 Welcome to the 13th meeting of the Health and Sport Committee of 2018. We have received apologies from Alec Cole-Hamilton and Sandra White. Can I ask everyone in the room please to ensure that your mobile phones are on silent and that if you are using electronic devices for other purposes please do not use them for recording or photography. The first item on our agenda is a declaration of interest and in welcoming Kate Forbes as our most recent recruit. I would also wish to place on record my thanks to Jenny Gullruth for her service on this committee. In accordance with section 3 of the code of conduct, I invite Kate Forbes to declare any interest relevant to the remit of the committee. Thank you, convener, and I have no relevant interests. Thank you very much and welcome formally to the committee and your first meeting The main item of business for us today is the scrutiny of NHS Lothian, but before we reach that point, just one other item that has to be dealt with, which is the subordinate legislation, we have one negative instrument before us, the national health service, general medical services contracts and primary medical services, section 17c agreements, Scotland amendment regulations 2018. There has been no motion to annul. However, the Delegated Persian Law Reform Committee has agreed to draw the attention of Parliament to the instrument on the grounds that it breaches the 28-day rule requiring instruments to be in place 28 days before they come into force. These regulations are intended to make various corrections to rectify errors in relation to two previous instruments that we considered in this committee, and it is for this reason that it breaches the 28-day rule. The view of the Delegated Persian Law Reform Committee is therefore that the failure to comply with the rule is acceptable in this instance. Are there comments from members on this instrument? If there are not, are we agreed to make no recommendations on this instrument? Thank you very much. That is agreed. We move on to hear from NHS Lothian. I welcome to the committee Brian Huston, chairman of the board. Jim Cromby, deputy chief executive, Alex McMahon, nurse director, Jackie Campbell, chief officer for acute services, Susan Goldsmith, director of finance and David Small, chief officer of East Lothian integration joint board. I understand Mr Huston that you wish to make an opening statement. Thank you very much and thank you for allowing us the opportunity. Can I just make one minor correction? You introduced Jim Cromby as the deputy chief executive. Jim is also currently acting chief executive, and many of you will know Tim Davidson, who unfortunately is on extended medical leave at the moment. So, just to make that clear. Thank you again, convener. I am not going to reiterate a lot of the long list of descriptive material that you have in the briefing pack, but I would just like to, by way of scene setting, I suppose, to touch briefly on a number of what we think the major challenges are. Those are probably self-evident to everybody by now, but nevertheless they are the things that override and influence the work of our board and indeed the day-to-day operations of the chief executive and his team. They are the obvious ones of the population growth trends that we face, the demographic changes within that, particularly the aging of the population, the rising in demand for acute services that that entails and the increasing incidents of multiple health conditions, multi morbidities, if you like, impacting on the complexity of care that we are required to provide, and all of that, of course, is set against the need to achieve financial balance. In the briefing pack, we have also listed examples of the progress that we have made in a number of areas, and I am not going to reiterate at least all of those, but it contains certainly the actions that we are taking against the outcome from the last annual review, particularly, and for the first time, of course, it contains information about the recently introduced regional health and social care planning process and how we are engaging with that. It talks, I think, significantly, given the number of the challenges that we face around primary care. It gives examples of what we are trying and testing and developing in terms of new models of primary care and primary care access, and it also contains, of course, examples of the hardware, the capital projects and where we are with commitments on those. The other comments that I would like to make, by contextualising what I hope that we are going to talk about today, is from a governance point of view, from the board's point of view, I think that it is perhaps important just to give a bit of a flavour of where the non-exec particularly board members see things in terms of NHS Lothian and its development and progress at the moment. I sort of summarise it by saying that we are moving increasingly into an era of risk management that we are facing, as I have indicated in the challenges, we are facing what Tim Davison would call the great conundrum. The great conundrum is about how we go about balancing performance management in terms of how we balance the protection, the sustainability of standards of patient care and quality and optimising things like access to services, balancing that with the need to achieve financial balance, also balancing it with the need to support a shift in the balance of care from acute services into community settings and undertaking the resource and funding transfers, which that implies, from acute to community services. That is the conundrum, if you like, the balance between those two, if not three factors and extending that further into our requirement and indeed our stated strategic objective to move up the supply chain a bit, to push ourselves back from treatment into the prevention and the inequalities agendas, which we all recognise are really the keys to sustainable long-term transformation of the way that we provide service. Because of that conundrum and the requirement to balance those issues, I think that we as a board find ourselves increasingly wrestling with what does that mean in terms of how we manage our risk profile, to what extent are we prepared to accept levels of performance in terms of capacity and access targets in order to protect a reasonable financial balance. To date, my board would agree that the levels of assurance that we have sought against the way that the executive is going about making that balance and optimising those competing, in some cases conflicting factors, is good. It is adequate, it is satisfactory, and we are happy that all the necessary stones are being turned over to optimise that balance. On the other hand, we do wrestle, if not struggle with, the judgmental requirement to take a view that says, for example, if our outpatient waiting list is going up from 5,000 to 20,000 over an extended period of time, then at what point, despite all the measures that we are taking to minimise risk within those waiting lists by prioritising patients and indeed other measures to do with access, at what point do we reach a level where simply as a quantum that total figure of waiting list becomes a level of risk inherent in that quantum, that we have to take different actions about, in other words perhaps putting at more risk our efforts to achieve financial balance. I merely sort of paint these briefs, as I say, that Tim's word, the conundrum, because increasingly from a governance point of view, those are the issues that we're wrestling with and trying to balance. I hope that's given you some kind of an oversight of where we see things and where we're at. In terms of responding to questions, I'm quite happy to feel these but to delegate these probably as the right word to my executive colleagues who will have more of the detail. Thank you. Thank you very much. That's a very helpful setting the scene and we will indeed have questions on pretty much all the matters to which you've referred. We had a witness on a different inquiry the other week who talked about the difficulty of delivering a preventive and health inequalities agenda because the department making the saving might not be the department that then had additional budget to spend. Is that something that you recognise as part of the conundrum that you've described and if you do, what do you do about it? Well I think it is and I think one of the difficulties in terms of the accountability of a health board is perhaps that you know health economics, let's call it, comes into play at this point and health economics of course has wider parameters than simply the accountability of the health board and therefore presenting as it were the business case which we would do in areas that are directly within our remit, presenting the business case that says we need to invest further in the prevention and the wider inequalities agenda within that. It's something of course that we can only seek to influence and not directly control. I don't know Susan Jim. I think one of the things that we are recognising is that we are going to have to take a risk so increasingly we are for example in the region we are prioritising investment into diabetes, the prevention of diabetes that is going to be a major strategic priority for us. We don't necessarily have a funding source but we have committed to as three boards is that we will put money into that so and it's the same you know in primary care where again the board is taking a risk because we think we want to support shifting the balance of care and so we may not necessarily be able up front to identify funding so we take a increasingly take a risk so just reflecting what the chairman said is that we're that's our focus is that is the risk worth you know taking that investment and we think it is. And what is that risk? What is the risk that you're contributing to? The risk is of not achieving financial balance and the risk obviously is if we don't invest then we will not you know we will not be able to sustain services going forward because the thing that is so significant is the upward trajectory and demand. Jim did you want to add anything? So I would just build on what Susan said that one of the prime examples of a transfer of resource from acute primary care is the shift of service out of acute hospitals to be prided in primary care and there's a view that to do that we create the services within primary care and we close beds and acute and the funding from acute transfers over and it pays. There's an issue of bridging that because often we can't establish a full service right away so we have to develop the service and in the interim we have to maintain the bed base and there's always that challenge and should we be a board that decided not to move forward unless funding was directly available there would be stasis and we wouldn't be able to move on that but I think the ambition that's been characterised by Susan details that we are willing to say that looks like a robust model of care we're going to invest in that and we'll use funding we'll identify funding that we'll use whilst maintaining the bed base with a view that once that's proven to deliver we can transfer the resource across. It's part of the order in which you do things. Exactly so. Miles Briggs. Thank you convener and good morning to the panel. In recent weeks we've heard about concerns with regards to the Endowment Fund and NHS Tayside so I wanted to see if the panel could give us a reassurance that in terms of NHS Lothian, endowment funds have been spent in a way which would be of the donor's expectation, specifically not on medical or surgical kit. Okay, also with a second hat as chairman of the trustees of the foundation, I think we can give that assurance but I'll pass to Susan, put me just to elaborate why that's the case. Within Lothian we have a very separate system of governance around our endowment funds. We refer to the endowment fund as our foundation so we have a separate charter, separate scheme of delegation, standing financial instructions, all our board members are inducted as trustees as well as board members and we have clear criteria against which any submission or application for funding comes forward against which the trustees prioritise funding. I have to say that the use of funds for medical equipment is entirely legitimate. The aims of the foundation and of the NHS are the same and our trustees recognise that we should not be using endowment funding for what we would see as core NHS business but there are occasions clearly when we will decide to invest in medical equipment and certainly some of the funds that are left to us are specifically for equipment, so I'm very confident that we have a robust system of governance around our endowment funds. I wanted to move on to GP services because one of the issues that, over the past two years since I was elected as a MSP for Lothian, has been what can only be described as a crisis within general practice. I don't have time to list the number of pressures in NHS Lothian and potential closures that we are already seeing. Where do you think that that can really be tackled and what sort of support do you think the Scottish Government should be providing you to enable that to happen, given what you've said already about the changing population, the growing population here in Lothian? I think that there's an awful lot happening currently in the planning phase or the early implementation phases in terms of changes to the whole scheme of general practice, including the recruitment and sourcing aspects of it, but I think that I'll pass to David initially to give us some more detail on that. I think that the agreement that the Scottish Government has reached with the BMA on the new contract is a landmark. The principle of the GP becoming an expert medical generalist and moving away from, over time, having to manage the whole team and the responsibility of premises is a landmark change. It's really important that the BMA and the Scottish Government health boards and the IJBs agreed in principle on the memorandum of understanding around that. It sets the scene for the next three years of change. In terms of the detail, there's a lot of detail in the contract, obviously, but there are several key points. The increase in funding for primary care is important and there's two tranches to that. There's the increased income for practices this year and there's increased funding to health boards and health and social care partnerships to implement the various stages of the contract. There probably are two or three highlights to pick out. One is how health and social care partnerships will meet same-day demand in primary care, but that, I mean, you've fallen your practice, you'd feel you need to be seen that day. It's not always possible to get an appointment with the GP. Part of the contract is about setting up new systems to allow people to be seen the same day by a range of professionals, not always necessarily a GP but a GP if necessary, to allow GPs to focus more on that expert medical generalist role. The transfer of vaccinations from GP responsibility to health board responsibilities is another key component, community treatment arrangements for things like taking blood or removing stitches and the transfer of premises responsibility from practices to health boards over time. It's a long-term programme, as people will be aware, no doubt, but those are key components of the transformation of primary care that we'll see over the next few years. The lead role for health and social care partnerships in terms of developing improvement plans is also really important because that will be done locally with local GP practices and local stakeholders as part of the integration joint boards responsibilities. I guess that we'd also be keen to demonstrate some of the work that we've already done. You characterise a situation of a service under du reste and I would concur with that. Often it's not just about new money and I think it's part of our role as a board to ensure that that which we already have we use most efficiently. In engagement with general practitioners and primary care teams, we've established a number of initiatives to just test different models of care. We've got examples where we're deploying Scottish Ambulance Service paramedics into practices to help triage and support the practice. We're identifying mental health practitioners, psychiatric nurses that are being allocated to practices again to take a burden away. We have pretty advanced in our use of community pharmacy to support GP practices and we're seeing positive feedback from the practices around the support and relief that that offers. So there's a number of areas that we are engaged with already that I think will form a construct for using this new money and supporting primary care. My question really was pointing towards what has gone so drastically wrong that we're not able to recruit people to Lothian. I've spoken to many medics who tell me that back in the day people would be queuing up to come and work in NHS Lothian in our GP surgeries and really where we're at now with the number of locums being used and actually an unsustainable service developing. How have we reached that stage and how do we come back from that apart from what you're saying is having to rely more and more on multidisciplinary teams? I guess the future is going to be a multidisciplinary primary care team. That's the future. What has driven that? Well, a reduction in individuals wishing or choosing to work in general practice. Equally there's a balance that's occurring now with general practitioners who are very clear that there's a work-life balance that they want to establish and the concept of partnership is not one that is as attractive as it used to be. So the workforce ambition, the workforce culture is changing and I think it's incumbent on us to recognise that and to support practices to ensure that services to patients whilst being provided by a multidisciplinary team offer the access that David spoke about, offer the outcomes and offer an assurance that people have been given for properly. Can I just pull Alex in here if you wanted to add? It's just building on what Jim had given by way of initial response so I think it is a multidisciplinary approach. We often talk about general practice and that refers to GPs when there are multiple other pharmacists and paramedics and nurses. Particularly from a nursing perspective we are now training a number at advanced practice, which means that they can do a lot of the assessment, the diagnosis, the treatment themselves. We're going through approaches just now of upskilling our general practice nurses once we work in practice so that they can do more around long-term conditions and indeed looking towards district nursing as well. I think that we can't be dependent on one professional group. We've got to look at them all. I'd just like to understand if you believe that difficulty-filling posts and a lack of supply doctors fundamentally begins with a lack of training places. If you're saying that more people are attracted to a better work-life balance and that being a partner isn't as attractive as it once was, are the 898 places that were available in 2017 sufficient or do we need to be ramping that number up? There are a number of issues around that. The attrition of trainees is a major issue that we need to look at. In training we need to assure that the concept of primary care is attractive to people and the training programmes need to reflect more opportunities to understand what is available in primary care. I seriously believe that we should not focus all of our attention on general practitioners. I think that the future, sustainable future, is predicated on a multidisciplinary approach. Although we might see an increase in trainees as being the answer, that needs to be balanced against the availability of other practitioners who would offer as good if not better a service to the practice population. I really do believe that that is a multidisciplinary future. Building on those questions, NHS Lothian should be in a relatively strong position to recruit and retain staff. I speak as a rural MSP in particular in terms of your location, but there are high vacancy rates among a number of medical specialties, particularly urology and dermatology. How do you explain those vacancy rates? I concur with your comments. NHS Lothian is in a very good position in terms of its ability to attract clinicians. You characterise a couple of examples where we are having difficulty. There are a small number of specialties where we are having difficulty attracting individuals. I think that, from a positive point of view, for the vast majority of specialties, we continue to maintain a positive recruitment model, but for certain areas such as urology—perfect example. If you looked at the situation for urology UK-wide, you would see that there are more posts available than there are consultants ready. Graduating consultants, doctors completing their training and being ready for consultant posts now have an opportunity to think of different posts. While we might assume that NHS Lothian is an attractive proposition, people are choosing district general appointments and people are choosing to return to the areas where they have come from in terms of their home towns. It is a complex environment. What are you doing to attract to those posts to be more competitive than other places? I think that we have an elegant and detailed understanding of what the demands are. We will continue to use urology if that is okay. We are identifying technology and innovation that will support the workforce to continue to provide a service. We currently have a small number of clinicians who have clinical expertise in prostatectomy. We identified that as a major demand stream. We projected forward and saw that as a major demand stream. We looked at technology that was available to support that individual consultant. We were lucky enough to be chosen to deploy the new urology robot. That has provided an environment where, for an individual consultant, that gives a bit of resilience and support. In terms of attracting new consultants to that area, that is a perfect example of the type of thing that we are doing. We look with the other clinicians at job planning, because work-life balance continues to be a theme that we have to evidence opportunity in our recruitment process. It is a combination of a number of things. Are you currently looking ahead in terms of the future for potential pressures in other medical specialties? In our submission, we talked through our workforce planning. That has become more comprehensive as we have engaged with our regional partners in Fife and Borders. We have identified a number of specialties where we believe that there will be pressures out there. That comes from twofold. The current workforce profile—those clinicians who are at a point where they are within five years of retirement, so we are identifying that in terms of a resilience issue. We are looking at the demand profile at a subspecialty level around what is coming into the organisation and the availability of trainees to understand whether there will be consultants. It has been more comprehensive around our agenda, looking forward around things such as the elective centres, where we are trying to identify opportunities to deal better with the demand. Jackie might talk about our process in that later on. However, where we have looked ahead, we see real pressures in some of the specialties now. We have talked about urology. Radiology is an issue, and aesthetics is an issue. Very often, it is a subspecialty that drives that real subspecialty and specialism in recruiting. Urology is a classical example, and Jim has described that at the moment we have a single-handed operator in relation to the robotic prostatectomy. Although we have not been able to recruit a substantive post there, we have been successful in getting a two-year locum to come in and join that team, so that will have a really positive impact there for urology. We have also just recently been able to recruit a consultant that will focus on some of our cancer pathways in relation to urology. It is very often that subspecialist area that we find as we are looking forward that we may have recruitment difficulties. Part of our response is similar to my response on primary care. We are identifying that the solution specialty level is not just consultant-based. It is an opportunity, as Alex Spolkov, to develop advanced nurse practitioners, to look at the role of the EHPs, to look at primary care in a different way in terms of maintaining people. It really is a whole system process to try and ensure our ability to deal with the pressures that we have seen coming. Thank you very much, Brian Whittle. What I wanted to do is explore workforce planning. It is not just about recruitment, it is about retention of staff and the increasing pressures of the environment in which they work. We are looking perhaps at what we are doing at the colegensant of the health of our healthcare professionals. That speaks to a continuity of care, and it speaks to absenteeism as well. I wondered what your thoughts are around the environment in which our healthcare professionals are currently working and what you are doing to try to create that environment that allows retention and that allows recruitment. I guess that the first thing is to really understand from the individual's point of view how they are feeling. iMatters is a perfect tool that we use to just understand elements of workforce feedback. Some of that raises issues around the pressure that people are under. Part of our process—I go back to it—is incumbent on us not just to seek new investments and new funding, but to ensure that we are using the funding that we have appropriately. Some of that can see the development of additional admin and clerical resources to reduce consultant time spent on admin work, allowing them time to deal with the clinical work, identifying other clinical staff—whether it be advanced nurse practitioners or others—to reduce the demand on individual people. Our occupational health service is a key support to us. Where we identify individuals, we can offer them rapid access to occupational health. We are cognisant in our workforce plan of the age of our workforce. Similarly to the dimensions and the demographic changes that we are seeing in the population, we are seeing that in our own workforce. There is a recognition that we are seeing an ageing workforce. Some of the other issues that we look at—the more acute specialties—is there an opportunity to take the older members of our team off things like on-call to try to reduce the pressure and strain on individuals. I think that there are a number of opportunities to be able to do that. I wonder whether you will just walk wide in and bring Alex in on the nursing dimension. I will build on what Jim has said. There are also interventions such as mindfulness and yoga and exercise that people might dismiss, but the feedback that we have had from staff during their lunch break is that having a 20 or 30-minute session such as that is a positive experience for them and gives them a bit of resilience. Resilience is the theme at the moment, in terms of how we make our workforce resilient for the current environment and for the future environment. One of the things that we have done alongside what Jim has said is to talk about what the career progression is that people can achieve from bands 2 when people just come into the profession at a relatively low level. The opportunities to move right through the bands, through education and training development that we can offer them. We are looking at them as an individual in that kind of career, but also from a wellbeing perspective. The other thing that we are doing is about wellbeing itself. How do we provide staff with the opportunities to get nutritional food, not just to carbohydrate the crisps, the snacks that they get sometimes? It is about fruit and veg and I know that sounds simplistic, but when you are working in a really pressurised environment like in a cute ward, actually making sure that you get a good diet and actually fluids into you, you know, drinking plenty of fluids is really important, so constantly reinforcing those messages is about wellbeing as well. Sorry, can I just add a little further on to that as well? We do actively support flexible working hours to support individuals and depending on their sort of personal circumstances, so we do that. The other thing that I think is really important building on Alex's points there just now about wellbeing, we do have healthy working lives awards and a couple of our sites are sitting with gold awards there. That is where we actively encourage and support staff around exercise as well as the dietary elements that Alex discussed there just now. One of the things that is really important, one of the things that we do, is that we say thank you to our staff, so we look at teams of the month awards, we look at recognising what staff actually do on a day-to-day basis and actually take that opportunity to formally thank staff. I think that all adds to the sort of environment of supportiveness for our staff. If I may, convener, I think that I find that of all the people in here, I will not dismiss the importance of nutrition and being physically active around the wellbeing and encouraging that into, encouraging that environment in our healthcare professionals. I think that we know from a nursing perspective, from a midwifery perspective that the health of our healthcare professionals falls below that of the national average. On a cause of submission, we did state that our healthcare professionals prepared to almost sacrifice their own health to look after that of others. I would be interested that there is a high absenteeism rate within the healthcare profession in many disciplines. I was wondering whether, if this is being introduced within Lothian, do you have any sort of numbers, figures that would tell us that it is being effective? I would probably say the answer to that around the nutritional bit, no, at this point. We have started a piece of work that falls on from the work that the chief nursing officer for Scotland has been leading on around physical and mental wellbeing. There has been research evidence published from the university, Napier University, here in Lothian that would tell you that nurses are more overweight than other healthcare professionals. From that point of view, it is about how we use that evidence to support those colleagues to get physically fitter and psychologically stronger. Some of that is about access to nutrition, some of that is about access to exercise, for example. Some of that is also about the working patterns that we want to look at, which is about working 12-hour days. Actually, they have a detrimental effect because you get up to go to work around six o'clock and you might not get home until a bit of living, then you are getting back up again to come to work. Now, they do that for three days, but then they are off for four. The evidence that we have said takes a couple of days to recover from those shift patterns. Again, one of the things that I want to do with other colleagues is to look at whether or not those shift patterns are the right shift patterns or whether or not we can move to something that is a bit more flexible, but also meets the needs of the wards, the teams, for example. Having less long days gives you the chance to go home, cook a meal properly, not just grab a snack and spend time with your family. From a family friend's point of view, I think that that is something that we need to pick up and do more around. Good morning, everybody. It is just a quick sup about other roles that nurses can do. I am a former theatre nurse who worked in California. Jim Cromby mentioned allied health professionals. Jackie, you mentioned anaesthesia as a vacancy issue. In my previous role, we had nurse and anesthetists and physicians assistants. Are we looking at developing nursing roles for nurse consultants in respiratory or urology or things like that? I will contextualise this a wee bit and then I will ask Professor Mike Manhattan to come in. The answer to that is yes. We are exploring a number of opportunities. An example that we might cite is around theatre nursing. It is one of the areas from a nursing point of view, if we look across the spectrum of nursing vacancies, where we do have a problem recruiting. We have identified the role of, essentially, scrub techs. They are individuals who can be trained up and become part of the scrub team and actually take the first place at the table with a patient and a consultant. We took the model from some ideas from the United States, but equally down south and in other areas, those posts have been developed. We have recruited from our own theatre teams. Care workers are working within theatre. We started a pilot study where we trained, I think that it was four initially, to see if that would work. Obviously, you will know that being a theatre nurse, there is a real important relationship between the scrub nurse, scrub tech and the consultant. We were keen to just test if that would work, overwhelmingly positive. We have rolled that out across our whole area. Is there a national issue on ODPs? Alex, you could have done that. Firstly, if you are still in the register, I could give you a job. From that point of view, please do apply later on. Jim has identified that at a national level there was a training programme that Glasgow Caledonian University used to run. It no longer runs it for operating department practitioners. They very much support the running of the theatre. We took the lead in loading to try and reconstitute that programme. It is currently out to tender. We have done that on a national basis rather than a regional basis. Again, that is one. The other area is that we are a high user of agencies. It is one of the small areas where we are still dependent on nursing agency uses for critical care and theatre. Again, we are looking at a regional bank. Used to we can actually make sure that the nurses we have got work in our areas, so we are trying to grow them. That is alongside a training programme. Theatres is definitely an area where, as Jim said, you scrub nurses and take nurse practitioners advanced roles, theatre technicians, etc. It is looking at everything from months four right through to seven and beyond. Jim mentioned advanced nurse practitioner training in primary care. It is not quite the same as nurse consultants, but we have a vision for the future of a strong cohort of nurse practitioners working in primary care, partly as part of the implementation of the new GP contract to create that workforce. We have already got some examples of them working in care homes in roles that GPs would have previously performed and managing a same-day access service in Musilbar, where nurse practitioners are the core of that service. We also use them in GP out-of-hours because of the difficulty that we have had with recruitment of GPs, particularly to work out-of-hours shifts. We have funded an advanced nurse practitioner training programme, which this year we are going to double the size of. It is a key component of moving forward, enhancing the role of the nurses in sustainability and primary care. Brian Hew, as the chair of the board, clearly it is your job to hold your colleagues to account for what has been presented today as a series of works in progress. What I am keen to understand from you is how do you measure success, how do you insist that work that is in progress produces outcomes, and when and how do you measure it? Over the past four or five years, we have put quite a lot of effort from a board perspective into the governance that sits around that question. For example, we have completely altered our system of risk analysis and risk management and the seeking of assurance about performance against those risk factors. We have restructured the levels of risk appetite that we are prepared to accept or aspire to in terms of all the various factors in our risk register. We then seek, from the board table, to delegate the scrutiny of the detailed performance against each of those factors to our various governance committees and now, of course, also through the IJB and the partnership links. We think that we have now got a fairly robust and secure system in which all the factors in our risk register, which of course reflect our strategic objectives, have been analysed out and delegated down to the governance committees who then scrutinise in detail the performance against those factors and report that back to the board when there are issues, whether there are gaps or where there are issues arising, or indeed decisions to be made about significant new remedial actions to be taken to correct that balance. I do claim that we have moved quite a long way in the past four or five years in terms of the security of that structure of governance around performance and performance improvement. Within the past year, we have appointed a head of governance for Lothian NHS Board. That person's job is to put the model of governance that we now have around performance and around risk and to keep that under permanent scrutiny so that we are seeking to continuously improve and further the security of that system. In fact, Susan Goldsmith talked earlier about the risk being particularly around financial balance, but what is the corporate approach, if you like, or the non-executive board approach, to the balance between that financial risk and the clinical risk, which has also been referred to? I will defer to Susan in a moment, but if you go back to my earlier remarks about that risk conundrum, it is exactly that. However, if you look at what the board has agreed, as defined as, and agreed as, its risk appetite priorities, the priorities absolutely, in terms of, number one, risks to patient care and quality of care and safety. Number two is about financial balance. We try to stick with that order of priority when we are considering the work coming back from our governance committees and assessing performance and the actions that need to be taken. I have to be honest and say that it is very often that we are wrestling with it, that we find ourselves in a difficult place in terms of making decisions because some of those decisions, in particular on the financial side of that conundrum, are relatively scientific. We can look at those and we can measure them and we can write down the numbers. When we come to look at the safety and care quality side of that equation, it can become more difficult. I instance the example of outpatients and simply the quantum of a dramatically increased total waiting list of people waiting outpatient appointments. There is an element of judgment. Once you have taken all the steps that we think it is reasonable to take to mitigate risk within that waiting list rise, you are still left with a decision, a judgment, which says there comes a point where simply the quantum of that number becomes something that we simply have to accept is at an unacceptable level of risk. That is a difficult assessment and a difficult judgment to make, but it is right at the top of our, it has the biggest share of our mind as a board. Let us put it that way, how to resolve that question. One of the other things that we have outlined in our submission is that we are trying to take a longer-term approach to the financial position of the board. Caroline Gardner appeared in front of the parliamentary audit committee and spoke about the requirement for boards to take a longer term approach to their financial strategy. We are trying to do that because it is only by looking forward and trying to plan for the size of the pressure that we are going to face over the next three to five years that we are able to shape and manage our response. We have just started that where we have spent quite a bit of time ensuring that we have good, robust financial management so that we are not compromising clinical care because we are not getting the money appropriately. We are now working on how we support an improvement programme across the board, which may not save cash but might support productivity and mitigation of that upward pressure. We recognise as a board that the only way that we are going to address that longer term financial strategy is working with other partners, such as the regions and the IGIBs, around strategic planning. The chairman is right that it is a continual challenge. The only time where we have made an explicit decision was when we did not have the physical capacity to meet all our access targets and we were contracting with the independent sector. At that point, we made a decision that we no longer had the resource to purchase activity from the independent sector. The rest of the time, it is just a continual balancing act to ensure that we prioritise clinical services. I appreciate the fact that you have spoken this morning about the need to tackle inequalities, the need to get to grips with upstream approaches and prevention. I appreciate the honesty that we are hearing about the fact that the board has taken an active decision to achieve financial balance. It might be that you cannot invest resource expressly in meeting targets. Has that inability to meet those targets led to the fact that Lothian has got the poorest A&E performance of all boards in 2018? It is useful to understand the quantum around that, because it is a very important question. When we have looked across Scotland, what we are saying is that the east of region, the south-east of Scotland, is pretty unique in terms of its population growth. The projections forward demonstrate growth in kids, in adults and in the elderly. That is unique in terms of the rest of Scotland. It is about double that of the rest of Scotland, and it is about four times the population growth of the west of Scotland. There is a real pressure building in our system. It is interesting to note that, in the past 10 years, we have seen a demand increase for outpatients of about 45 per cent, and we have seen an increase in A&E demand attendances of about 35 per cent. We are seeing a real pressure from population coming into our process. Some of that A&E pressure will be to do with the lack of GPs. A colleague lodged a motion yesterday about the GP crisis in West Lothian, and I think that we will be having a member's debate on that soon. Undoubtedly, all of those factors have an impact on people's perspective. We are now tracking part of our ambition as a board to really understand data and to understand the elements of demand, the elements of pressure at a micro level. We are now tracking from individual practices the yield to attendance at hospital in the emergency room and the yield to admission from that attendance. We are starting to create a portfolio that we are working with the IGBs and the IGB chiefs to really try and understand the dynamic. Is that because, when they called primary care to get a GP appointment, they were unable to offer access and therefore that converted immediately into an A&E? Is it an issue of ease of access? I do not need to call the GP, I can just show up at hospital and I will be treated. Is it because we are not identifying early enough in a clinical pathway that a condition, a chronic condition, is changing and resulting in an emergency admission? There are a number of flow issues using the data. I think that it will allow us to explore these in a lot more detail than we have before. Moving away from A&E, one on-going area of great concern—even yesterday, I was contacted by constituents who are very concerned about the paediatric situation at St John's. How is that being dealt with? What I would like to understand is that if you had all the cash and resources in the world, would you be able to solve that or is there another problem at the core of that? I am going to ask my colleague to come in, Jackie, to talk in detail. I guess that it is not an issue of cash and I need to be clear on that. It is not a funding issue. The board in its review of the St John's inpatient service committed itself to maintaining the service there and committed, as Susan characterised, at risk an additional £2 million to make sure that we could attempt to recruit additional members of staff to support that service. However, I will ask Jackie to in detail talk through where we are. As Jim has described, we have an on-going commitment to maintaining and delivering a 24-7 service at St John's, so that has not changed at all. In terms of recruitment, despite what is a national backdrop of shortages of paediatricians, we have successfully recruited seven additional consultant paediatricians into NHS Lothien. Currently, I am working in the department. We have five working. One of the most recent appointments we just appointed earlier this year and does not start with us until August. One of our most recent appointments is on materna to leave, but we have five additional consultants into the service. Over and above that, we have been training to advanced paediatric nurse practitioners, and they should be ready to start to participate in an out-of-hours rota towards the end of this year. We are about to recruit again and advertise again next month in relation to further advanced paediatric nurse practitioners, both to see if there are any trained practitioners out there, but also to recruit trainee practitioners. We have a further course starting in September. As Jim said, that is not about money. That has been an active and proactive and continuing recruitment drive, but, despite all that, we require 39 out-of-hours shifts to be covered every month. At the moment, based on our substantive staff, we could provide about 21, so we still have a way to go around having a sustainable out-of-hours rota. You are saying that specific issue is not about cash, but with regard to all of the other issues facing NHS Lothian. Do you feel that you have the financial resources to meet the targets that are being asked of you, or is it simply impossible with the package that you currently have? I guess that I would say that there is a requirement for the board to demonstrate an effective use of its £1.5 billion that it gets, but we have characterised a gap in our ability and our capacity to deliver against the access targets. We have been clear to the board to the Government that there is a significant element of funding that would be required to allow us to recover. Part of the request from the Scottish Government was to present what the characterised as an operational plan used to be called an LDP. It is now an operational plan for 18-19. In that, we have characterised all of our intelligence around demand, all of our intelligence around efficiency, productivity and maximising the use of our resource. Even doing all that, we have characterised a gap and we have characterised the quantum of funding that would be required to allow NHS Lothian to return to the levels of performance in terms of patients waiting over 12 weeks at March 2017. I think that one of the other elements of that is that even if we had the funding to return to March 2017, we do not have the overarching capacity either internally or with the external providers in relation to that. There is often a lead-in time in starting up capacity, which is why Susan Desiwes described that we are really keen to be looking at at least a three-year programme so that we have an opportunity where we can look at additional resource whilst we redesign our services behind that. We have presented a number of options, a series of options that see incremental improvement, they see delivery of key clinical priority services and they see the return of NHS Lothian to 17. You have characterised not only the existence of a gap, but you have also described the quantum of the gap. What is the quantum of the gap? So, to return NHS Lothian to the position of March 2017 is £31 million. So, essentially, that is your assessment on the basis of the services that you are responsible to deliver of the shortfall in funding. Thank you very much. David Stewart. Thank you very much, convener. We have touched, I think, already today on the issue about how you assess risk. You have covered that quite substantially. What I am interested in is how you assess risk and how that feeds into developing your strategy and how flexible you are to do that. On your submission, the very last page of the very interesting triangle, when you said, basically, in order to look at transformational change, it is beyond our own capability that we need to look at regional and national strategies. Is that a correct analysis of your triangle? I would also extend it further. If you look at the submission that has been made by the regional team under Tim Davison's leadership, it states very clearly that the best efforts of the regional planning team to seek additional efficiency-driven benefits, let's say, going forward, has come to much the same conclusion. It has basically said that, as far as we can see at the moment, we can see a way clear to adding some additional benefit and taking the bottom of the pyramid that you are referring to, the pyramid diagram that is in Susan's financial plan. It takes us only still to the bottom two rungs of that. Therefore, from the regional planning function in Tim's view, now becomes one that says, okay, we will do everything that we can to go out and maximise those two bottom chunks of the pyramid, but we are saying now very clearly that, in order to move us up to a six to seven per cent cumulative annual savings target, we are going to have to come up with some different prisms through which to look at the business model. We don't have those answers. We are saying at the moment that this is a grey area, that we understand the questions, but we need now to put a lot more effort. This, of course, is a regional, if not a national, issue. The other regions are coming up with very similar, very simpler views about it. There is a task to be taken on, which is about the transformational level of change, if you like, which sits at the top two sections of the pyramid that Susan and her team have constructed. Clearly, you are the second largest board in terms of population. You have got some characteristics that other boards do not have. If I could just flag at some of these, in your high risk, or in your medium risk, I should say, you talked to prescribing being a problem. Obviously, all the boards in Scotland will come before this committee, and that is a problem in other boards as well. If I take issues like hepatitis C, where you have got some considerable issues, is that one of the factors why your prescribing has been a problem in terms of being beyond budget or something? Absolutely. Again, it is not just Lothian. Across Scotland, the proportion of our spend on drugs, whether through GP prescribing or in our hospital sector, has become an increasing proportion of our budget. As a result, we have invested a significant amount of resource with Scottish Government funding and our own funding into providing pharmacy support. That has generated significant savings, but those savings just have to be plowed back into supporting that upward trajectory that I keep referring to. We do see benefit from investing in pharmacy support, but we require it to continue to fund the increasing drug spend that is either coming from the demographic or, indeed, in GP prescribing, one of the things that we are seeing now is short supply and that affects price. We have done well nationally in securing reductions in the price because we have worked together across Scotland, but in GP prescribing we are seeing the impact of the global economy on some of the drugs that we procure. It is a continual pressure for us. How flexible is the board when it comes to the strategy? For example, if you see changes in the characteristic of your board area, how quickly can you change the strategy that you are looking at without being frivolous? If I can throw in the military analogy, I think that it was a German military strategist who talked about any strategy collapses with the first contact with the enemy. I am not suggesting that that is the way that you would look at it, but it is relatively easy to develop a strategy in anivary tower if whether it works in practice is another issue. It is not too much your German friend's analogy. It is more to do with the scale and complexity of the deployment that is required from the point of agreeing a change to strategy to getting that into place. We are striving to get better at that process all the time, but we are still a very large and complex organisation. It is not an incident process. We developed a strategy in 2014 and published it. Alex can talk through the detail of that, but that was an attempt to characterise what our vision of the future was. It took account of demand, demographic changes and disease profiling. Alex, do you want to say? Our health and care of future was the name of the strategy from 2014 to 2024. It describes a lot of the discussion that we are currently having, but it also articulated the stakes in the ground, as we called it, so that we are all in the film of Edinburgh, the western general, as sites that we would not be discussing coming off, but how we would develop or redefine some of those sites. That allowed us then to go back and look at what other services we had on other sites that it did not necessarily have to be on those sites that we could repatriate on to others or make them maximise their opportunity. That allowed us to progress with a number of—I will use the word closure, but if you want to talk about shifting the balance of care—shifting the balance of care—for example, Corsdorff in hospital, Murray Park, the reduction in the libertine site in terms of the bed base there as well, the development of the loading community hospital, the work around the Royal Edinburgh reprovision. Those were all characterised in our strategies, so we have been progressing those and enacting those over the last couple of years. I touched on earlier how you need other groups to help, so tell me a little bit more about the help and support that you receive from the Scottish Government when you are developing the strategy. What discussions do you have with them? Is there any wider issues for the committee about issues such as how capital planning and revenue planning is allocated? Is there any issues that we should understand from you on those issues? Alex, I will pick up on the general strategy point. It is probably fair to say that when we were developing the strategy, our Scottish Government colleagues were very close to us. I say that in a positive sense, from the point of view of the ambitions that we have in the Government has around shifting the balance of care, about providing care closer to home in the community. We talked earlier about the financial aspects of that. We do not have bridging monies anymore, so it is about how we actually secure that transition whilst making sure that patients are kept safe or that we build up the community capacity whilst running down the inpatient capacity, for example. I would probably say that, from a planning perspective, they have been very helpful with us. In terms of revenue, Susan, I am not sure if you want to talk about Enrack. Well, Enrack, we talked earlier about some of the pressure that we feel in loading around the demographics. One of the challenges for us as a board is that, because of the way that the formula works, which influences our bulk of our allocation, it is based on population. Of course, it is relative population. As the east population grows, and the west declines relative to the east, we are perpetually trying to catch up in our share of the total pot of money. Almost year on year, we are behind our target allocation. That clearly gives us a challenge. However, if we are in dialogue with the Scottish Government, it is recognised that that is an issue for us, and we will continue to be in dialogue with some year on year. Just on the final question that relates to finance on Brexit, you have probably followed our discussions on Brexit in earlier committees. One issue that I raised with the cabinet secretary, which I am quite concerned about, is the effect on receptacle healthcare. For example, the S1 and S2 schemes that Brits abroad get. If there might be a transitional support there, but for new Brits going abroad, there are real issues that they will not get healthcare, and we will return to Lothian in other health board areas. I know that there are Scottish figures on that. Have you looked at this in Lothian of the effect on additional social care and primary care demands from people who are currently living in the 27th? We are only just in the middle of doing that piece of work on an assessment of what Brexit might be. I cannot answer your question explicitly, but that is a piece of work that is under way currently. In relation to the shortfall on NRAC that you described, how does that relate to the £31 million gap to previous performance levels? The £31 million gap relates to access targets. To achieve access targets, we would need to spend an extra £31 million, although that would only take us to our March 17 performance. The NRAC is on top of that. It is just to support all demographics. To achieve your full NRAC allocation, what additional funding would you have received this year? For £18.90 million, we will be short by the time we get to the end of £18.90 million, about £14 million. I read with interest through your submission, specifically with regard to some of the areas of performance shortfall, and I will come on to them in a minute. There are just a few things that I will work through picking on some of the points that you have made earlier. It is very interesting introduction, and I understand the challenges that you spoke about in the conundrum. You have mentioned a couple of times about waiting lists and the overall waiting list target and the way that you manage them to make sure that individuals are not exposed for a lot of a better word in terms of where they are in that process. Do you think that that can suggest that we are at a top level working and maybe measuring their own things if we are focused on an overall target, but, within that, there are other things that are more important? That is always the question, is not it? Is Harry Burns characterised in his report? Are we hitting the target and missing the point? I think that there is an element to that. If you spoke to clinicians, they would characterise examples of that. However, there is absolutely, certainly from my opinion, a benefit to us delivering earlier access to treatment and to assessment. I think that that is an important principle. We have, however, recognised that we are in a different place than perhaps we were before and with so many people waiting, either for outpatient appointments or for inpatient treatment. We need to change our approach to managing this. Jackie, I think, could you talk through our approach? That might offer a bit of insight into that. As Jim described, it is an area that we have recognised that is a risk for us as an organisation with our long waits on our outpatient waiting list. We have worked with our medical director and we have developed a clinical risk matrix that looks at services and the volume of patients on those waiting lists for those services in terms of the probability that serious diagnosis could be delayed and being diagnosed or that a patient's condition could deteriorate. On the back of that risk matrix, what we have introduced is a keeping in touch process where we actively contact patients that are on our waiting list. We do that for a two-fold reason. One, we give the patient reassurance that they are still on that waiting list. It gives us an opportunity to assess if there is any change in the patient's condition. It gives us the opportunity if there is a change for us to escalate that back to the clinical team and to potentially bring an appointment forward, depending on what is said there just now. We have also found through that process that there are a number of patients whose condition has got better and they advise that at that time they no longer require to be on the waiting list and that that has a benefit for other patients on there. We are looking at a clinical risk basis. Another good example is probably within our endoscopy service, which is one of our higher risk services, where we have worked with the clinical team to understand fully from the consultant perspective where our highest risk patients are. Although we do look at report on urgent suspicion of cancers and urgence, within that service some of our highest risk patients actually sit in our repeat or surveillance queues, not in the new queue. We actively have converted some of our capacity for those high risk patients, so we continually work with the clinical teams and calibrate our capacity to our highest risk patients. There is a lot of good stuff there. If you have a suite of measures that you use internally to understand the profile of what you just described, you can track that. I am moving on. I talked about preventative spend and it was really interesting. You talked about taking a risk, which I fully understand. You mentioned diabetes in primary care. I suppose that the question is how well do you understand that risk? If you are putting in x million here and expecting y million back, y being greater than x at some point in the future, how will you understand the time-phase of when that happens and what that ratio is between putting the output? If you are experiencing leverage in learning from other health boards or other parts of the world, go on this journey. One of the things that we are developing and Jim referred to earlier is our use of data and metrics. The answer to your question is currently. We probably do not understand it well enough. What we do know is that we spend probably about 10 per cent of our total allocation provides healthcare to individuals who have diabetes. They might have other conditions, but they have diabetes. That is very much worth taking a risk. We spend some money and we will not get the return for a long time, but that is almost like a no-brainer. For other areas, we will develop on diabetes measures. Using the data that we are increasing using, we will develop measures for that kind of investment. Primary care, we know what the demographics look like and what type of activity we need to see provided in primary care and community services. Increasingly, we will measure that, but I think that that is very much developing at the moment. On the diabetes point that Susan has made, we in Lothian have about 35,000 diabetic patients. Most of those are type 2 diabetes that can be prevented or reversed. That costs us about 110 million pounds a year to treat. There is a whole sweth of evidence that says that if you get people on two dietary programmes, weight loss programmes and sustain it, we can reverse that number. That saving could be reinvested. That is absolutely a punt that we need to take in terms of investment and money. We will do that through moneys that we will get from the Scottish Government around the obesity weight management strategy that has come out to make sure that that is the kind of thing that we need to look to invest in going forward. The return on that from an individual level is huge, but from a society and an organisational point of view, it is significant as well. I want to touch on that one of the things that we have mentioned. We have looked at as well as round about hep C, whether some work is going on in Spifial and Dundee. If you invest significantly now, you can reduce the incidence to such a level that the reinfection rate is going to drop right off and you can save in the long run quite a lot. Is that something that you are focused on as well? Yes, absolutely. We do try to channel our investments in a way that will support our reduction and the level of cost of care that we provide. It is in another area that is in your submission round about demand management. You have referenced that in terms of A&E, and you have actually got a graph that shows quite a significant improvement there. You talked about early triage, flow centre, clinical algorithms and stuff like that. Do you really just want to talk a wee bit about what you are doing in demand management across the piece, because that does sound like something that is... I guess we were shown a reduction in demand until the beast from the east arrived in that bluer trajectories out of the water. I guess that it brings me back to the point that I was making. We are challenged as a board, and we should be challenged as a board to demonstrate effective use of the resources that we are allocated. One of the areas that we need to look at is not just expanding capacity to meet increasing demand, but to look at the causation of demand and try to reduce that. You have seen from the data that you have had a look at some of the outcomes associated with the work that we have done. Jackie, David, I would be keen to get your view on actual examples where we are demonstrating an impact. You have already discussed the flow centre. The flow centre is our real success for us in NHS Lothian, and it is an area that we are looking at on a regional basis. The flow centre works in collaboration with the Scottish Ambulance Service, with our primary care colleagues and with the acute sector. It looks at how we best divert patients to the best place for their care, and that may well be to an ambulatory care areas such as a rapid access clinic, rather than having to present to ED. We have put in place a frailty hub at West Lothian, or based in St John's, but it is part of the West Lothian working there just now. We have put in rapid access respiratory clinics so that patients, rather than having to present to ED, can have access to that clinical team there just now. It works very well around diverting patients to the right place for their care. David, do not talk about some of the work that is happening in primary care, but before I hand over, some of the other areas are a real success story around demand reduction. Again, I think that within our submission pack there is, if we look at gastroenterology, again one of our really pressurised outpatient services there. Through working in collaboration with our laboratory colleagues, with the clinical team in gastroenterology and with our general practice colleagues, we went through a testing and then a full implementation of a new test that can be carried out in the GP practice that has actually reduced the number of referrals into secondary care by 400 a month, and we have seen that as a sustained reduction. That is a really good example of working collaboratively and reducing our demand. I can add some examples from primary care. There are two levels to this. One is the work that we are doing across the whole of Lothian, and then there is individual work in each of the partnerships. Across Lothian we have a referrals adviser service. It is a GP who works between secondary care and primary care, and they work on referral protocols for elective outpatient referrals, the kind of thing that we have been talking about, to ensure that the most appropriate patients see the right kind of specialist. Then they turn that into an electronic referral process, so that the GP can make the right referral while sitting in the clinic, but it is the right referral to the right specialist. We also go through with the patient all the other things that need to be done before our referral is appropriate, because there are often our steps that can be missed and things can be dealt with in primary care. We also have a secondary care primary care interface group and a laboratories interface group where primary care and secondary care sit together and discuss exactly those kinds of issues, demand for tests, taking of blood, etc. To ensure that we get the balance of demand in the right place for the right kind of patients. At a more local level, in Midlothian they are testing an enhanced triage system in two practices. In East Lothian we have been piloting what we call the Musselburgh access service for 30,000 patients, so same-day access. There is some early evidence that the A&E referrals from the Musselburgh practices have dropped off, hopefully as a result of that early days, but we would hope to be able to demonstrate that. In Edinburgh they have been putting physiotherapists into practices to deal with musculoskeletal problems that can often end up in A&E and orthopedics, and in West Lothian they have been the lead area in Lothian testing SAS ambulance service paramedics during home visits, so that home visits can be done quickly on time by the right kind of person and again to try to avoid A&E referrals. That is all good. My final kind of area that I wanted to touch on was what I would call improvement process. You have touched on that already and talked about the data tracking stuff. To my mind of what you do there is you figure out the reasons that the drivers are causing things, then you pre-todact look for the biggest hitters, then you go figure out the action plan, then you go around to look and see if it is working and then you should see that they will come in down on your top line. We have all that stuff. How recent is that process? How robust is it? Is it still being rolled out? The second part of that is, at a very top level, how much of an improvement do you think that can deliver as you can start to drive those improvements? In terms of the first question constantly and continually, we look at reports weekly. Our ambition is to look at some of the demand issues on a daily basis once our information system evolves to where we want it to be, but certainly weekly, absolutely monthly and then we trend look at what is happening. We can identify if a new service such as David or Jackie described comes in to be. We can track what is the outcome from that. David said that we are already seeing early indicators of the difference, the approach that is being taken in Ethlothian around attendance at hospital. That is something that we are tracking and we will wait and see where that goes. It is a consistent and continual process that allows us, if we think that that is not delivering what we thought it would deliver, why is that? We can look at that quite quickly. I forgot what you are saying. I mean, it has just been optimistic about that stuff. Continuing to do that, what impact do you see on the top level in terms of performance, but also in terms of financials? You should see a one or two per cent per year improvement there, if you are doing it right. What does the thing that I was going to add is that, as well in our submission, we have referred to the development of our quality strategy. We have developed a quality academy, which is giving our staff those kinds of skills so that, wherever they identify an opportunity and for improvement, they have the skills. We will also provide additional data analysts, improvement advisers and project managers who are required. That links into the triangle and the improvement aspect of our longer-term financial strategy. We are still at the early stages of that, but the board is absolutely committed to the roll-out of the quality academy across the organisation. I want to ask the board particularly about the issue of delayed discharges and how that relates to the IJBs, because we know that delayed discharge is an indicator of the success of the entire system, not just the discharges itself. In your submission, you said that there are specific and acute issues relating to performance within the Edinburgh IJB. I suppose that my question would be what is the board doing to support the efforts of the IJB in this area, particularly with long-standing delayed discharge? In your answer, it would be quite helpful for the committee that we know that that is a serious issue. We also know that we are probably not quite seeing the progress that we would like to see here. Could you explain areas where you have been doing things that maybe have not worked so well and what you are going to be doing differently in the short term to address that? We agree with the question and the way that you framed it. That is a huge issue, and it has been a recurring issue, and we are extremely frustrated about it, I suppose, as the first thing to say. Having said that, Robert David. You characterised delayed discharges as a major issue for the board, and I would absolutely concur with that. I guess that the first thing to say is that we are not about characterising the IJB as the responsible officer for this, because I agree with your view that I think that it is a whole system approach. Our approach to that has been to engage fully and in a sport of manner with the leadership teams in Edinburgh. You will be aware of some of the socio-economic issues that the city of Edinburgh faces, with relatively low unemployment. The ability to characterise care jobs at a salary range that they are offered against somewhere where they might work in a supermarket or somewhere else has been difficult. The care job is complex. It involves moving around and dealing with individuals that might not be completely compliant and polite. Therefore, it is an environment that causes issue with recruitment. Part of our approach, which I think that Alex touched on earlier, is to join us in terms of a care career. There is an opportunity for you to progress beyond that which you are joining in the organisation. The offer of education and development to allow people to move forward. We are really trying to exploit the whole integration thing that says health and social care working together, so there is an opportunity to flip across into a health career and move forward in that way. Equally, we have identified tests of change where we have tried to take care workers from the hospital environment and allow them to work with community colleagues and care colleagues to try and involve different models of care. We have tested that to see if that would work. We have tried to look at the criteria that says how we can reduce the demand that actually sees care required. Evolving rehab programmes, ensuring that we can maximise people's outcome as quickly as possible to reduce the demand on that. Particular examples, David, might you want to cite? I think that it is a difficult situation and Jim is giving a good explanation for the reasons for Edinburgh in terms of the strength of the economy and full employment. The implementation of the living wage is probably starting to help, but the next stages of that, we need to stick with that and the funding that the Scottish Government has made available has obviously made that possible. I think that that is really important so that a career in care is as financially rewarding as an alternative that might be available to people in that high employment scenario. Edinburgh has achieved some major successes. If you look at where Edinburgh was a year or so ago around, for example, the Royal Edinburgh hospital, the transformation around people delayed in psychiatry of old age beds, which was a real critical issue in terms of the opening of phase one of the new Royal Edinburgh hospital, that whole situation has transformed. A nurse led team is now providing rapid response for people who might otherwise become delayed. The bed numbers are now adequate for the demand that is placed on them because of that change that the integration joint board and City of Edinburgh Council are working with NHS Lothian have brought in. If you look at the length of stay of delays—the number of delays is important because each of those is a person, an individual person and a family—the length of stay is important because the number of bed days that delays occupy and the number of days that they have in hospital that could otherwise be used for other forms of care, the average length of delay is coming down, perhaps not as dramatically as we would like, but it is coming down steadily. That is a really important figure. I think that the Scottish Government has recognised that in, for example, one of the six indicators for integration joint boards that has been agreed is the occupied bed days for delayed discharges rather than the absolute number of delayed discharges. I think that you need to look at it in the round. I will add one thing. This is another area where we have also taken a financial risk because we have agreed with the City of Edinburgh that we will both make an additional £4 million available. It is clear that we have got some conditions attached so that we would want to see some improvement, but we have taken a financial risk because we know that part of the solution has to be about the investment that goes into that service. Can you speak to maybe the IJBs? Do they have a new strategy for getting additional provision into the system? That is one of the major issues. There is currently a review on going to look at the providers that are in play, offering both care at home and a locality basis across the City of Edinburgh. There is an exploration of what the contract was expected to deliver and what it has actually delivered. Part of the issue has been provider failure not just in City of Edinburgh but across Lothians and beyond. It is a real exploration of what causes system failure and provider failure. That work is on-going right now. You spoke about potential new models of care. Can you give a bit more of an example of what sort of things you are looking at in that area? We are very keen on the concept of discharge to assess. That is a model of care that sees actually once an individual, a person, a patient has completed their health treatment in an acute hospital but has residual needs. Currently, that assessment process takes place in an acute ward. That sees individuals that might not be dealing with that individual in the community taking forward an assessment process. We are very keen to look at how we can bolster our assessment and rehab service, which is primary care community-based, that allows an individual to be discharged home. For that assessment and rehab to be put in place within their home, more realistic, more appropriate, takes me back to my point. If we can reduce the need of individuals, then overall we can reduce the demand on the care service. That is an area that we are looking at. Equally, we are trying to look at how we might sectorise the care provider so that there is a target within a community area, the engagement of, within that area, of both care and health resource, to look at how we might provide services in a truly integrated way, is something that has been explored right now. That is helpful. Hospital at home is another one. You have probably heard it referred to by various things, frailty model, et cetera, but we have tended to call it hospital at home in Lothian. One of its main functions is to see people at home who might otherwise need admitted hospital. They have another function, which is to take people from A&E or medical assessment back home quicker than they might otherwise have done, and to prevent them going into the system and becoming a delayed discharge. Hospital at home often links with discharge to assess as well, and they work hand in hand to make sure that people get that final stage of their care, which might otherwise be delivered in hospital at home. The other innovative thing that we have done is hospital to home, which is NHS-employed nursing assistants providing personal care as a transition, a bridge between getting home and the independent sector providers kicking in and providing the service. That has been implemented in East Lothian and Edinburgh, for example. I am looking at those numbers. I am seeing in February more delayed discharges in Lothian than in the next two highest boards put together. That is a quarter of all the delayed discharges occupied by bed days, as David said, are in Lothian. Who is accountable for that failure to reduce the delayed discharge? Brian. Who is accountable for it? The trite answer is that we all are. The chief executive of NHS Lothian, who is accountable at the end of the day, is accountable. The chief officer of the IGB is accountable and the chief executive of City of Edinburgh Council is accountable. That is the model that we have set up, so it is a shared accountability. At the end of the day, the accountability primarily rests with the chief executive of the health board as accountable officer. I think that what you have described is a number of mechanisms to try to address the consequences of delayed discharge, but it rests with people coming into hospital and not coming out again. Many of those people should not be coming in. The practical manifestation of that accountability is the fact that the outcome of all of this and the failure to fully resolve the issue is that people end up lying in our acute beds in the Royal Infirmary. They are not piled up outside the city chambers or anywhere else. They are occupying those beds. Therefore, in a practical day-to-day sense, that is where the accountability starts. Given that, have you set targets for reducing this very large number? Will you be reporting publicly on the achievement of those targets? We did establish performance trajectories in 1718. We saw some of the evidence that has been cited by your colleague where we saw a reduction in attendance at the hospital and a reduction in admissions to hospitals. We were tracking that very well. What we have been hit with and what the system has been hit with is a series of provider failures where anticipated capacity and resource were not able to be deployed. We saw that immediately hit us in terms of that. The characterisation of demand and capacity modelling in care provision is something that has only recently started to evolve in terms of its elegance and the information that we are taking from that. I think that we are in a place—we are working now on 1819 trajectories to manage and monitor the impact of some of the changes and some of the initiatives that we have spoken to you about. On reflection, I think that the city of Edinburgh faces a really difficult journey ahead. The new leadership team will take up post at the beginning of next month. One of the early agenda items that I will have with the new chief officer is on how we can best move forward to improve the situation. Finally, on bringing in Emma Harper on the regional aspect, what is the relative cost of a delayed discharge person in a hospital bed versus that person in care provision at home? It depends on the type of ward. It is about £1,000 to £1,500 a week, but that does not take account of all the fixed costs in the infrastructure. It is that sort of magnitude. It depends where you are and what the rates are. You are talking two to three times the cost, and therefore a very significant part of that financial hit that you were talking about earlier. Emma Harper. I am interested in the issues around the health and social care plan for the regional issues as we move forward. It was interesting to read in the report that it says here that, in September 2017, the progress report on the development of the plan highlighted a degree of frustration that work on the propositions included in the plan made marginal improvements to existing models of care. It is similar to what Ash Denham has talked about with IJBs, but it is generating transformative propositions to deliver disruptive innovation. It is interesting to read the word disruptive, because I know that change is disruptive. Is there a culture of people who are early adopters, change agents or naysayers that you need to bring dragging along for change? What is the plan for regional issues as we move forward with the IJBs? Against the characterisation of individuals' approach to change is well rehearsed. There will be individuals who will immediately and enthusiastically embrace the concept because they see the outcome associated with the change. There is a spectrum down to individuals who, no matter what the outcome is, will just disengage because change is so angst for them. We all recognise that that is part of NHS provision that has been for the last 40 years, so we need to recognise that and move forward in terms of that. The most up-to-date report from the region characterises movement and improvement. The ability for us to characterise significant change to generate savings, however, is limited. Some of the advice that I gave you earlier around the south-east region being characterised as an area of growth, a south-east region being characterised as a 10-year demand model showing 45 per cent for outpatients and 35 per cent for ANE continuing to increase is an issue. The boards in the south-east of Scotland have gone through a disruptive transformation in terms of acute services, so we have rationed, reduced the number of sites, reduced the number of ANEs, reduced the number of hospital beds. We have tried to move our acute specialties on to one campus rather than have them provided on different campuses. There is the opportunity to look at, could we centralise a specific specialty to a specific area and disengage that process from a locality? That is significantly disruptive. I guess that that would be part of our programme as we move forward around real alternatives and real challenges to the paradigm, Susan. Do you want to go? I am just going to give you one example, because I think that we need to have early examples and give confidence. We have just agreed that we will have one operational management board for laboratory services across the south-east region. That will eventually bring about a change in how we deliver laboratory services across the region and using new technology, which means that we do not have to have every service on every site. Again, we are at very early stages. If we can deliver that, that creates confidence in the change agenda. That is not going to save us lots and lots of money, but it is going to allow us to continue to provide the service. One of the examples that I would also say is around radiology. We saw one of our sister boards having a real issue around its ability to recruit radiologists. The clinicians from NHS Bordd or NHS Lothian and NHS Fife considered how we best, as a region, provide support to NHS Fife. Using the PAX system, which is the picture archiving system that allows images to be acquired in one specific location but examined in various different locations, would be used to try and deal with the clinical issues around provision in Fife. However, the issue was that the report generated by the clinician found its way on to the host. If an NHS Lothian radiologist were looking at a report from Fife and reported it, it would go into the NHS Lothian reporting system. However, working with the supplier and working with eHealth and others, it developed a prototype that allows the report to be generated into the host board. That has seen a real stability being brought to bear around the provision of radiology. It is a good example for me where regional working has actually, clinician led, has resulted in an ability to sustain a service. That will be a theme as we go forward. I am also just a quick sump about—there are certain pathways that are currently in process. For instance, Dumfries and Galloway is considered part of the east cancer pathway, which is bizarre, because Dumfries and Galloway is not in the east of any region, and Stranraer folks then have to travel to Edinburgh for radiology as part of this managed clinical cancer network. It is part of the regionalisation that other boards will then have to move and move services and pathways to other areas, for instance. Does that affect the ability for the boards and the planning? Is that put further challenges, I suppose, pressures on other areas? I guess all that needs to be tested out. We do work closely with the other regional groups. Ideas, issues, changes or disruptive changes that are being developed and evolved in the west would be subject to discussion with us in the east and with our colleagues in the north, to really understand not just what is the impact here, but what might be the ripple impacts that might impact on other boards. There is a process of engagement and collaboration, so I think that anything like that would be tested out. The current overlay of the regional structure that has been in place now for a year to produce to look at planning from a regional perspective has been fairly roughly hewn. It was put in place fairly quickly and a lot of people recognised that there were anomalies and overlaps and perhaps gaps in the way that the lines have been drawn between east, west and north. As Jim said, that is being reconciled pragmatically by making sure that we all stick together on this and talk to each other about it. I can well imagine that as the regional initiative develops and gathers strength, there will be further revisions and honing, if you like, of regional boundaries and definitions as we go forward. Regardless of the regional work, when we are reviewing the cancer centre and its provision, a lot of the focus here is about how we can provide care closer to home so that people do not have to travel from Dumfries up to Edinburgh, so what could we do more closely at home? We provide a facility for people to stay overnight, so that is great. However, much of that could be repatriated back to the actual board itself. Regardless of the regional bit, it will get picked up through that process. There is another process that issues like that would get flagged as well. Such as radiotherapy or something like that to be disseminated in the world? I guess that it will be dependent on each pathway. I think that the point you made was pathways as well. What could be reasonably done in a local hospital versus the stuff that needs to be done in a centre? That is the more specialist high-end stuff, so it will be more of the kind of more routine treatments that would be provided more locally. The oncologist would be very clear, though, that the cancer journey should be within a team, a recognised network, because if elements of it are provided or undertaken out with that network, then there can be differences in approach to different protocols and increased risk for individual patients. It is not as simple as taking a part of the journey of the cancer clinical pathway and moving it around. It is about looking at the whole process and saying, how can we best offer a service? As Alex said, our ambitions around our new regional cancer centre would see us engaging with all current users and all boards to see if there is a better pathway that could be evolved as part of that development. Thank you very much. That has been a very full session. Can I thank colleagues for their input and our witnesses for their evidence? I apologise to those colleagues who have still had further questions that they would like to ask. We will write to you with a further follow-up letter probably in the course of next month, and no doubt some of those additional points will be raised there but also to pursue some of the points on the evidence that we have heard today. Thank you very much. We will now take a five-minute break and then move on to private session thereafter.