 Good morning and welcome to the sixth meeting in 2015 of the health and sport committee. I would ask everyone in the room, as I usually do at this time, to switch off mobile phones as they can often interfere with the sound system, although I would ask visitors and others to note the fact that some of us are using tablets here this morning instead of our hard copies of the papers. Can I welcome Jackie Baillie MSP, who joins us for item one on our agenda? Welcome, Jackie. Our first item on the agenda today, of course, is to take evidence from the cabinet secretary following Lord McLean's report on the CDVSL outbreak at Vale of Even Hospital in 2007, which sadly 34 people lost their lives. The cabinet secretary has asked to speak at this point, and I will give her that opportunity now. First, I should welcome the cabinet secretary, who has shown anormative health and wellbeing sport for the owner of McLean, who is the chief nursing officer of the Scottish Government, and of course Paul Gray, director general of health and social care and chief executive in NHS Scotland. Welcome to you all. Now, I will give the cabinet secretary that opportunity to make some opening remarks, and then we will go directly to our first question from the committee. Thanks for inviting me today to discuss the Vale of Even hospital inquiry report. First of all, I want to reiterate my sincere apologies to the patients and families affected by the Vale of Even hospital's CDVSL outbreak in 2007-08. Secondly, I would like to again put on record my thanks to Lord McLean and his team for their commitment to the inquiry and for producing such a comprehensive and detailed report. Since Lord McLean published his report on 24 November last year and my statement to Parliament on 25 November, I committed to undertake a number of actions to ensure that the recommendations within the report are implemented. The focus of those actions has been to ensure that focus is on making improvements across the NHS. Although the focus of the work going forward is Scotland-wide, it is important to remember the patients and families affected by this tragedy, and that is why they are included throughout this whole process and will enable them to be assured that the recommendations are being implemented. To assist the committee, I would like to provide a very brief summary of the actions that have been taken since the report was published. I wrote to all boards following publication to ask them to assess themselves against 65 recommendations for health boards in Lord McLean's report and to respond to me by 19 January this year. As I stated in my paper to the committee, I am pleased to confirm that NHS boards have responded. The committee will recall that we undertook to implement all of the recommendations, and that is what we will do. I am pleased to report that boards have assessed so far that they have either fully or mostly implemented around three quarters of the recommendations. Once further analysis of the responses has been undertaken and completed, I plan to publish those responses on the Scottish Government website. I would also be happy to share them with the committee if members would find that useful. I committed to establishing an implementation group to oversee the implementation of the health board recommendations. However, following the group's first meeting on 16 February, it has agreed to oversee the implementation of all 75 recommendations. The implementation group has agreed the remit in terms of reference, and I would be happy again to share those with the committee. The implementation group will be chaired by Fiona McQueen, interim chief nursing officer, and includes a number of stakeholders representing patients and families in NHS social care and the unions. The minutes of those meetings will be published on the Scottish Government's website, and we will be developing the web pages with family members. The implementation group will ensure that its work links into current policies and the work of other groups to prevent any duplication. In addition to a patient's and family's representative being on the implementation group, I have agreed to also establish a reference group. This group will help to provide assurance to the patients and families and the wider public that the recommendations are being implemented and to give them a voice to challenge and support the implementation group. The group is being established to give the patients and families and the wider public a voice in the implementation process. Invitations have been issued to ask a number of stakeholders to nominate a member to be on the reference group, and it is anticipated that the first meeting will take place in March. As with the implementation group, the minutes will be published on the Scottish Government's website. In my statement to Parliament, I also committed to publishing the Scottish Government's full response to Lord McLean's report in the spring. It is my intention to stick to this timetable and I would be happy to let the committee know in due course the date for publication. The Scottish Government officials are working on the full response and will ensure that there is input to it from the implementation group and patients and families. I hope that this demonstrates the Scottish Minister's commitment to progressing this work and to assure you that I am taking the necessary measures to make the improvements that are needed to improve patient care across the NHS, and I would be happy to take questions. The first question is from Colin Kear. Good morning, Cabinet Secretary. I must admit that somebody who has come just into this for the first time in terms of the Vale of Leven was a very trying report to read. I can well see how this can obviously be a very emotional subject for a great deal of people. Can I ask on the first recommendation, I think, with the, in relation to HEI and being given the power to close wards to new admissions? Will this require primary or secondary legislation? We could do it either way. We could do it through the primary legislation vehicle, whether that is the public health bill, or we could do it through secondary legislation. Where I am at at the moment is really to look at what would be the most efficient and speedy route for implementation. That may end up being secondary legislation, but the committee can be assured that there would be the full opportunity to input, discuss and debate the measures and the legislative proposal, whether that is through the public health bill or whether it is through secondary legislation. However, I would like to get this into legislation as quickly as possible. In light of the report, do you have any plans to, at this minute in time, enhance the inspection and monitoring process that HEI could use? Is there anything that you have in your mind as being a must-do? First of all, I should say that the healthcare environment inspectorate is a very thorough and effective tool at inspecting our health service. It does not pull any punches. We would only have to look at recent reports to see that it absolutely reveals where practice is good and where improvements need to be made. It is a very effective organisation. If there are ways of enhancing that, the recommendation was part of that in terms of the ability to close wards. I know that there will be no doubt discussions and will be discussions with HEI and others around if there are any other measures that they would like to be taken to strengthen the work that they do, but I have to say that they at the moment do a very good job. I think that they have been instrumental in driving improvement, but if they come forward and say that they would like additional powers beyond what Lord McLean recommended, I would certainly be willing to listen to that. There is just one more question that is really in relation to what you said about the replies that you have heard from the boards across Scotland, the three quarters of the recommendations dealt with. What is the timescale that they would anticipate putting all the recommendations into practice? The implementation group will be working very closely to make sure that the three quarters of the recommendations are monitored and overseen in their implementation. Quite rightly, the implementation group would want to make sure that all the three quarters of the recommendations that have been implemented are implemented to the extent that the implementation group is happy with, so that they will be oversight and monitoring in terms of the rest of the recommendations as soon as possible, but making sure that they are done thoroughly. Fiona, do you want to add a bit? I think that although we are saying that there are some that are not fully met, in many cases they are almost fully met, so there has been really good progress. Other aspects will be met in some boards sooner than others. By the time that the report is published, we will be able to say with confidence that the majority will have been met completely. In particular, the relatives are keen that we do not have a tick box exercise, so we absolutely need to find ways and we would be looking at our inspectors to help us to check and test what boards have said. By the time that the report is published in spring, the majority of them will have been met and if they are not met, there will be firm plans in place where we have to put new systems and processes in place, so that they will have started with a trajectory of when we will have been able to meet them. The report recommends that each health board has a task force set up. Every health board has a team in place who has an infection control committee and there are good lines of governance from boards to bedside on that. Nationally, I am reconvening the task force, so I am changing the approach whereby we monitor each AI and through that we will then look at specifically what is meant by a task force. So we do have an infection control committees, we have an infection control managers and doctors and nurses who have specific responsibilities. We have reissued our guidance on the infection control manager and we are reviewing what needs to be done. While they might not have a task force, every board has an infection control committee that essentially works as a task force. The national task force that I will be pulling back together again to, although we have had systems in place to monitor each AI, my view is that I want to take forward a smaller more focus group so that we can fully oversee what we are doing. We would then work with boards to determine whether the current infection control committee situation is suitable and satisfactory. I am absolutely confident that they do a very good job when you look at the rates of reduction in infections, whether we need anything additional and more for a task force. They may not have a task force called a task force but they have teams who work in that way. Who is involved in those teams? Infection control manager, infection control doctor and infection control nurses. In the majority of cases that lay members of the public are also involved and other clinicians and managers, cleaning staff, hotel services and facilities staff, where the engineers are a full-wide multidisciplinary team. There was a recommendation that all the policies that came from the Scottish Government should have an implementation strategy associated with them. Is that happening and how is it being monitored? That is happening. It is being monitored through looking at the AI, the difference, so within three months the inspectors will be looking to make sure that that has been put in place and taken in force. The task force that I have been chairing will also oversee what is happening with the implementation. Okay. What focus is that having on cleaning? Cleaning is still an issue. We are still picking up the newspapers and reading stories about cleaning. How is that being dealt with? Some of it is captured within some of these recommendations but there is other action that we need to take. One of the things that I asked the chairs—I meet all the chairs of the health boards—on a regular basis at the last meeting, I asked every single one of them to take personally, to go out with their team, the senior management team, and to look at all of their hospitals in terms of the cleanliness of them. Not to wait for reports to come in to analyse whether or not their cleanliness standards were up to scratch, but to go out proactively and look for themselves and to report back to me on assurance that they have done that. That process is under way. Fiona, you have been overseeing that. I have written to the cabinet secretary with some very detailed plans and proposals of what is happening in terms of going out and taking that forward. We do routinely monitor and we have the Health Facility Scotland do monitor what is happening with cleanliness, but you are right that there are areas where our inspectors are finding that the cleaning standards have not been met. With the cabinet secretary having written to the chairs, we will be looking at that within our implementation group to make sure that we are reaching the farthest corner of the farthest ward to make sure that the cleaning standards are maintained. It is not just day-to-day cleaning standards. If you have an outbreak of something like C-diff, you need to have the resources available to you that pools in cleaning teams almost immediately. Nurses have to nurse, and we know that they are under more strain now than ever in time pressures and the like. If they have to decide whether they are looking after someone who is really ill or if they are cleaning up after somebody else, and if the nurse is cleaning up but then going round other patients as well, that includes an infection risk. There needs to be dedicated cleaning teams that can be called on at the moment's notice and get in there. Under the infection control procedures, that is part of it. If an issue is identified, then the systems are there to ensure that that happens. There is a wider message about basic cleanliness. Is everybody's responsibility and is everybody's responsibility to raise concerns? In some ways, in the same way as we have that message getting through around handwashing and basic infection control procedures, I want to see the same attitude towards cleanliness. Obviously, there are complex issues around infection control. You can clean and clean and clean and clean, and it only takes one finger on one part of the uroth to spread infection. It is not just as simple as clean, but without doubt, for public confidence and patient reassurance, people should expect to see the areas that particular patients are in to be of a clean standard. There is more that we want to do around that to make sure that that message is pushed across. We make sure that there is proactive action taken to address any shortcomings in that, particularly within patient areas. We also use the learning from the reports that have not been good, because some of those are addressing some common themes that we do not wait for further reports. We take that action and each board is expected to act on the reports. Whether it is from their health board or not, they should be expected to act on the lessons that are being raised through that particular report. The work that Fiona was describing will make sure that we do that. Is there any concern that you have had pace in your statement recently in the Parliament? Is there any sense that there might be a cynic here? I noticed the difference from the language this morning in the report that we got from the Government last week, where we were talking about 80 per cent of the recommendations. Today we are talking about 75 per cent of the recommendations. We were talking in the lines this morning about the definition of task force not being cleared. There was just one other point that has escaped me, that raised my attention. Are you absolutely confident, cabinet secretary, that the pace in this is not slipping and you are going to meet the deadlines that you have placed on the boards to address the issue? I can explain that the 75 per cent is of the 65 recommendations, the 80 per cent is of the 75 recommendations, and maybe we should have just used the consistent language there, but you can be absolutely assured that the time frames that we have set out and the commitments that we have made will absolutely be the case. I think that the fact that we have involved the families in the implementation group and the reference group should bring an external scrutiny to that, which I think is really important, because it is not just about boards telling us that they have implemented the recommendations, it is about having that external assurance that the families are absolutely confident and they feel that the boards have done absolutely everything to implement the recommendations. Now, there is oversight and monitoring of that, so absolutely. We may return to that. Richard Simpson, I have got on my last bob Doris. Good morning, cabinet secretary. I am a Glasgow representative, but I am born and bred in the Vale of Leven. All my family are still down there. I have elderly relatives, particularly my mother and father. Unfortunately, they have to use the Vale of Leven hospital on a fairly regular basis, and I know that we are talking about an absolute tragedy that happened in 2007, but I would like to place on record the excellent service that my family gets at the Vale today. It is in that context that I want to ask some questions. Without any complacency at all, because we have to try to make sure that we are implementing absolutely every aspect of the recommendations, but I thought that that was important to say. Looking at some of Lord Macleod's recommendations, recommendations 10 to 12 talk about information that was or was not provided to patients and relatives in a couple of really terrible examples in relation to C-diff being compared to just a wee bug and kind of played down and real mixed messages over how you deal with soil clause and should families take them home and how are they stored and that kind of thing. Real basic things, I suppose that we would have to say, so my kind of questions in two parts. I am hoping that those real basic things have, I would like to think, long before today now been dealt with. They are looking for some confirmation in relation to that, but there was a wider kind of recommendation and I think that the cabinet secretary referred to in her statement to Parliament where she said that she would want to roll out a robust quality assurance system to put patients, families and their experience at the centre of the work to ensure that information in relation to all this is easily accessible to the public. In other words, clear messages are out there at the hospital on the ward and how to deal with all this. In two parts, I suppose, I would be confident that those what might seem silly wee things but deeply worrying, deeply worrying things in 2007 have already been addressed, but I suppose the wider question is when the work that I think it was the chief nursing officer was going to do forward working that information, has that started? When will it start? What kind of timescales are there around that? I'll bring Fiona in on some of the detail in a second, but absolutely. I think one of the real issues that arose was the inconsistency of information, different messages, no clear information, for example, around dirty clothing, soil clothing, all the things that just really were hard to understand now that that could have been the case. So absolutely, there is very clear patient information now that that is standardised and clear and something that was well taken down the road and sorted well before the report was issued because it's such a fundamental issue. Fiona, do you want to? I think that the care assurance system that we're looking at, and you're absolutely right, there's a number of these essential components of care that have now been changed, so information that people have access to that information. What we've learned from the patient safety programme is that if you put a big system in all of a sudden, it doesn't necessarily work. So putting systems in place and testing it, changing it, moving it forward, we find is the best way to do that. So what we're calling the care assurance system, where we recognise that individual components of care are incredibly important, but when you look at them altogether, it becomes even more important to people who run well. So information to families and patients' loved ones, cleanliness, nutrition, caring for people for the fluid balance, and what we would call the person-centred care, wrapping all of that together. What we have is we've agreed and defined standards. In three health board areas, we're currently testing these standards. They have been well researched and well evidenced, and we're confident that these are the right standards that we need. What we then need to do is put them out across Scotland once we've agreed and have a form of what we would call assurance and accreditation, so that each ward is safe, it's clean, it's person-centred, and people who use the wards will have confidence about the information. We've already, as you see across Scotland, we have information about care within wards, but we would put a simplified straight forward, so no matter which warder department you went into Scotland, our care assurance system would be there in a very straightforward and meaningful way. We've started testing it. I expect by the beginning of May that we will have agreed the whole system and planning that for roll-out. That would be clear and ambiguous, including workforce, including infection control standards, there for the public to see and have assurance and confidence. We would start rolling it out by late spring, early summer across Scotland. That's very helpful to get the timescale around that. Of course, with any care assurance system, there has to be checks and balances in the system. I suppose that it's in that light that I would see HEI who do unannounced inspections. From 2009, they started doing unannounced inspections. I don't want to be alarmist here at all. I would expect more cases of poor hygiene to be identified by definition that there are now unannounced inspections in the system. That would be a check and balance to make sure that health boards and hospitals are doing their jobs properly. I would be clear to hope that there are a number of checks and balances in the system. I don't see that in an alarmist way, but by definition unannounced inspections should lead to identifying areas for improvement. That's why we have it. I'm wondering how that all fits in with recommendations in nursing care. That's 13 to 33 in Lord McCain's report. You were talking about nationally-agreed standards. I'm going to read from my notes about Lord McCain. He said that he talked about clear and effective lines of responsibility, keeping of accurate patient records and auditing them, the role and responsibility of the nursing charge of each ward, ensuring proper systems of care, planning, communication with relatives, ensuring the right skills and staff mix in each ward. I'm not sure if that's what you were talking about, Ms McQueen, when you were giving that information, but the cabinet secretary also rightly said that every healthcare staff member has a front-line responsibility in relation to hygiene. In relation to that skills and staff mix, I know very well that my nurse being a wife, you get domestics on ward, you get exalgades on ward, you get various categories of nurses on the ward, each of their own role within the system. I'd want to be confident that every staff member out there is clear, irrespective of where they are as a cog in that machine, that they have that front-line responsibility and, obviously, some information around—I don't know if we were talking about the same nationally-agreed standards or not—that you referred to in your previous answer when the ones in relation to care planning and nursing documentation, when they're likely to be agreed and when they're likely to be implemented. Will you be looking at that specific about what the staff mix is like? I'm accepting, and I agree wholeheartedly, that every staff member has a front-line infection control responsibility. However, as part of that, every nurse, every auxiliary, every domestic, every doctor has their own parts of the cog within that machine. Is there a need for greater clarity over who's doing what? Will that be taken in within the skills mix? Is that the kind of thing that we're talking about, about nationally-agreed standards? Yes. Part of the issue that was raised at the Vale of Leven was about the skill mix and also about leadership and who takes responsibility. There absolutely is a need for everybody to take responsibility in terms of infection control being everybody's business, but there also needs to be leadership in what happens to make sure that any issues and problems are identified and then, more importantly, acted upon. Of course, part of the system at Vale of Leven update wasn't there and didn't work. The work that's happened since then is crucially important in addressing that. Do you want to pick up a few of your questions? In terms of looking at nursing numbers and skill mix, we have the workforce tools that we're putting in place. I've agreed with the nurse directors as recently as last week that we need to do more work on skill mix, so that's the work that we're going to be taking forward. The workforce, in terms of the care assurance system, is an integral part into that. In terms of who's job is it to do what, if it's with regard to cleaning, that is something that our inspectors currently go and they'll go in an unannounced way and they will ask the junior doctor or the cleaner or the physiotherapist or the nurse if they know what to do with a spillage or what to do with personal protective equipment, so that's currently being looked at. We've also asked Health Protection Scotland as a consequence of that and, in part, looking at the time it takes to clean to do a bit more detailed work on timing of cleanings and checking and testing who is the best person to do each piece of cleaning. In terms of the standards that you asked about, currently there are standards. Each health board has standards of record keeping, models of care for care planning and what we will do is agree a national approach to it so that there's less variability, more transparency about the standards that we have. That's all very helpful and I'll go back and reflect on that evidence, but it's very detailed. Are those a different set of standards that we're talking to and we're talking about standards in relation to the care assurance system? I'm saying once, thank you, that's very helpful. Is there a number of inspections or is there an inspection plan that you're aware of that won't be carried out? There's a cycle of inspections that ensure that there is a good balance and that the HGI get around the system and look at different parts of the system, so whether it's a focus on older people's care or whether it's the front door of the hospital, so there's a cycle of inspections, but it's nearly out looking at what they've done the previous year and the year before that and then I look forward to make sure that they get a good balance and that they are inspecting enough of a range of services to be able to bring out any issues that would have application to similar settings elsewhere, so they work, they do have systems to identify that. And the risk assess, healthcare in Scotland do risk assess, so they ask for information from boards and they make their own decision about where they would want to go and what you might notice in the HEI, so the cleaning reports, because there's some time between the inspection and it published, if the inspectors go and they find a hospital is not clean, they may go back the next day or they may go back the next week. That often is published in the one report, so it's not obvious, but they do follow-up in areas where they've not found things to be satisfactory. But they inspect in a wide area of responsibilities, so how do we ensure that they've got the balance right for the purpose of this discussion that's cleanliness, so there's a big pressure, there's reports there, the debate in Parliament, cabinet session before the committee or so, there's a big pressure to do that, so have we got the resources to take on that, those additional inspections, have we got the expertise in terms of the staff and the inspectors, because they'll have different specialities, is that an area that needs bolstering, have we got the people and the resources to do this properly right across the board? Yes, we do, they have the ability to draw on experts and inspectors from a whole range of different areas and they do that depending on what the inspection is that they're undertaking, so they can draw from a whole range of individuals with different backgrounds depending on the area that they're going to inspect and they're able to do that, but obviously if they, you know, we are giving this a huge priority and we'll make sure that the resources are there for the inspections that we certainly haven't had any concerns raised around that, but we certainly keep a dialogue going to make sure that they do have the level of resource required to do a good job and I think they are doing a good job. The balance as well is, you know, it's not just that they go in and inspect and that's, you know, the health improvement side of things actually works with the board and the local manager team staff to make the improvements identified in the report, which is really equally as important, so the issues are identified, but before the inspection team go back to make sure if there were concerns that those concerns have been addressed, the improvement processes will be put in place and they will be helped to make the changes that they need to make, so they're not just left to get on with it and to share best practice that's happened elsewhere. I suppose that the concern is a shared learning, because we see many reports from one year to the end of the year and for the two-year period where we're identifying the same problems and each, you know, that an inspection report is something to survive and get over and manage publicly. Sharing, you know, what makes me wonder that in a two-year cycle we identify many problems and one hospital board or one hospital within a board and that's, and we then, a year later or even two years later, identify the problem again in another hospital within the board and the question for me is why does that happen when the, you know, why isn't there any shared learning, why are the issues that are addressed in one hospital not automatically pushed forward in others and I think that continues to happen, which is a real concern. You raised a very good point and that was why the message I gave to chairs at the last meeting was absolutely about that. Don't wait for the inspection team to come in and inspect your services. Look at what's happened, not just from reports from hospitals within your own patch but reports from hospitals in other boards and take the learning from that and make sure that proactively you are looking at what those issues and are more importantly doing something about it. We've also taken that work further though and Health Improvement Scotland are also doing that work, so they are taking the learning from a report and are then making the recommendations to the service that, you know, you need to look at this so exactly your point, don't wait for a report to find the same things in another healthcare setting, make sure you are looking to make sure that your hospitals have already addressed this, so we're stepping up that work. The senior management team within each health board area taking more responsibility for that is important too. There's the role of the non-execs as well that a lot of boards are trying to involve more in some of that work too, so you make a good point and what I would like to see and I'm more confident of is that we are getting better at doing that and hopefully we'll be able to demonstrate that to you. I would, but as I get back to this thing, we spend all our time on the inspections getting that and we're not getting back to ensure that that's your learning. I don't know if there was an assessment about what would need to happen in the inspection service. I don't know whether there was an evaluation from yourselves over the resources that the inspection agencies have, whether their budgets need increased, whether the resources need increased, whether they need more full-time employees rather than part-time employees or using experts from the health service themselves, where we get into a conflict situation or a possible conflict situation where we're using the health service not independently but people whose careers depend on the health service to inspect the service themselves. I think there are questions that arise out of that, would you agree or not? One of the things we've just done in the budget of course is to allocate another two and a half million for quality improvement which is absolutely part of making sure that we improve quality and learn the lessons, apply those, don't wait for inspections just to do that, so that resource will help to do that. I think that there are two or three things to mention. First of all, I'm sure that the committee is aware, but in case there are not, the chief executive of Healthcare Improvement Scotland comes to the meetings of chief executives and the chair of Healthcare Improvement Scotland to the meetings of the chairs. Although there is a degree of independence about what Healthcare Improvement Scotland does, nevertheless those points that the cabinet secretary has been making and that I've been making to the chief executives are made with Healthcare Improvement Scotland in the room, so they're not separate from that discussion. Your second point about whether it's appropriate to have inspections carried out by people who are within the NHS. I think that the evidence of the Healthcare Improvement Scotland reports, for example, done on NHS Lanarkshire and NHS Grampian would make it fairly clear that the colleagues from other parts of the service do take their professional duties very seriously. Indeed, if a robust report is required, they will deliver a robust report. The risk associated with having any form of improvement inspection or review carried out by people who are exclusively not within the service in filling out their professional duties from day to day. You then risk getting an inspection regime that depends on people who are not day to day involved in the delivery of patient care and services. The committee's right to ask the question, but getting that balance is very important. I would certainly want to see inspection regimes continuing to include people who are, themselves, part of the front line in delivery of patient care and services. That's maybe an issue that we can't move on. Do you supplement it? In terms of the frequency of inspections, does HIS look at the variation? That's a theme that I've certainly been pressing on a whole range of issues. If we take, for example, the last report, that Lothian had a rate of 48.1, which had increased from 41.8 in terms of the rate of better occupied days compared to the target figure of 32. It was going in the wrong direction, but does that mean that HIS takes that into account in terms of their unplanned? It's also the whole of Lothian, which is a big area. It could be any hospital in there that's causing the problem. They would risk assess all that in terms of where they would focus their inspections on, so, as Jonas said earlier, when they're making their plans for the inspection processes for the coming year, they will look at all those factors in order to risk assess where they think their time is best spent, and they take those factors into account. The other bit of supplementary is if you take something like the PVC bundle report on Glasgow, which was repeated three times in three separate reports and was still unsatisfactory and was still a high priority. In terms of the McLean report, what action do you expect HIS to take when they get not once, not twice but three times a repeat on the same high priority issue that the PVC bundle is not being, guidelines are not being appropriately followed? I think that that is something, and I know that Glasgow have taken that very seriously, and they've invited other help and support in to make sure that the PVC bundle is put in place. What HIS would also do is take Health Protection Scotland's advice, so looking at the other infections such as the Staph aureus, the bloodstream infections that would be caused perhaps by the PVC bundles not being appropriately made, and Glasgow's performance in that is good. It's looking at everything in the round, and Health Protection Scotland as well will advise HIS in terms of looking at the monitoring of infections as a consequence of the bundles. PVC bundles are part of the patient safety programme, so there is a continuous improvement element of that to make sure that that's fully implemented. It was also just to say to the committee that when Fiona McQueen took up her role as interim chief nursing officer, one of the first things I discussed with her was my concern that we followed through on inspection reports and that we had assurance that this was happening, so if it would be helpful to the committee in due course, we could provide a report that describes the actions that we're taking, not just about the Vale of Leven—very significant though that is—but to assure ourselves corporately that we are taking every inspection report seriously and that we are not simply waiting until the next time an inspection comes round to work out whether we have responded appropriately. I think that it's entirely appropriate that we have that assurance and I've asked Fiona McQueen to help me in providing that. I think that that offer is appreciated. It's a long time since the committee has actually looked at the inspection regime. We did look at it in some detail and we may want to come back to that at some point because we know that the inspections are sometimes directed by Government, such as the acute sector and all that. An update on that would be useful and we appreciate the offer and, indeed, the offer of other information in terms of the analysis that is currently going on that the cabinet secretary offered earlier. Thank you very much for that. We've won, and I think we're none yet, followed by Dennis. Thank you, convener. My original questions about communication have largely been preempted and I'll go on to something else, but before I do, in my experience of the health service over many years, communication has always been an issue, not just with infection, but just to get basic proper communication between medical nursing staff and patients has always been an issue. It's quite concerning that we're in the 21st century now and that is still an issue. I know that you've been working on it. Are there any further steps that any of you think can be done to try and get this proper culture of openness really going right through from the top down to the patient level? We are, of course, looking at the duty of Canada in terms of the public health bill. I think that the most important thing with that is just again the opportunity to reiterate the message of openness and meeting to make sure that there is a duty on all staff, no matter who you are within the organisation, to report any concerns and that that becomes the cultured. Clearly that was an issue at the Vale of Leven that what people saw, some people brought concerns to the attention, but then in some cases that wasn't acted upon, but others perhaps didn't. The duty of Canada I think will help to add to the cultural changes that are happening and a need to happen that are absolutely about a culture of openness and people speaking up about things they see that are not right. I think also our person centre programme of putting people at the centre of everything that we do will help. Government expects there to be open visiting so if families and loved ones are there more helping with care then that level of communication almost disappears because they are there and they know what is happening, but we are expecting there to be full open communication, people involved in decisions about their care and their loved ones and getting access to consultants or nurses. We know what times can be problematic but we are expecting that to improve and some of the person centred work that we are doing showing big improvements in how people experience communication and it will also be part of our care assurance programme. Just in responding further to Ms Millan's point, let me start with something that doesn't work. There has been a long tradition in the NHS in Scotland of issuing things called chief executive letters. I have more or less put a stop to that. There are some times when you have to do it because there is a legal requirement to convey information or it has to be done in that way. To be quite simple about writing a letter to chief executives saying something is no way to get front line staff to understand what the issue is or to engage them in any delivery of it. For example, what the cabinet secretary did was not write to chairs and say, dear chairs, here is the veil of leaving report, it is very important and I expect you to do something about it. Instead, we wrote to chairs and to chief executives and said, this is the veil of leaving report, here are the recommendations, now come and tell us what you are doing about it and that is why we are able to report to the committee today on the progress that we have made. On this patient safety programme, we are increasingly embedding the culture that it is important to put up in the ward where patients and staff can see it, the trends on patient safety. I believe that as we become more transparent in the NHS in Scotland, we will improve the services. I have said to this committee and the Parliament audit committee as well that sometimes it will be difficult, sometimes we will see things transparently that we wish we had not seen but, in fact, only by doing that will we improve the service and only by doing that will we give patients and staff the confidence that it is all right to say something. The last point that I would make is that one of the parts of the patient safety programme is that it gets people to speak to one another. For example, in wards or in accident and emergency departments, we have morning huddles where the staff come together and discuss what the issues of the previous day have been and what the issues of the day are that can be seen. That, I have to say, works a hundred times better than a letter from me telling people to do something. I am very serious about face-to-face communication. I think that it is the way forward. I am pleased to hear that. It is almost reminiscent of what we used to have with nurses getting together on the handover and discussing patients and handing that over. A lot of patients are still a little bit in awe of a white coat and a uniform. That can be much less formal and better communication. That would be great. I was going to ask about antibiotic prescribing. Lord McLean was very critical about the mismatch pre-2008 on the difference between the guidance on prescribing and the actual practice of it. I wonder if you are confident that things have been a lot of advance since then, but are you confident that Lord McLean's recommendations will be carried out in that respect? The other thing is that the report highlights quite unacceptable delays in starting appropriate antibiotic treatment for patients who are diagnosed with the acidifasil. There has been a huge amount of progress in this area, driven by the Scottish Antimicrobial Prescribing group. I do not know whether you have seen the latest report that they published in January, which is certainly worth a look at if you have not seen it. Basically, there is a huge amount of work on the use of antibacterials in hospitals and the appropriate prescribing. The amount of work that has been done in that area has shown big benefits when you look at the reductions in infection levels on MRSA and on Cdiff. We have come a long way from those days, particularly around the prescribing policies. We need to keep one step ahead, because when I was visiting the hospital recently and we were talking about the success of the patient's safety programme, in some ways it is always trying to keep one step ahead of the next big challenge when it comes to infection. We are always going to face new challenges and it is difficult to keep one step ahead of that. I think that the work around the patient's safety programme is trying to do that so that there is absolutely no complacency there whatsoever. A lot of progress but no complacency because fighting infection in our hospitals is an on-going battle and one that we absolutely need to keep ahead of. I do not have anything to add other than that our acting CMO Dr Keill had the controlling antimicrobial resistance group as part of the national UK approach to taking that forward. Absolutely, when you look at the numbers and figures of reduction in the antibiotics, we want to see reduced that happening. As the cabinet secretary said, our sepsis bundle is part of the patient's safety programme, which is an indicator of getting antibiotics to the patient within an hour. It is certainly showing some very, very good progress. There is also a specific issue with the incidif of nanospectrum antibiotics. Dr Simpson will keep me right if I get wrong on that. South of the border is prescribed for first recurrence or people at risk of recurrence, whereas SNC recommendations for Scotland are simply for first recurrence and not for those at high risk of recurrence. I do not have any comment on that. I think that the prescribing of it is very patchy across health boards, particularly in Scotland. It is a matter for boards in terms of their own formulary for what to prescribe, but Dr Keill's group under the HCI task force will be looking at prescribing. Health protection Scotland also gives us views and advice on prescribing, but the treatment of the individual patient is up to the clinician when it comes to that doctor making a decision about what is best for their patient. I was actually going to go on the antibiotics and I shall move on slightly, but there was work criticism that was mentioned with reference to the specimen identification and getting to the laboratories and timely results from the lab and getting it back to the doctors. Is that improved? Yes, it certainly has. When I was visiting the Aberdeen royal infirmary, I had the opportunity to go behind the scenes to visit the labs. What struck me was the amount of technology and technological improvements that have been brought in to speed up a whole range of procedures and tests that have transformed the ability to get important information back into the hands of clinicians who are making judgments. It has improved significantly. If I may move on, in your opening statement, Cabinet Secretary, you referred to the reference group. Are the members of the reference group from all over Scotland to reflect the different health boards and the requirements of each individual health board? I will let Fiona say a bit more about this. I have met some of the Vale families on a number of occasions now. It was really important that they were satisfied with the arrangements that were being put in place. The reference group was really borne out of those discussions. We wanted to make sure that they had an on-going involvement and a really important role. We also recognised that there was a wider Scotland-wide perspective. Fiona, with her work with the group, has looked at that. Do you want to say something? I apologise. I am not sure that we have somebody from every geographical area in Scotland. Our families from the Vale are clearly represented, but perhaps our public partners from Healthcare Improvement Scotland or our third sector voluntary organisations such as the Alliance, the Health Council and representative bodies that can have a representative role across Scotland are working with us. It is important that, given the situation that came from the Vale, that each area can have the confidence that it is being represented in the reference group? Yes. A lot of the work of course of the implementation of the recommendations is for the boards to take forward and there are public partners involved in that. We would expect them to involve their public partners in that work. The reference group's role is about making sure that the work of the implementation group is overseen and that the public gets that reassurance that the pace is enough, that the monitoring is enough. In terms of the detail locally, we would expect the boards to also be involving public partners and their non-execs in driving forward the improvements that need to be made. Can you advise what discussions have taken with the general medical council given that they are the regulator of the medical profession and what their views are with regard to Lord McLean's report? We put the report in front of the GMC and the nursing and midwifery council at the time. If the committee would find it helpful, I could ask Dr Keill to give a report in writing on engagement with the GMC on the issue, because I do not think that it would be right for me to try and give a superficial account of that. However, if the committee would wish, I can certainly ask Dr Keill to do that. Will discussion have taken place? Yes, we have already been in touch with them. We now move to Richard Lyle. Thank you, convener. Actually, one of the questions Dennis has just asked, but I will be more than happy to carry on with another question. Lord McLean made six recommendations, 36 to 41 to NHS boards, relation to medical care. These covered the range of issues including sufficient medical staffing levels, clinical assessment of patients with suspected 6G diff, ensuring clear and accurate patient records, ensuring there was no unnecessary delay in processing laboratory specimens. He found that medical care of patients suffering C diff was inadequate, poor record keeping, failures to carry out proper medical assessments and review, inappropriate prescribing and unacceptable delays in the commencement of appropriate antibiotic treatment, which again has been covered slightly. So what do you, cabinet secretary, expect from NHS boards and ensuring that the lessons from Lord McLean's report, in respect of the failures of medical care, are learned? Just before I come on to answer that, I maybe can just having looked at the figures that the convener asked earlier on, just to clarify that point, that 11 boards have met 80% of the recommendations and those apply to the 14 territorial boards, so the average is 75% across all of the boards, so I hope that that clarifies that point. Sleit variances when you're… I know, well it's important just to put that on the record, but in terms of Richard Lyle's point, I think, I mean this gets to the nub of really some of the issues here on the medical care and the nursing care, that there was appalling practice and poor record keeping part of it, but just of the whole poor care from clinicians and from doctor and from nurses, that was laid bare in the report. In terms of what has happened since then, we've touched on some of that already in terms of making sure that there were no delays, making sure that getting information back on tests, all of that is completely different from what it previously was. Things around record keeping have improved, but we absolutely need to keep a watchful eye on that because still sometimes when complaints are raised, sometimes record keeping is still an issue, not to the extent it was in the Vale of Leaving report, but there are still issues that we need to make sure that we improve that because it is important and communication as well. Again, that was highlighted very clearly in the medical care and nursing care that there was very, very poor communication. Again, although huge improvements have been made since the report, it's something that we need to keep on top of because sometimes when complaints are made again, it is often about poor communication and particularly with families. We're not complacent by any manner of means and we want to make sure that any other complaints that have been investigated or reports that come up, we always are trying to make further improvements. Do you want to say anything about the medical care problem? I think that this is an integral part of the board response. Just in responding to Mr Lyle, what I'm concerned to see is that the board responses to the 65 recommendations are all of a peace so that there isn't a part that this is down to doctors, this is down to nurses, this is down to cleaners, as though we went back to a siloed approach that left people with the impression that as long as they did their bit, everything would be fine. It is only when we join this up. I think that again to refer to the Scottish patient safety programme, one of the things that that has done is to, in my view, greatly improve the communication between medical and nursing staff, allied health professionals and other staff who provide services face to face with patients. My response, Mr Lyle, would be to say that it would be important that we set these very important recommendations in the wider context of the whole delivery against the recommendations. However, I can assure you that both the national clinical director for healthcare quality, Professor Jason Leitch, who leads on the patient safety programme and our acting chief medical officer, along with our chief nursing officer, have been personally engaged in ensuring that the recommendations for all parts of the service are met appropriately and in line with our current safety standards. I am sure that, from the time that I have known you, Mr Gray, I know that you are committed to the NHS and that you want to drive forward as much and ensure that we have the best service in the world. You said earlier that you do not do chief executive letters any longer, so, given that Lord McLean stated that NHS Greater Glasgow and Clyde learnt lessons from the failures after 2008, what work are you doing to undertake to ensure that these lessons are rolled out to all NHS boards? I know that you are not doing letters, but what instructions are you putting down to these boards to say that we cannot tolerate that situation? I said that I have tried to greatly reduce the number. There are some circumstances in which I cannot do it by another means, but what I am seeking to convey to the committee is that I am not going to hide behind a letter and say that I have done my bit of the job by writing a letter. Both the Cabinet Secretary and I have engaged directly with the chairs and the chief executives, and when Professor McLean has completed her analysis of the responses, we will be going back directly to the chief executives and to the chairs with that to discuss with them both the quality and timeliness of their response and also their plans for implementation, as overseen by the implementation group. That is not something that we have done, either the Cabinet Secretary or I, on a one-off basis. We have done our duty by ensuring that a plan has been produced. This will be kept under review, and this will be the subject of discussion directly with both chairs and chief executives. Lastly, if you allow me to the Cabinet Secretary, what further actions do you believe would be required to implement the recommendations of Lord McLean in the area that we have just discussed? We have got to make sure that we are satisfied and that the implementation group is first of all satisfied that all of the recommendations are properly implemented. That is why, earlier on, we were talking about the oversight and monitoring of that. It will absolutely not be a tick box exercise. It is about making sure that some of the changes that have already happened, and it is worth reiterating that boards did not wait for those recommendations to come out in Lord McLean's report. Many of the fundamental things had already been actioned and changes had already been made, as you would have expected, on such important fundamental issues. We are now down to some of the other recommendations that are maybe going to take a little bit more time, but absolutely will be implemented. Then it is about making sure that the monitoring of that goes on, that the foot is not taken off the pedal, if you like, to make sure that we constantly keep up the pressure and scrutiny around those fundamental aspects of how healthcare is delivered. To reassure you that we will be monitoring and making sure that boards do not just say that they have done it, but that we know that they have done it, and that we keep monitoring the on-going effectiveness of the recommendations that are being implemented. Two quick questions. One is about recommendation 74 in the report, which is about comparison with other jurisdictions. One of the problems is, of course, when you look at Wales, Northern Ireland and England, they actually report differently. We might be useful in having discussions with them to try and have a uniform system of reporting so that any opportunity to learn lessons is based on comparable data. Having said that, the two areas of variation that interests me at the moment are that England reports from the age of two, whereas we report from the age of 15. I appreciate that there are probably very few cases between two and 15, but, nevertheless, it seems to me, even if there are a small number of cases, that it might be useful to understand why there is a difference. The other thing, which has already been raised by Nanette Milne, is the difference in guidance on Fidaxa Mysyn, where potential recurrences and high-risk patients are recommended in England, but not in Scotland. I appreciate that it is a new drug that is just coming out. It is expensive, but, nevertheless, if there is a difference in the recommendations, it would be interesting to be asking SMC what the reasons for this are. If there are good reasons and we stick to our guns on that, it would be interesting to have that. I wonder what other things you have looked at in terms of the recommendation 74 variation that might tell us something. On the broader points, we absolutely learned from any report. The Francis report we wrote to boards asking them to absolutely look at the findings of that report. We are awaiting the report on Morkham Bay, which, again, we will make sure that lessons are learned for the service here. In terms of communication, I just had a video conference with the Welsh health minister last week, and one of the issues that we were looking at was very much around the sharing of the Vale of Leaving recommendations with the rest of the UK. The Welsh health minister was keen to look at the application of the recommendations to the health service in Wales. I understand what you are saying, but sometimes the systems are different, and there may be good reasons sometimes that we do things in a different way. However, there are always lessons to be learned from difficult and challenging reports, no matter where it occurs, not just within these islands, but further afield as well. On the point of the age of two to fifteen, I do not know, but, on both points, we can ask Health Protection Scotland for advice about the differences, similar to the fact that we can go back to SMC and write back to the committee on that point. On chapter 16, death certification, whether that has now been sorted out in terms of recording. One of the questions that the Vale of Leaving families were concerned about was that it was not always recorded that it was a contributory factor. I hope that we have got that reasonably sorted. If there has been an episode of C-difficile, even if the patient dies, subsequently from another cause, nevertheless, obviously the weakening of their condition through C-difficile should be recorded, and families explained as to what is actually going on. Just one of those recommendations, 68, 69, 70, 71, have been... On that, HAI deaths, as you are aware, are already recorded by the national records of Scotland. Since September 2008, GROSS has published information about CDI deaths on their website. However, once the death certification act comes into force this year, it will provide an additional review mechanism. That will include random sampling and giving ministers the discretion to direct a review in any area of concern. It is another check in the system. The only other thing to say in response to Dr Simpson is that we were reviewing what the boards have put to us, but we will ensure that, encapsulated in further advice to the committee, is also the progress on the recommendations that were not for the boards, just to make sure that, again, having made to Mr Lyle the point that we want to give a complete picture here and not be piecemeal about it. However, I understand entirely the point about the importance of accurate recording and death certification, and ensuring, as far as we can, that it reflects the actual circumstances, as opposed to just a single cause that might have had other contributory factors. Of course. Just a small supplementary on that last point to Mr Gray. With reference to the certificates, I hear what you are saying. Obviously, co-operability makes it quite difficult with some areas of the actual cause of death. Are you saying that the other factors and other ailments are going to be recorded within the certificate? There are lots of reasons why people die, sometimes on an operating table, for instance, and the cause can be very difficult to identify. Are you giving us an assurance that all aspects of the patient's health, in terms of a contributory factor to their death, will be recorded? No, just for clarity, Mr Roberts. I cannot give such an assurance, because clearly the decision on what to record rests with the person who is recording it, and I am not clinically qualified to decide on or overrule any such decision. However, as the cabinet secretary has said, there are provisions coming in that, if there is a concern, based on the sampling about the extent, accuracy or completeness of the recording, there will be opportunity for that to be reviewed. However, it would be wrong of me to give an absolute assurance to the committee, and, indeed, the fact that there is a review mechanism in place suggests that this is something that we will want to be keeping an eye on. Would that be clinicians and or patients that would actually bring this forward if they were not satisfied with the certificate of death? I think that that can already be done, but if the committee would find it helpful, we can provide a more detailed briefing on the provisions and the legislation and what it is intended to produce by way of effect. Very briefly, on the recording of C.diff, and if you want to write to me with information, that would be fine as well, because I am keen to allow the constituency member to get in and get some questions as well. Just in terms of when C.diff is recorded more generally within the hospital estate, I am understanding that many people will present to hospital who are going to have C.diff on arrivals. It is not a matter of whether it is about footfall to hospital and people having C.diff, and then whether they contract it whilst in hospital, and then the certification of death where tragically C.diff is a contributing factor, or not as the case may be, but they may have had it on entry to hospital as well. Is that New York's within statistics, or is that something? I am conscious that I do not want to tie health boards up with bureaucracy, but just in terms of understanding the patient flowing the statistics and how that is rolling out through the hospital estate, is that something that is New York's within the statistics? Yes, it is. You are quite right to highlight the fact that people from the community bring in infections often to the hospital, and that is one of the challenges. The recording of hospital acquired infection is absolutely that. It is about infections acquired in hospital, not acquired in the community. That is an important distinction. What we would record is where there has been an infection from one patient to another within the setting. I think that that is a point well made that many people have the cluster individually within their system, and they live a very healthy life. It is either when they are given other drugs that causes a flare-up, or tragically, if it were to be transmitted within hospital, that that would then cause a problem, and yes, those figures are recorded as such. Thank you very much. I thank the members. I now move to Jackie Baillie, a member for the Barton Brackets Vale of Leven, for her opportunity to ask some questions. Thank you, Jackie. Thank you very much, convener, and I thank the committee for the opportunity afforded to me. Can I put on record, right at the outset, my welcome for the approach that the Cabinet Secretary has taken, in particular the involvement of the families in the implementation, and the discussions reported to me by the families have all to date been extremely positive, so I very much welcome that. Can I start by just craving your forgiveness? I lack confidence in self-assessment, and I know that you have asked the boards at the initial phase to self-assess where they are against the recommendations. The Cabinet Secretary will be aware that self-assessment was part of the problem in the first place that health boards were asked to self-assess their HAI measures, and they just comprehensively failed to do so. So can I ask, given that I think we would agree that we would want on-the-ground verification that this is real, and that you're reporting to us in spring, will that verification have taken place with all health boards, not as a paper-based exercise, but in reality before that time period? I think that you make an important point. The involvement of the families in the implementation group and the reference group is really, really important here, because you're right that self-assessment takes us so far, but it was a starting point. We needed boards to tell us, first of all, where they were at in relation to these recommendations, but the implementation group is very clear that its job is to verify and to monitor and to check that that is indeed the case, not just on the 65 recommendations, but on the 75 recommendations, so the recommendations that are for others to implement. That process will be an on-going one, and we will have got to a good position in spring in terms of our response and to the report in terms of where we have got by the spring, but the work of the implementation group will go beyond that and will be an on-going piece of work to make sure that they are satisfied, in particular the families are satisfied, that no matter which health board it is, that these absolutely have changed practice where that needed to change, bearing in mind a lot of the recommendations on some of the fundamental things that were implemented well before Lord McLean reported. The reference group, I suppose, provides an additional level of scrutiny to all of that, to scrutinise the implementation group in a way that gives the families more satisfaction again and reassurance that the implementation group itself are doing a good job in monitoring all of that. So I think we have put in, I feel we have put in enough safeguards that we have, and I think you are right, I think the families today anyway feel that they have been involved, but we are not complacent and we want to make sure that that continues to be the case. I suppose Cabinet Secretary, I want to know in my head that by the time you stand up in spring what those self-assessments say is real, and I accept what you are doing in the medium term, but it is that short term, sorry, check, and I wonder whether the healthcare environment inspectorate does not have a role to go in and check the validity of what is being said just now, and I wonder in your response, I am intrigued. 11 boards have made the 80% mark, which ones haven't, and how close are they? Okay, I will come on to those in a second. When I stand up, I will want to have been assured that absolutely the implementation of these recommendations is real and making a difference, and that will be the case. However, the implementation group's longer piece of work is supposed to make sure that the momentum behind those recommendations is kept up, because it is not about a moment in time job done, everybody is happy, it is about making sure that the culture, the changes that the recommendations make are forever, and therefore the involvement and the reassurance of families of that for me is very, very, very important. In terms of the three boards that have to make the further progress, we have three boards, Dumfries and Galloway, Lothian and Orkney, have fully or mostly implemented less than 80% of the 65 recommendations, but only just. They are all in the 70s, so only just, and we will make sure that all of those three boards are get to the position of other boards and that all boards implement all of the recommendations. There is no ifs and buts there, that is exactly what will happen. I move on to the HAI task force or whatever it is that we are calling it. We got kind of lost in language there. Let me be as blunt as possible, because there has been an infection control team in Greater Glasgow and Clyde, there has been an infection control committee in Greater Glasgow and Clyde, all of these structures were in place in Greater Glasgow and Clyde, they just failed to work, so whilst I hear Fiona McQueen and absolutely agree the need for these kind of structures and accountability, Greater Glasgow and Clyde would argue that they had those in place that would enable you to go from ward to board in terms of reporting mechanisms. Now, we know from the report that the clinician responsible didn't attend meetings from July 2007 that she was responsible for chairing, didn't attend Greater Glasgow and Clyde meetings for 18 months over this period when the infection was raging at the Vale of Leven hospital, so I wonder, given those systems were in place, given we've had a description of them just now, what's actually specifically different? I can tell you very directly because I get alerted straight away when there is any cases of C.Diff or other infection within hospitals, whether that's in Glasgow and Clyde or elsewhere, because the monitoring systems work and that information is relayed very quickly to us and therefore any action required is taken very, very quickly. Now, in all of those cases, these are not necessarily outbreaks as such, it's just cases of C.Diff, so that dashboard, if you like, is working and I know it's working because I get alerts to any cases. Now, that would not have been the case back in the Vale of Leven, certainly not within Glasgow and possibly certainly not the speed of that information is very different and I have seen it for myself, so I'm reassured that we have not just the processes and the people in place, but that it actually works and that flow of information is very, very quick and more importantly, the response to it is very, very quick. So, for example, patients are isolated, all of the procedures you would expect to kick in to prevent infection spread happens when I go into hospitals now with the live screens and tell the story very visibly about who is where and whether where, if there are any cases, where they are, people, that information is there for everyone, not least for the staff to know in terms of anybody coming on shift what the actual picture at that moment in time is. So, I hope I can give you reassurance that that, you know, I have seen it for myself and I'm absolutely reassured that those systems are now working and that the situation that arose in the Vale could not happen again because of that, there are so many people watching and monitoring that information for very good reasons that, you know, we don't just, you know, we don't rely on a single person in the system to report, there is a lot of people whose job it is to make sure that these matters are monitored and acted upon. That's helpful to know. Can I ask Fiona McQueen may have made an inadvertent comment or maybe I just misheard her. You talked about the reconvening of the national task force, has it been dormant? No, it's not and I did try and correct that suggestion that it hadn't been, there's a national advisory group, there's different structures that I think could be more efficient and therefore I'm renaming and reforming, smaller, more efficient and effective and more targeted group. Great, we like reform and efficiency, that's always a good thing. Can I ask the cabinet secretary raised the question of isolation facilities and that was a particular lack at the Vale of Leven hospital. Can she advise the committee whether isolation rooms are now available in every hospital in Scotland? Well, certainly the processes that kick in when someone is alerted as being infected so a test comes back and immediately as I was describing to you earlier on the person is moved or in fact if there are any suspicions then the person is not in a bed alongside other people so those processes kick in straight away to minimise infection often while the test is being commissioned and awaited. So yes, there are absolutely the change in the way that infection is handled is very very different and staff now know how to minimise infection potential. Sometimes unfortunately there are still cases of hospital acquired infection but the numbers and the drop in them I think tells its own story that those procedures, isolation being one of them, not just in terms of when the test comes back but if there are suspicions, all of that and all of the other actions that staff now know to take in terms of good infection control have resulted in those huge reductions in HAIs. I accept what she describes about the process. One of the significant challenges raised by nurses was that in order to fulfil the process she describes they need in isolation facilities and they just weren't physically there and that caused quite severe problems at the Vale of Leven but indeed on an ongoing basis. So my question was quite specific about do we have those physical facilities that enable that process you described to happen? Well, so for example I saw for myself at the Glasgow Royal Infirmary when I was visiting it's very visible where as someone with an infection they are isolated and indeed the information is very clear in terms of the barrier that is required that patients are not staff and patients are alerted in terms of that person's space so all of that is very different from some of the issues that we had unfortunately at the Vale. Can I deal with just the very real pressure on beds at the moment? Again that was a feature at the Vale of Leven, a hospital kind of operating under a great deal of pressure. I think you know over the winter period there was a significant footfall at the front door as we're seeing across Scotland and what hospitals do is they open new beds to cope with that pressure, albeit on an interim basis. Those beds tend to be squeezed into the same space so actually the proximity of beds to each other is much closer than is desirable. How do we ensure that that doesn't happen again in responding to temporary pressures, the likes of which we see currently in the NHS? So the system over winter has been challenging and you know there's work to be done on why particularly in Glasgow and Clyde the acuity of patients. There are also issues of kind of late flu surges which we're looking at at the moment so all of that has led, as you rightly described, a pressure on beds. However there is a lot of preparation for winter in that surge beds are planned for and therefore open when required and those surge beds would be, we would expect the guidelines around space and staffing and infection control to be the same for those surge beds as they would be for the beds that are there in the system the rest of the year. We're also of course developing and expanding the intermediate care beds and again it's really important that the infection control systems around those beds are good because quite often these are elderly people who are on their way home but they're clinically ready for discharge but not ready to go home so again vulnerable potentially to infection so making sure that the protocols and the guidelines around those beds are good and follow the best practice in terms of infection control. So you know we absolutely need to make sure that where beds are being used and there's a high capacity that the turnaround of beds that there's the clientliness standards are there and again we need we're keeping a close eye on that to make sure that where that there enough time is spent in cleaning the patient area when someone is discharged from a bed and someone's coming in to a bed so all of these things are absolutely our issues but one that we need to keep a very close eye on not just over winter when beds are in demand particularly but just all the year round because it's good it's the best practice and we know it controls infection. Okay my final question on the basis I'm testing the convener's patients recommendation seven from the public inquiry deals with you know whether it's structural reorganisation or significant change and it talks about specifically regular reviews of process and a review should include an independent audit now I'm conscious the southern general is probably the the largest project of its kind certainly in the Scottish NHS if not the NHS across the whole of the United Kingdom has there been that independent audit of infection control when was it undertaken and by who can I first of all answer the issue on service change I think what was apparent in this case as you know was the fact that there's just a lack of certainty over the hospital at the time I described it in the statement as a hospital that was out of sight and out of mind and was not being given the attention it should have been and the lack of certainty about this future played in I think to staff morale and and all of that so absolutely lessons have been learned and had to be learned around any service change proposal to make sure that that we you know make sure we learn the lessons from that I mean in terms of the new south Glasgow hospital I mean it is the you know a huge change as part of a long-standing acute services review in Glasgow the facilities at the new hospital are second to none in the state of the art and all of these processes and procedures are will be tested as before staff and patients migrate on to the site from April onwards as you can imagine this that is no small feat it is a big big job to to migrate all of these services on to the new site but infection control is critical and of course one of the reasons that the hospital has been built in the way it is with the single rooms was part of wanting to take best practice of infection control procedures and that's part of the design of the building and so you know you can be assured that absolutely all of these issues will be taken forward let me press you on this because you know here we have a new hospital that's going to open after the public inquiry has reported that is in greater Glasgow and client a specific recommendation was an independent audit I'm asking you has one been carried out when was it carried out by whom and can we see the conclusions well what I certainly will get that information to Dracula I don't know of you yeah I mean there is a the cabinet secretary has already met the chair and the chief executive of NHS greater Glasgow and client to discuss the plans for opening the new hospital I was part of that discussion we've asked for an update on the whole scope of these plans and if it's helpful to the committee we can provide information including a response to miss Bailey's question just so I'm has there been an audit carried out as per the recommendation I haven't had the report so the answer you don't know convener is I do not yet know I have to check that and we will we'll get that answer to you and to Jackie Bailey that that's fine whether it's taking place or not or what information is available and if it hasn't it will yes so okay okay can I thank the members and Jackie Bailey for being with us but most of all the cabinet secretary and their colleagues thank you very much for your valuable time and evidence with us this morning I'm going to suspend at this point very very briefly I'm going to ask members to remain in their chairs and don't break up we're going to clear the room and we're going to move to our next item on the agenda which is item two which we have previously agreed we would hold on private