying to tackle here there will be some variation that's very acceptable because a rural you know very remote and rural Scotland you know there may well be variation that's that's warranted but what we're talking about here is unwarranted variation where there's really no reason other than the way things are done that there are very different outputs and outcomes so you know there is we're really we think that there is a lot of scope here in elective care particularly to to make big big inroads and on the public health side as well and of course this afternoon there's an opportunity to to explore some of the issues around taking forward public health policy in the area of of diet and obesity and I think that we we can look at some really exciting preventative work there's a lot of work going on in type 1 diabetes for example that we're testing out with the results of which are on the pilot have been very very exciting indeed of being able to actually through through a management of the patient being able to avoid type 1 diabetes which is very or type 2 diabetes I should say is very very exciting indeed and we could share that information with the committee but I saw a presentation at the chairs meeting about some of the early results and you know the the percentages of of those patients with type 2 diabetes that were being turned around if you like there's not a technical term but you know what I mean and through through exercise and diet was very exciting indeed so those are the types of ideas we want to take and and roll out excellent thank you very much I have a number of colleagues who wish to ask about scrutiny of NHS boards and I'll start with David Stewart thank you convener if I can move on as the community has said to scrutiny of NHS boards the panel will know that we've had a number of written submissions which have suggested that should be the creation of an independent regulator of the NHS in Scotland can you ask the cabinet secretary and her colleagues whether they agree with that submissions so we have had this debate on a number of occasions and you know really I guess I asked myself this question what is it we look for in terms of the the performance and scrutiny and safety of our services and the reason that healthcare improvement Scotland was developed in the way that it was was to have a dual function so we could have set it up as sitting over there inspecting but if it didn't have an improvement arm then you leave the organisation with a set of problems without a set of solutions to go with it and the reason that healthcare improvement Scotland and the answer is in the title has a focus on improvement is to yes through their inspection and they don't you know if anybody's read any of his reports I think it would be hard to argue that they pull their punches in any way and you know the times I've had to go in front of a camera and talk about you know ex his report on a particular service they don't pull their punches they're the very robust reports and of course we have the healthcare environment inspector it within that focusing very much on the you know issues of cleanliness and infection control so they identify out of their inspections the set of issues to be resolved and then they work with that organisation on their improvement plan and I think from a patient safety point of view that dual approach for me is a better way to proceed because it then helps the organisation concern whatever board it is to do something about the issues that have been identified so you know I for me that is the critical point now in terms of the the work that his does with others it has an memorandum of understanding for example with the health and safety executive so if there are issues around health and safety there is a clear relationship there and it can be assured that the the right issues will be dealt with by the right organisation if that's the nature of the issue that's being looked at so you know I I believe very strongly that healthcare improvement Scotland has worked well in improving patient safety I think we've 10 years down the line of the patient safety programme is testament that we have a safer system and I think it's because of that dual role that his has of inspection but also of improvement that has helped to deliver that I'd certainly say to you convener that healthcare improvement Scotland an excellent job in terms of best practice I think the IHUB which referred to a few months ago and particularly work around diabetes is really first class but could refer the cabinet secretary to the recent report by the OECD and what they say and I'm quoting here the mix of roles between scrutiny and quality improvement I'm quoting this bit the mix of these roles means that the system's inspector risks marking its own homework what's the cabinet secretary's view in the OECD report about this well I guess and I understand the OECD's report I've read that that bit of the report and I guess the answer to that is the nature of the reports themselves if there was a an idea of it was all cosy cosy and you know his were doing these kind of rosy reports of of services that they go into inspect and all was fine but that's actually not the case as I said earlier his do not pull their punches those reports are very robust they have exposed some very difficult issues on the and some of those reports and you know the they provide a lot of of public public scrutiny and those reports are in the public domain I get I read them the action taken by his with the organisation to address and then of course they go back to check that what the board said they were going to do about that particular service has indeed been done and of course the government engages with the board so I've had a number of phone calls directly with the chair of said board about a report to say what are you going to do about that and then I follow that up so you can be assured that you know there's no kind of softly softly around these reports they are robust in nature but they have an important improvement element so that when his go back there is an assurance there that what they were to do and the shortcomings that were to be addressed have indeed been addressed earlier so you convene it I mean I think his does an excellent job particularly in its quality improvement I mean has the government looked at responding to a cd report by separating out the functions keeping the quality improvement and the basis of a and broke why fix it but perhaps having an independent scrutiny function I think that would be really difficult to do within his because if you have if you separated out those functions essentially you would not have the strength that I think his has of identifying the problem but then supporting the organisation to address the problem if you had that separated out then those two things would not sit together and I think the strength of his is the fact that they do sit together I should also say though that they bring in external people his don't just it's not just a group of people that sit within his and they say oh who's going to pick up this report they bring in people from outside his they bring in that external expertise quite often from out with Scotland to take part in particular reports so the idea that there's not that external scrutiny is is not the case there is and you know it's not worth the professional reputation of of those individuals who come in and do work on behalf of his to compromise that in any way and and you can see from the reports that they absolutely do not these are reports that do not pull their punches and those that external expertise is brought to bear in the full light of the the public reports that are then made but the important bit that happens after that is the improvements that take place and then the checking that those improvements have taken place so I think we have a system that that that works to constantly improve and continually improve the service here in Scotland and that from a patient safety perspective is actually very very important thank you thank you thank you cabinet secretary and officials for coming along to talk to us well now this afternoon I was going to talk about board scrutiny but just before I go into that in terms of the review process I just want to comment on that conversation about HIS and I'm glad to see that there is a grown-up approach to contain some improvement processes because certainly in my experience it's very important that both of those roles are combined and you understand what the problem is and then go on to fix the solution and drive the improvement processes using that same methodology rather than splitting the two up which would be much much less effective in terms of specifically on board reviews I suppose I just want to drill into how those happen how often they are how effective you think they are in terms of holding boards to account for their performance and if you think that process is set up to be as effective as it could be so boards have annual reviews which are open to to the public and ministers are involved in every two years I think that by last yeah by annual yeah so board so I've chaired numerous board reviews and then the following year it would be an official from the Scottish Government that would would share it and the opportunity there is to look back on what the board has done for that previous year and to ask questions about that in a public domain and then to look forward to the following year in terms of their plans and it's an opportunity for me and the ones that I've done on other ministers as well to drill down and to meet with so for example part of the the board review I would meet with the area partnership forum meeting with the staff side and having a kind of full and frank discussion with them also with the clinical community with patients who receive the services and again it's an opportunity to hear from from from them what they think and you know it's a you know the again they don't pull their punches some very positive responses but sometimes very challenging as well and then after the public session there is a drilling down further in a private session with with the board around some of the the detail and Christine and others will look at financial aspects for example and Christine gets in and about some of the financial plans and so it is an opportunity if you like to for the board to showcase some of the work it's doing but also for us to hold them to account so it's quite a lengthy time between reviews what kind of review process goes on on a kind of monthly weekly quarterly basis so the senior management team and Christine can say a little bit about this work on going with boards I mean that you know every week there will be some kind of contact with boards and if there are issues and concerns that will be very frequent I also meet with I meet with the chairs on a monthly basis to discuss with them particular issues so I'll make them aware of things that are coming up for example they'll raise issues with me over a kind of strategic nature and we'll have a good discussion about those Paul Gray meets monthly as well with the the chief executives and there will be more operational issues discussed at that so it's fair to say that the engagement between the Scottish Government and the boards particularly their senior management teams is very regular and very close and so it should be because it's important that we know if there are issues within boards and likewise that they alert us if there are any issues Christine so I think a number of the conversations recently are about individual components of a wider system of assurance that we operate so none of these things you know his report any particular single instance is part of the wider assurance system and we tried to join up all those different components when we look at the overall performance of a board in the management of risks so for instance as well as those planned meetings there are also mid-year reviews with all of the boards that are held with officials in NHS boards and with Scottish Government and if there deemed to be a higher level of risk within particular boards then we we may have more frequent formal meetings with boards of quarterly or bi-monthly or whatever the need is with a very specific set of actions to take forward also things like governance statements that come through from boards as part of their audit process with external audit scrutiny and assurance on that so we we take all of these components into consideration along with if there are particular levels of risks in boards we look we have a case management approach we will look at staff clinical issues along with issues of performance issues of finance to bring them all together to take a more rounded view of the performance of that board so that I think the annual review is a much more public part of that overall piece of performance and assurance but it is only one component and the success of it I think is based on the success of everything you do on a on a daily weekly monthly basis with the system right that's great thank you very much thank you Miles Briggs thank you convener and good afternoon to the panel I wanted to look specifically around culture within governance because I think that's something which for all the work we've been doing on this keeps coming back to us and from people who've given evidence and I don't know if the panel's had a chance to look at the research which was conducted for the committee by Spice and with over half of the health board members and specifically with regards to Governments role within health boards one said that the level of political interference in NHS health boards was excessive and negative while others said that it spent too long firefighting rather than planning ahead and specifically one some board members also complained that they'd had little control over their strategic direction as the Scottish Government was so dominant in the delivery of healthcare so I just wondered how would you respond to these points which was which were put to the committee and do you recognise these concerns in terms of planning and governance so let me first of all say that you know we should always take these issues very seriously but overall I thought the feedback was actually very positive and you've highlighted a few issues there but overall the feedback was very positive I mean it's interesting because and it's this balance isn't it of local and national I mean if I had a pound for every time a member of the the parliament has asked me to intervene to knock heads together to tell a chair to get a particular board issue sorted I would be a very rich woman indeed so you know sometimes it's about you know you should do this and you should intervene and you should get a grip and then other times it's like political interference you should let there so there is a balance to be struck and I'm sure members around this table and in parliament would not expect the cabinet secretary for health to sit back and say you know you know do whatever you want there is a strategic direction for the health service we expect patients to be able to expect a kind of consistent level of care and we talked about that earlier on about variation and therefore that you know without a kind of national strategic direction I think we would be failing in our duty to deliver that however the flip side of that is we of course expect boards particularly with their partners through their IGBs to be interrogating their own data coming up with local solutions and it's just about getting the right balance and terms of political interference as well I mean that that could be levied as much at you know opposition politicians in a local setting as it could be against government ministers and I have had a number of of particularly non execs say to me that actually sometimes when it comes to making changes and service changes that actually the political resistance to that from from local members can be very very difficult so I'm not sure they had necessarily just government ministers in mind when they may be made that remark and I think really for us as politicians it is about getting the balance right of making sure that there is accountability and as the cabinet secretary for health I'm ultimately accountable and take that very very seriously and therefore I need to assure myself that you know our services are you know carrying out and the boards are carrying out their duties in a way that is consistent with what we would expect on the other hand we also need to allow boards to take forward decisions in a way that there's clear guidance around and that is sometimes a difficult balance to be struck and it always will be and you know sometimes we get it right and sometimes maybe we don't. To go back to the point which the chief medical officer said with regards to the Atlas of variation or I think whatever on sort of knows his postcode lottery across Scotland how we can then look at how that is shared and actually I think that's one thing which our enquiries have shown that often when health boards are getting things right they're not necessarily sharing across the country their best practice I think that's where really if we can make an impact in terms of governance trying to make that really at the heart of our health service in Scotland and like the chief medical officer said you know a country of 5.4 million people surely we can get that best practice across the health boards and I think that's really where in terms of the political leadership which is at the heart of that I wanted to pursue to see how you then see that developing because it's quite clear that it's not worked to date in making sure that happens. I think it has worked in some ways if you look at the patient safety programme that's now 10 years old and when I go around speaking to clinicians and we did just this last week to hear about the development over those 10 years of the patient safety programme you would not go into a care or health setting now and for them not to have implemented the patient safety programme and best practice so we have a safer service because people have taken the evidence from the patient safety programme and applied it and some of the work I was looking at at the western around the way that they have you know developed that programme to reduce harm save lives and has really engaged the clinical community because they see the benefits of it so I think that's a good example of that happening everywhere but there's more work to be done in terms of addressing variation and I think we're moved away from the kind of not invented here syndrome there's a lot more regional working going on so we've seen the emerging priorities of the north east and west around what they're collectively going to do to not just share best practice but to share services to to look at doing things differently in order to be more efficient but also to deliver better patient care so we I think we're seeing a picking up of the pace of that which is important and the work that Catherine's doing around the atlas of variation will bring a rigor and scrutiny to the data that we then expect boards and their partners to not just scrutinise but then do something about so we've I think over the next few years you'll see far less unwarranted variation and far more efficiency in the way that things are done and technological advances will help that as well there's no excuse to not doing something if it's evidentially working there would need to be a pretty good excuse for not doing it. My line of questioning is about public confidence and in particular as I asked the last panel it's around expectation management and that is something that we can do something about at a national level through government policy but that's really also the preserve of the implementation by NHS boards and this speaks very much to I think Dr Calderwood's thesis on realistic medicine and everything you've told us about realistic medicine this morning that when credited with the facts about their situation the public will be far more understanding than perhaps clinicians might expect and may make more mature decisions and decisions that might not be expected of them in the first place. Now I have lost count of the number of times that in my surgeries I've been visited by constituents who've had already long delays in treatment or waits for treatment extended still further beyond significantly beyond what they were originally told to expect. Now that happens a great deal and I'm sure it varies from board to board but can the panel tell us how we can do better at expectation management around waiting times because I think in a lot of these cases had my constituents been told that this is what you can be prepared to wait. They would have accepted it, it would have been uncomfortable but it wouldn't have been as demoralising as then halfway through that wait being told they would have to wait the same again still further. First of all let me say that improving access in all its dimensions is important so if you take and I'll come back to waiting times in a second but if you look at in primary care the whole reason for developing the multidisciplinary team is to improve patient access and patient care so and that is about expectation management and to the extent that the flip side of that is that you might not always see a doctor but you'll see the right health professional or care professional to meet your needs so you'll get quicker access to that team but it might not always be a doctor so I guess that is a good example of that discussion with the public and the Alliance are doing a lot of work in engaging the public around well what does that mean for me and actually it's quite interesting I sat in a session that I should be very open to that because they want they don't actually care what label the health professional or care professional has as long as they can deal with their problem and do it in a speedy manner that is easy to access. In terms of waiting times we do have a challenge with waiting times I absolutely accept that and we're doing a lot of work not just in investment but in reform as well so the work that Professor Derek Bell is carrying out around elective reform is absolutely about improving and reducing the time people have to wait by making better use of the resources we have and the investment that is going in is helping to transform the way we deliver things so that people can get more can get quicker access to the treatment they need and within that they'll always be on a level of clinical prioritisation so for urgent cases we've got a big focus on on cancer pathways at the moment to make sure that that people are getting more rapid access through diagnostics into treatment and so there's a big focus on that so it is going to take time given the demands on a service and we if you look at the growth and demand for outpatient appointments and for treatment for procedures we have a huge growth over the last 10 years we have an aging population so it's no surprise there so just finally on building capacity with the five additional elective centres work progresses on those to make sure that we do have the capacity for the growing demand for knees for hips for ophthalmology and that is like chasing a never moving target to be blunt because it is you know we're increasing capacity but demand is also increasing and trying to get that into balance is quite a difficult thing to do so yes there is a you know a discussion with the public about what they can expect the work on the modern outpatient programme is to for example avoid default being a GP just refers everybody to an outpatient appointment when actually other outcomes might be better for that patient and that's very much the realistic medicine territory that Catherine spoke about earlier on. Good afternoon rather to the panel. In terms of board diversity, I've heard from the previous evidence session at the moment our board membership from the responses we had tends to be comprised of those over 55. We don't have from the boards that responded to us anybody who's sitting on a board who's in the 18 to 24 age bracket and in inclusion Scotland also flagged up last week the issue of disability in terms of how you get those with disabilities on to boards and having a meaningful contribution to that process. Does the panel therefore have any views with regard to how we can get more people involved in the board process itself? Do you recognise that there are problems? I know that cabinet secretary spoke about the gender representation on public boards legislation in your opening statement and I wondered if the Government had considered perhaps looking at an advertising campaign which targets certain groups and therefore makes it more accessible to them than it currently is. Yes, a lot of work has gone on to try to recruit a more diverse group of people and we can talk about some of the examples. I think that we should recognise that progress has been made though if you look back over the last few years at the moment we have for all appointees we have 48.8 per cent women which is a big increase from where we were but you're right to point out that for younger people, for people from an ethnic minority background, for people with disabilities and so on we have still under representation. Part of what I touched on in my opening remarks was that we have to broaden out first of all how the positions are advertised and also the skills and experience that are required so being it's not just skills and experience are important you always have to be able to do the job and that's a given but we also need to look at that wider range of experience and what someone would bring to the board so there's been huge attempts to do that and that work is on going to try to make sure that we're not missing the opportunity to recruit. Shirley, you want to give a couple of details? I'd like to try and respond with a few examples around that and perhaps touch on some of the questions from Mr Briggs too in terms of the culture of boards and how we share experience because you're right that a board will be more effective if it represents the demographic of the people that it serves and there are some challenges in that and the construct of part-time non-executive positions and what is quite a challenging role to hold boards to account for complex systems of governance and complex systems of procedures but that shouldn't prevent us from making some significant efforts and the kind of efforts that I'll point to are around things like using social media campaigns rather than print media in the sort of traditional thing revising the application form process working quite closely with the office of the commissioner for ethical standards in public life obviously to try and make sure that that's right but revising the application form to make it less onerous less experientially based to attract younger people to try and reconfigure we've got examples now across a number of boards reconfiguring the interview process to make that less formal to try and use people's judgments and values rather than necessarily a long track record of experience which obviously plays to a different market we've done two of the things that might be of quite useful importance in respect of the specifics of diversity on the board one has been to look to have sort of open sessions for example we had a an outreach event in Maryhill community halls and as a result of that outreach event attracted approximately 190 applications from a variety of different people it wasn't just you know a standard small advert in the back of a paper somewhere the other thing that we've been doing which I think is really important is where we have the opportunity to recruit a number of board members at the same time we've predesignated some of those posters development posts so that we can take into account bringing people who've perhaps not had experience in that space and then linking the two the two questions that Mr Briggs questions it's really important that we understand the the breadth and importance of the role of non executives and their role which is not necessarily as evident just from saying I'm a non exec so we've produced in very easy to read terms a series of support materials entitled what do non executives need to know so there's no great confusion to the language or whatever there are eight of them at the moment and and I wanted to play particularly to five that help to answer the question about share and sharing of best practice and they relate to quality efficiency and value quality improvement and measurement innovation person centered care and improvement focus governance and just for completeness the others relate to health inequalities induction so that people really understand the basics of governance and then personal effectiveness so there's a battery of materials now available apart from all of the board development and induction and training programs that take place there's a battery of materials written as simply as it's possible to be without you know spoiling the story in that space but as simply as it's possible to talk about the role of a non executive in both holding the system to account and sharing that practice. I'm very conscious of time and with two other areas we need to cover very quickly. I would like to ask Sandra White if she would comment on the question. Thank you, convener. There were issues. I wanted to raise that particular one as well. I think Jerry Gurruth did also particularly how it affects people who are on benefits. Perhaps we could write to the camp site on that one if that would be all right. Thank you very much because there's a number of issues in that particular one. I wanted to talk about as quick as possible on the governance of the IGBs. We heard from the previous panel that that's the proper way to go from the bottom up as has already been said by Dr Calderwood also but there are difficulties in the cultural situation there and obviously we'd heard from Audit Scotland in 2015. I just want to know if in an update is actually working better than the IGBs and some of the issues that were raised about potential conflicts of interest with board members you know sitting in both boards, chief officers, local authorities, that type of thing. Should we actually, in fact, when the respondent mentioned the fact that we should perhaps look at the review of the IGB, basically government's arrangements? I just want to quick questions, have things improved since the report from Audit Scotland in 2015 and should we be looking at a different approach to the IGBs? In the interests of time, obviously a lot of work has gone on since the Audit Scotland report. I'll ask Christine just to briefly respond. Okay, so I think probably the most important thing is that you're aware that Audit Scotland are doing the second report and the work is underway and that is due to report in November of this year so that will give you a more independent assessment of that and I think that that is everyone's very aware of that and looking at that as being a bit of a milestone and looking at the progress but certainly if the purpose here was to bring parties together in joint working then it certainly achieved that. The governance is a different set of governance than we've had previously but I think again in one of the examples of looking over the Christmas period and how partnerships work showed that governance didn't either certainly didn't hinder that ability to work well and lots of good examples of where partnerships working with the acute service and the ambulance service worked really well and I think that some of those anecdotes are things that give you the evidence on the ground that these things are working in that governance working in a different way didn't stop any of that happening. A lot of the governance is about looking at having a three-year commissioning plan as much as it is about the day-to-day operation so I think that there's a lot for us to build on. The way in which governance is operating is different and we need to make sure that people understand the differences and feel comfortable and that there's a sense of a conflict that we take action to ensure that that's not the case but I think that I'm relatively confident that we can see the signs of progress there but I think that we'll look to the Audit Scotland report to give us all that clarity and the independent assessment. I just wanted to touch briefly on the regional planning boards and the situation there with regard to governance and you'll know that that has come up through the inquiry that we've done. Is there a framework for governance at that regional level or is there role more to act as a sort of a coordinating structure? In the interest of time, Shirley-Anne you want to respond, you've been most involved for the regional plan? Yeah, the introduction of regional collaborative planning and delivery has not taken away the governance structures that previously existed so boards in Tayside are still responsible for Tayside, board in Highland is still responsible for Highland. What the regional structures are doing are planning those services that can best cooperate with each other to deliver a better service for patients on a regional basis so there are actually a number of tiers, the national delivery plan which you'll be aware of that has the national boards providing certain of those solutions too, the national boards focusing around things like digital platforms and that kind of thing. There's original tier that is at the moment in the process of planning to come forward with a series of proposals that we will give consideration to in due course on things that could be delivered in a slightly different way. Some of that harks to the point that Mr Briggs was making about variation and trying to establish best practice that is delivered across a region rather than just board by board but it hasn't taken away the governance structures that existed beforehand so the board remains accountable for the services delivered in its patch and we'll see what comes forward as part of the delivery plan. The expectation is that regional and national plans will be submitted for consideration towards the end of March and it will then take us some time. If there are things in those plans that require the service to go into consultation around future arrangements then the consultation arrangements for those changes to service have not changed either. Thank you very much and I thank the cabinet secretary and our colleagues for a very helpful session. Clearly, governance of the NHS is something on which committee members would cheerfully interrogate you all day, but it's been very helpful to have such well-focused responses. I know that you have offered us, cabinet secretary, some further information. I think that you particularly highlighted preventative matters around diabetes interventions. Shirley-Rodgers talked about some examples of the impact of whistleblowers and Sandra White suggested that the evidence that we heard in her last session about the impact of appointment to a health board on somebody on benefits and what that might do as a disincentive. It will be very useful to have your views on that as well. Thank you very much.