 Dwi ddim yn fawr i gael i fynd i ddefnyddio y 30-th ac y gweithio'r gael y ffônifyd drosllegwyd y cyfosbyddiadau ym 21-18. Ieithi'n gaffer Angela Constance i gael i gael i'r gweithio'r gael i ddefnyddio'r ym Mhwylwyr Nid ownersenol phobl Nol o amgor i ddefnyddio eu bobl yn ardaligol i ddiolch i ddech chi i'r partyn gael ei ddweimaliau oedd ag i ffodol a'r gael i'r gael i ddech chi i gael i'r partyn Item 1 is decision on taking business in private. Do members agree to take items 4, 5 and 6 in private this morning? Agree. Thank you. Item 2 is the section 22 reports, the 2017-18 audits of NHS Highland financial sustainability and NHS Ayrshire and Arran financial sustainability. I would like to welcome our witnesses to the meeting this morning. John Burns, the chief executive of NHS Ayrshire and Arran and Professor Elaine Mead, chief executive of NHS Highland. Both of our witnesses this morning are going to make opening statements and I'd like to ask Professor Elaine Mead to go first. Thank you convener and members for inviting me here today to give evidence to the committee regarding the 2017-18 audit of NHS Highland financial sustainability. As you are aware, NHS Highland is currently not financially stable and I would like to take a few moments to outline the reasons for this position. There is an increasing challenge in balancing the three areas outlined by the Auditor General, namely finance, waiting times and the quality of care. In NHS Highland we have continued to ensure a clear focus on the quality and safety of care including adult social care. Through our Highland quality approach whilst maintaining key waiting times for patients which has been to the detriment of our ability to maintain financial balance in 2017-18. There are significant challenges which are specific to the delivery of care in remote and rural areas and island populations which without doubt are complex and more costly due to the significant distances. Covering 41% of the most remote and rural geography of Scotland with an ageing population, it has been more challenging every year for NHS Highland to be able to sustain the historical models of care within budget due in part to our inability to recruit key members of staff. Our focus has been on ensuring that we can provide an appropriate and timely response to keep people safe, both in and out of hours, but this has come at a significant cost. As a board we are committed to the reduction of waste in the system and the transformation of services to ensure that we have sustainable and integrated care fit for future generations for the people of the Highlands. In order to do this we must change. This change inevitably takes time, but we have already embarked on that journey and I would like to thank our outstanding staff for their continued efforts. I will be very happy today to do my best to answer any questions from the committee. The 17-18 audit of NHS Ayrshire and Arran set out in its summary that we needed to address both efficiency and transformation to tackle the challenges that we face in Ayrshire and Arran. In the submission that we have made to the committee for this evidence session, we have set out in the document our approach to looking at this across the whole system in Ayrshire and Arran across integrated health and care planning. Our tenure strategy is called caring for Ayrshire. It is a plan that will be delivered through our transformation programme. That transformation programme will underpin the reform that we believe is needed to our model of care and strive to deliver the right care in the right place in a system that has the right balance between acute service provision and community provision. As well as the transformational programme, we also recognise, as the audit report set out, that we need to have strong operational grip in terms of our day-to-day management and in doing this to also ensure that we provide our services at best value, as well as with the right safety and quality. This is a significant programme of work that we are undertaking and to ensure focus we have established a robust operational governance and programme management arrangement. We have a delivery plan in development for the next three years that will address our performance, service delivery, service change and redesign, as well as bringing together the impacts on workforce infrastructure and pulling this through into the three-year revenue plan. I believe that the work that we are doing is building a strong foundation for that three-year plan. Finally, convener, I would like to reflect the hard work of the teams across Ayrshire and Arran in committing to the work that we require to do, but also to our partners who will play an important part in delivering the reform that we need in Ayrshire and Arran. I have a question for Ayrshire and Arran. Your submission describes the effective prescribing programme and, specifically, your respiratory prescribing to care work and the improvements that have been brought about by this initiative in the short term. What are the clear long-term outcomes against which that initiative will be measured? The work in respiratory is a programme looking at the pathway, end-to-end pathway for respiratory care. Within that, we have looked at the impact of prescribing. Ayrshire and Arran was, on the benchmark, one of the higher cost prescribers in respiratory medicines. We have taken a view that the best way to change is to look at how we transform with our clinical teams and deliver services differently. In terms of the respiratory pathway, we have specifically focused in on how we affect change to prescribing, particularly around inhalers, and we have moved some money into community-based pulmonary rehab and specialist nursing. Taking some reinvestment from prescribing to other services that are evidenced to be highly effective. You have highlighted that the cost seems to be highest in terms of the steroid inhaler. How do you reduce the use of those when, presumably, people are dependent on them? We have worked with our respiratory team, our primary care teams, pharmacists and others to look at the care pathway and where medicines can effectively and properly be used. Within that, we have recognised that by investing in areas such as pulmonary rehabilitation, investing in specialist nurses, we can provide support for patients that improves and enhances their quality of life, while reducing the level of prescribing and the spend on prescribing and moving some of that money to that investment where there is evidence that it has a positive impact. The early indications that we are seeing from our work are that patients like it and that it has reduced the number of unscheduled care admissions to hospital, and for those who need to be admitted, it has reduced their length of stay. It has a very positive impact on the outcome for patients. Has there been any negative impact? There hasn't been no, no. Perhaps I can ask a question for NHS Highlands. In your submission, you talk about redesigning modules of care and so forth, but you say that the new modules will be more sustainable, but they have proven to be very difficult to consult and agree, even where there has been consensus through public consultation, decisions have come under constant public and political challenges. Not surprisingly, the pace of change has been very slow. Can you give some examples of public and political challenges that you have encountered? Yes, indeed. We continue to consult on any of the changes that we would like to make, but clearly a number of those services are very precious to local people. Sky may be an example of where we had looked at the out-of-hours services, and how could we reconfigure those services to give us the best possible value to meet the needs of the people. As I said in my introduction, the important thing for us is to make sure that services are safe for the people. As we've redesigned services in Sky and looked at the Sky services, the local population have not felt safe and have said that they were concerned about any reduction in the level of care that was being provided. However, there is a significant cost to how we provide out-of-hours services. For example, costs in West Ross could be cost per case as high as £1,400, whereas in an Inverness practice you will find that out-of-hours costs could just be £70 per cost per case. Whilst that must be driven on access and safety, there is a cost element, and we need to make sure that we can provide the best care for people 24x7. The opposition that we have had is that people do not always understand about emergency care and feel that the out-of-hours care, which is provided primarily as primary care for GPs, is the same as emergency care, which is a 999 response. That's where we need to communicate better, engage much more with politicians and local people to make absolutely sure that they understand by changing the out-of-hours service that actually wasn't having an impact on the emergency care services that we were providing for them. Indeed, and we've involved local people, local politicians. We've had Salus Ritchie join us on that with that work, and actually we're making some progress now, but there is an additional cost to any of the changes that we've wanted to make. Now, you've mentioned political challenges as well as the public. What political challenges have you had? So, we've had political challenges at all levels, at a local level for local members providing support to their constituents, but also party members bringing forward concerns of their local constituents. Understandably, as people are concerned, right across our patch on changes that we're attempting to make. So, most recently, in Cateness, we've had a public consultation that's been wide-ranging, and that's been over a number of years as politicians, local politicians and the public have asked us about why we're needing to make the changes. And the reason we need to make changes is because the current models of care are simply not sustainable in their current form. In my experience, the first thing you do when you're suggesting fairly radical changes is you get the local politicians fully briefed and understanding the reasons behind it and get them to get behind the whole thing. That doesn't seem to have happened from what you're saying. We could have done better, but we have made every attempt on a regular basis to meet with our brief local politicians. Clearly, we have now the full support in Cateness of all members of the local authority, which is a motion passed last week. So it takes time to go through that conversation, to share the evidence, to help people to understand all parts of the jigsaw in a local area that lead us to need to make a change. I think that it's the time, Mr Beattie, that is the issue for us. We need to really spend a lot of time explaining the need for change and why the current models of care are no longer sustainable. Do you think that the current type and level of communication that you've got with public and politicians is adequate? We can always do better. We always reflect on how we're engaging. We do meet regularly with our MSP colleagues and MP colleagues, but we also meet with our council colleagues locally, both with Highland Council and Argyll and Bute. Do you think that, obviously, your changes have got to be open to public scrutiny? Indeed. Do you think that it's worth revisiting how you're approaching this? Clearly, from what you're saying, your whole project here is being slowed down. Those modules are being slowed down and everything is coming under public and political challenges. Clearly, you're not going to achieve your targets within a reasonable time. That's the difficulty that many boards face, but particularly in our area where we have a need to change the models in remote and rural areas. We see right across our whole patch from Campbelltown right through to WIC that we have changes we need to make and we need to engage in all of those areas with all of those communities. For us, just as an example, it would take us two and a half hours to drive just to have a conversation in WIC, which is something that is timely but takes a huge amount of the local team's time to continually engage. We can't make changes without engagement and we understand and accept that and we will continue to do our best to engage with the local people. Thank you. Willie Coffey. My questions are for Ayrshire and Harren. Good morning, John Finch. First, I'd like to echo the comments that you made yourself to be a tribute to the great work that's been done by the staff throughout Ayrshire and Arm NHS and in particular Chris House that I know very well. However, the Auditor General has written some fairly detailed reports on Ayrshire and Arm over the recent years. Principally concerns about the brokerage and overspend that Ayrshire and Arm has been showing. She also highlights a lack of attention to detailed financial planning and the consequent impact that this is all having on performance and ultimately says that she's finding it difficult to see how the board can get in balance in coming years. How do you respond to those findings in the round? I think that we started this journey in 1617. We recognised that we needed to do more than just deliver an efficiency programme, as I've referred to in my opening statement. We have been developing a new approach to deliver transformational change, whilst delivering the operational grip that is necessary. We have, in the last 18 months, made significant changes to our approach. We have a much tighter operational scrutiny programme. We have a very detailed programme management, where every programme, every efficiency is tracked and is reviewed regularly for progress and delivery. We have introduced clear accountability for each and every programme. We are now seeing change deliver. In year, we review matters through a financial control schedule so that we are clear about how we are delivering, what we are delivering and, if something is not delivering, the scrutiny and interventions that we need to take. I believe that we have moved on significantly and have a strong position on which we are building forward. Is there anything that you think is peculiar about Yersharanar and, I mean, the funding model? It has been widely reported that you have overspent considerably. I, for one, at this committee have said that you are spending money on healthcare and the needs of other people and the population actually have. There is an argument in the discussion to be had there. What is your view? Is the funding formula correctly reflecting the health needs of the Yersharanar population? Or should there be some thought being applied to adjusting and revisiting that to fairly award what Yersharanar perhaps needs to deliver on healthcare? I think that we recognise that the funding formula is the same for all boards in Scotland. We need to work within that formula. I think that we have recognised that we need to change the balance in our healthcare system in Yersharanar. I think that there has been an over-reliance on acute hospitals. What we are doing with our health and social care partnerships together is looking to develop the right balance of that service. For example, we have recently introduced a significant investment into intermediate care and community rehabilitation across all three partnerships to support patients coming out of hospital, but also where patients do not need to be admitted to provide additional support for them in the community. We believe that there is a strong evidence space for that work, and we believe that that is already bringing change to the use of unscheduled care beds. We are seeing quite a lot of change in transformation. However, we recognise that we have some real challenges in terms of our population health across Yersharanar. Again, we are looking to ensure that we are providing our services in a way that supports patients to take ownership of their own health and wellbeing, where that is appropriate, and we are looking to use digital technology and other examples of technology to provide some of that. Where that works, and it is in very early stages, it works well. We need to scale that further. We need to continue to look at the reform agenda in Yersharanar to get the right balance. You mentioned a couple of key areas of their unfunded beds and so on, but what are the key areas for you in Yersharanar that are going to help you to get control of the finances in the coming years? Is it workforce? Is it prescribing? Is it agency? Is it all of this? How are you making progress in turning it around? It is all of these factors. I think that in terms of prescribing, we are making very good progress. We have excellent working with our primary care teams in prescribing, and indeed this year we will exceed our target. Likewise, in hospital, we set an ambitious target for hospital prescribing changes and we will slightly exceed that based on forecast at this time. There is no doubt that workforce is a challenge and we are very clear that we need to be a board that can attract staff and also retain staff, particularly medical staff, in areas where the skills are scarce. We have a record of being able to recruit staff, but there are some hard to fill posts. That does necessitate locum spend for doctors to maintain services. We need to continue to look at how we redesign our services to make them sustainable, because if we cannot get the medical workforce, we need to look at the workforce model that supports that service. We also need to look regionally at how we work with our colleagues for some of those solutions. As you know, we have examples of where that works very well, where Yershar partners with other boards and the pathway back to Yershar is effective. What do you think, John? Out with your control, I know that you rely on working with partners. You have three boards that are north-east in South Yershar, which are presumably running at different speeds and at a different pace. What factors do you rely on that you do not control in order to deliver the successful transformation strategy that we seek? I think that as we look forward, because much of it we can manage within health and care, and the strength of our partnership is important there. You are right that there are different paces and the three are different, but we do work well together. I think that the biggest change is how we—indeed, Elaine referred to it in our earlier responses—making sure that we have the right communication with our communities about change. We need to make sure, and we are certainly, as Elaine has highlighted, that we are looking to work and engage with our communities in terms of that need for change and why it is important and what it will give our communities. Not what it will take away, but what it will give our communities in terms of sustainable services with the expertise when you need it. Burns, forgive me, but the communication is within your control. I think that Mr Coffey asked you what factors were not within your control. If we cannot get the workforce, that is not something that we have a direct control over. We work with NHS Education Scotland in terms of training posts, but we need to work with our communities. I accept that the communication is in our control, but I think that the ability to influence and impact change sometimes requires that control to be shared with our communities so that it is not just us that we are moving forward together. The pace of change in the three councils, for example, in terms of health and social care and discharges from cross-house, you do not really have full control over that. You are working very well with partners and so on, but there is a different pace there, as I understand it from previous discussions with you. What can we do to help you to move that along a bit faster and quicker so that all three councils perhaps are operating at the same pace in assisting this whole health and social care integration agenda that we hope is going to be successful? I think that all three in Ayrshire are. I think that we recognise that they do work and are in different places. Some of that is because their reform within social care is at a different place. One of the things that we should and could encourage is the sharing of best practice across systems, health and social care. My last question is for now, Jenny. You are projecting an additional overspend of £13 million for 2019-20, but we do know from the budget that you have been allocated in extra £25 million. Can you assure the committee that you will get the budget on balance in the coming years, as you have stated in prior papers, but are you confident that you can achieve that in the immediate years to come? I am confident that we are doing everything that we possibly can to achieve that. That is absolutely our intent. We are very clear from the cabinet secretary's position in planning our revenue over a three-year basis, hence the three-year plan that we are developing. We are very clear that we need to deliver a balanced budget. None of the issues that we are hearing about are unique or, indeed, new. Can you just help me to understand why this transformation was not started earlier? Did the Scottish Government never pick up on any of the issues coming down the line through monitoring? I think that we recognised, as I said, in 1617, that the level of change and the pace of change that we had in Ayrshire and Arran was not sufficient. We needed to look more widely at transformation because we were seeing financial pressures at that point. 1617 was the first year in which we felt that we had been able to balance our books and deliver efficiencies over many, many years. 1617 was the first year in which we saw that difficulty. We started our work at that point to develop the programme that we have today. I will come to the workforce challenge. I want to pick up on what we are calling BT. Professor Mead, you said that the current model of care is not sustainable. I think that we all probably agree with that. The question is, is it not sustainable because of budgetary pressures and the need to make efficiency savings and cuts? Is it not sustainable because we have workforce pressures and we simply do not have the staff to deliver the service in a sustainable way? Or three, is it because there have been so much advances in medicine and medical technology that it is simply not the right thing to keep the model as it is and that is why we need a transformation? Which one of the three is it? I believe it is all three. I think that is the combination that we are all challenged by and are here to celebrate. There has been such fantastic innovation and progress in medical technologies over the year. We are keeping people alive longer and therefore their requirements and their needs are more extensive. The innovation, the technology and the new drugs. Just in NHS Highland, we have had a 35 per cent increase in the cost of hospital acute drugs in the last five years. We need to give those drugs to our patients. The sky example, if we had the budget and we had the GPs, would you still want to reduce our services in the sky? I think we would want to look at best value always and make absolutely sure that was the right model. We are not looking to change the models because of money. We are actually not able to recruit the GPs. So in Highland particularly and maybe as a barometer of some of the changes in the rest of Scotland we see most acutely the pressures due to the lack of being able to recruit staff. Therefore there is a need to make the public understand that we cannot have everything in the way that we have always had it. So we want to be able to reconfigure things that are really not best value and not necessary whilst maintaining safe services and we will never compromise on the safety of our services. So just to clarify, if there was adequate GPs and there was adequate funding, we wouldn't be a reduction about our services in the sky? We would still be wanting to have a conversation about is that the right thing to do with the resources that we have available. We have other pressures across the whole system. So the innovations, the costs of drug, we've had an increase of 55 per cent in just the requirement for imaging CT and MRI for example in our radiology services. So all of these things add up to additional costs. Is it something that we wish to continue to invest in? Are we getting best value for that? What are the needs of the local community? And I think it's a conversation that we need to have more widely with the public to understand exactly what the needs are going forward. A huge vacancy rate amongst radiologists and radiographers, which is a huge challenge across the country. A major problem, and for NHS Highland we have 36 consultant vacancies currently, 13 per cent vacancies. All of those positions at the moment would need to be covered. That in return gives us a £15 million cost in locums while we're continuing to provide the same models of care. We've been looking to change those models over time for a number of years now. All boards are doing that. Off those consultant vacancies, what proportion are you advertising as 8-2 contracts and 9-1 contracts? We've moved to being able to be very flexible with our contracts with colleagues now. We will allow conversations. In fact we're looking not just to recruit to individual posts but we're looking to recruit families, partners to join us. We're doing everything that we possibly can, and it's not because NHS Highland is not a fantastic place to come on work and practice. As you've already outlined, there are simply not enough consultants in many specialties. Is that the same thing there, Sharon? Around the 8-2-9-1 contracts, does the BMA make it very clear that there's one of the big frustrations in terms of trying to attract consultants to come to Scotland, compared to other parts of the UK? Has the 8-2-9-1 issue been a whole range of other issues, being a key factor? I think that we've moved away from the 9-1 position. I think that the issue is good job planning, whether it's 8-2-9-1 or whatever. It's making sure that you've got the right job plan for that service, for that consultant team, as part of that team that reflects all of the work that a consultant does, which is not just the direct clinical care that they offer. John Watt, I found it really interesting from your earlier answer to Mr Coffey about what is not in your control and the one that you picked was about workforce planning. Obviously, the way that workforce planning is being redesigned, we're waiting for a comprehensive workforce plan that will be published at the start of next year, is trying to make it a national strategy. How much connection do you think there is between the health boards around coming together for a comprehensive workforce strategy? How is that gap in not having that comprehensive workforce strategy impacting on your service delivery in your own health boards? We have our own workforce plan and workforce strategy, and I'm sure that all my colleague boards have one as well. I can only speak for the west, but we are looking at workforce planning across the west of Scotland as part of the regional working that we have under way, because we think that it's important that we can identify and support new roles beyond a single board. There's important work going on regionally, and that will connect nationally, because that connects into training programmes and training needs. When I say that it's out with our control, the ability to do the training numbers is not something that we control, but we can control our workforce plan and we can control how we redesign our workforce around a much more of a multidisciplinary team approach. If you connect the two around the service reform that needs to take place in terms of making it financially sustainable as well as for patients in terms of a sustainable service and in terms of the workforce challenges, do you think that there is a gap in terms of would it help you as local health boards if there was a national strategy and a national intention from Government, from all political parties around? Let's be honest with the public around. We're not going to find magic 5,000 people to fill the vacancies around nurses and consultants and GPs. We're not going to magically find the money. If we want to make it sustainable, we do need a programme of reform across Scotland, and that involves all health boards if there was that national intention and that national message from the Government and all political parties. Would that help that local engagement that you need to have and that the ability to persuade local people about the service changes that are taking place in your individual health boards? I think that there's no doubt that a common message across Scotland around reform and the need for change, that it's a positive message about delivering safe, sustainable, high quality care for the future, would be an important part of how we can all move quite difficult agendas forward. Do you think that that's missing, Disney? I think that we could do more of it, yes. Do you like some leadership on that in terms of from this place, from this Parliament? Yes, I think that it would be a very positive thing if we had a common view on the need for reform and the importance of that reform. Excellent. Moving on to the issue around the culture. When you speak to NHS staff, they're clearly under more pressure than they've ever been before. They clearly feel that there's not enough of them. The work load adds to the pressure. They think that that leads to a fear around what might happen in terms of the delivery of care that they do for their patients, increases the risk of clinical errors or indeed the perception of a clinical error. On top of that, there is now a growing feeling from right across health boards around a culture of bullying and intimidation and a lack of a genuine whistleblowing process. I know that Highlands has had some particular issues around that. Can you address that issue directly around the culture of intimidation, bullying and the lack of it seems a robust whistleblowing process? From an Irish and Arran standpoint, we are very open. The whistleblowing process is shared across our organisation, so staff are aware of it. We also have worked very hard on culture and values in the organisation and worked to engage staff on change. We don't get it right all the time. We can always do better, but I think that we've got a strong foundation in Arsalan. In Highland, I would agree that honesty and local engagement is absolutely critical. Staff are very tired. They are often working in pressured circumstances. I am optimistic because staff are keen to change. I think that support to be able to change, to have a conversation about why we need to change will be helpful for front-line staff. Professor Mead, you said in your answer to Mr Sarwar that there was a 50 per cent increase in CT and MRI. Why is that? The technology now has improved. That allows imaging to show more diagnostic benefits. We find that clinicians are continually asking for the newest technologies, the newest tests. Those imaging machines, CTs and MRIs are now becoming invaluable in diagnosis. So, your diagnosis rates have gone up? Absolutely. The tools and techniques that people are using to make better diagnosis is increasing. Again, as I say, that is to be welcomed, but that added to the point that some authority made that the lack of radiologists who need to read those images puts huge pressure on the department. Has the diagnosis rate gone up 50 per cent to match the expenditure on CT and MRI? I cannot tell you. I would not be able to tie those two things directly together because it may well be that you are using just a different tool, a different imaging technique to be able to make a similar diagnosis. I do not think that there is a correlation between an increase in CT and MRI and an increase in the number of diagnosis. They will just be using it to diagnose in a different way. Those are clinical decisions, but CT and MRI are hugely expensive. How much does an MRI scan? I am afraid that I cannot tell you exactly, but we can find the information for you. My understanding is that it is quite a lot of money. It runs into thousands. Indeed. The cost and the time that it takes to report many hundreds of slices of those images is significant. Do you think that there are health economists in the Scottish Government that can marry those figures up? There must be. There must be and I would welcome that. Can I ask you about the cost of locums in NHS Highland? I think that this is probably a question that you anticipated as the committee has looked at this when we took evidence from the Auditor General on her report on your health board. You very helpfully provided a breakdown of costs in your submission, so thank you very much for that. If I am reading your table correctly, the total pay costs for two locum doctors in your health board runs to over £900,000. Is that an effective use of taxpayers' money? It is stark. That is why we have wanted to put this information into the public domain in the way that we have. That is a good use of taxpayers' money because we need to provide a sustainable service in this particular hospital. This is a rural general hospital where we need to have 24-7 response to emergency care. They need to be expert in that care and they need to be able to address anything that may come into a rural general hospital. So, not having an appropriate senior level response is simply not an option for us. These are geographically important to Scottish Ambulance and for the patients that we provide the care for. What is stark in the table and nearly over £900,000 for these two individuals is because we have actually managed to secure people who have wanted to come back on a regular basis and therefore have been paid and shown us two individual costs for two locums who have continually come back. That helps the team by having the same people coming into that team on a regular weekend basis. What we might have not shown as such high cost by ten people coming in ten times would have been the same cost but we wouldn't have had the continuity of care. I hope that that tries to explain why, whether we would have had two locums or ten locums, we would still have had to pay the same amount of money. It is just in this case that we have secured two locums who have continually come back. I understand the reasoning around it and I agree with your decision that these hospitals must be staffed with people who can do the job. That is the right thing but, as a countable officer for NHS Highland, you must be tearing your hair out when you are approaching the end of the year and you are looking at your books and finding that you have had to pay nearly £1 million for two doctors. What is the process that leads you to this situation, that you have to pay out nearly £1 million of taxpayers' money just for two doctors and what would prevent that situation? We do not just address that at the end of the year. It is something that we look at throughout the year. The medical director is tasked to oversee the costs of medical locums and I take his professional advice on a weekly basis about what is appropriate clinical care and cover to these various hospitals. My question is, what would prevent you having to make this hugely expensive decision? It is quite simple to be able to recruit permanent, high calibre medical staff into these roles and we are continually trying to do that in all of these roles. What is your obstacle to that? Are we not training enough doctors? The role of the specialist generalist, if I might describe it as that, an individual that would be in a small rural hospital who has to address anything that comes through the door is not a post that is very commonly trained now. It is not particularly attractive. Is that the fault of our workforce planning strategy? I think that it may be due even further back to some of the training options and certainly NHS Highland is working very hard to have junior doctors rotating through our rural general hospitals to make them attractive for them in the future. These are very challenging roles in rural general hospitals without huge teams of support that you might get in bigger hospitals. I am going to take two supplementaries on this point specifically from Liam Kerr and then Anas Sarwar. On the local cost point, the point here is that these two individuals are coming through an agency, so there is an agency cost to that. Why aren't they employees? Presumably, you offer them employed jobs. If so, what is salary? Is it the same as what is on this table? Or actually, are you saying to locals such as these? I appreciate it. We are focusing on two particular, but it would be throughout the system. Do you say to them, look, we will offer you an employed position and they say, no, thank you. We will come through an agency because an agency gets, let's say, a 10% cut, plus we can invoice more. Indeed, Mr Kerr, that is the situation that we would always attempt to secure in-house locums or permanent staff, wherever, first and foremost. But we would try to have internal locums if we possibly could or offer short-term locums where we have attempted all of those things and we have still been unable to address that issue. We have to go out to the market. We have a very tight way of going out through one particular agency to be able to secure individuals. It's not a completely open market, but we do then have to secure the cover. And often, as that gets closer either in a hospital like this or, frankly, in an out-of-hours service, as it gets closer to the time where we need to have that, then the market forces will require us to be able to pay higher than we would pay often as a salary. And there are some individuals that will work as locums rather than choose to take a permanent position. Professor May, this must be infuriating for you and I can completely understand your frustration. I mean £900,000 for two doctors, equivalent of almost nine consultants, must be hugely frustrating given the other financial challenges that you have. As you said, it's dictated by the market, so the market is dictating what you're having to pay those staff because you have to have those doctors in those settings to deliver the care that you want to deliver for your patients. What intervention do you think there needs to be from government in terms of how this is regulated? Should it be regulated around what an agency can charge? Not capping what you can spend on locums and what you can spend on agencies because you still have to get the agencies in, but should we be looking at capping what an agency can charge for a single shift or what a single nurse or a single doctor can charge for a single shift so there isn't this complete manipulation and abuse of health service budgets as a result of the challenges that we're facing across the country? It's a conversation that we've had as chief executives many times, I would say, about how can we manage that most effectively and we have held a line often with agencies, even together as boards, but there comes a point and particularly in rural areas where we have a particular need, we would have to say we need that doctor today. Therefore, it's very difficult to hold a party line unless you get to the point where you say we will not be able to have patients admitted to that hospital. Should that party line not be led to left to the chief executives of the health boards but actually be nationwide so we're trying to put it in law here from this Parliament? In order to balance out that market then we would see for sure there would be sometimes when we would say we cannot have a doctor. Going back to the question about Skye, local people in Skye when they see £900,000 spent on two doctors and then think that we can't get our GP out of service in Skye because it costs £1,400 per patient, can you see their anger and understand their anger in that situation? Indeed, and I can understand that we have to look at all of these issues as a whole health board and the people of Skye would not necessarily be looking at what's happening in other parts of Highland. Equally, they would also benefit from Skye of having these doctors in their local rural general hospital if they needed that emergency access. Professor Mead, you said to Annas Sarwar earlier on that there were not enough consultants. In your submission you say that one of the challenges around that is that there's increasing specialisation in medicine such that consultants are no longer trained in a way that they can work in a generalist setting such as a rural general hospital. That's highly concerning, so is this something that you've raised with the Scottish Government and or the medical training facilities? Indeed. And what sort of response have you got? I think that we are recognising that now and certainly the rural colleges are in conversation with us and the Government about how we might want to reconfigure the training for the future. Certainly, we're benefiting, as I've mentioned already, from having trainees moving through rural general hospitals, but that training of generalism is almost moving now in a completely different direction to the super-specialism that we've seen in the past. And we're now not benefiting in smaller hospitals from having physicians, for example, who can be a respiratory physician or a cardiologist or all those many things that they can do, but wouldn't necessarily have still maintained the skills to be able to take on a role in a rural general hospital where you have to cover many specialties. Let me just be clear. It surprises me that we're in this situation, but let me just pose a direct question. Is the situation being addressed such that there will be these generalists going forward? The colleges are discussing that. I can't speak for the actions that they're taking, but we're hopeful that people are beginning to recognise the importance of this generalism role as a specialty in its own right going forward. And certainly, in NHS Highland, we've made many representations to try and rebalance the way that the doctors are trained in the future. It might be something to put to NHS shortly. You also, Professor Mead, go on to refer to the difficulties in GP vacancies. In GP? You suggest that you've developed a number of initiatives and approaches to address that particular challenge. First question is, can you tell us what they are and the approaches and whether they're working? Yes. It's more difficult for us to be able to, as GP's independent contractors, identify and give you an exact number of the vacancies, but we still see vacancies in about 12 per cent of our practices now. The initiatives that we've had to take are looking for other members to join the team who are not doctors but undertake some of the functions that previously the doctors may have led on. For example, in some of our north coast practices, we now have pharmacy practitioners who are working at an advanced level who work as part of the team but take a huge amount of pressure from the doctors. We tried that as a trial in the north originally, but we're now finding that it is possible for us to recruit some pharmacists to be able to give them extended roles to work as part of a team and take significant pressure from the doctors on a day-to-day basis. That's an initiative that we're looking to spread out across NHS Highland. If we start from a position that says that the initiatives that you've put in are working to address the shortages, how is that knowledge being shared? For example, is Mr Burns on the phone saying, how are you sorting this out? We regularly share at the chief executives meetings and we present to each other some of the innovation and some of the things that we've been doing. Most of our innovation has been out of immediate need and some of our needs are more challenging in remote areas than others, so we're always happy to share. I'm just thinking particularly because I would represent north-east region and so we would have often very similar challenges, I would suggest, and I would be pleased if NHS Grampian, for example, were on the phone saying, what are you doing that's working, is that happening? We do have those conversations. I don't recall we've had a conversation about extended role pharmacists, but I'm very happy to share that. Mr Bowman, you've been very patient. I'm just the information on these particular consultants. If I understand correctly, one of them worked 5,188 hours and if my maths is correct, that's on average 14 hours a day for 365 days. Every day of the year they've worked and been paid for 14 hours. So they'll be paid for out of hours as well as in hours, so they'll be paid for overnight calls as well. One of the difficulties that we've got with locum doctors is that they are paid even if they are not called out. So they'll be available to us and on site often for us to be able to call them. It seems a very high number there. This is a snapshot of this year. Would this individual have been working the previous year as they're continuing to work? Forgive me, I can't tell you about the previous year. We may have had other doctors. I can certainly tell you that we've had vacancies in this particular hospital for a number of years, so undoubtedly there would have been similar costs associated with this hospital and maintaining 24-hour cover. So you don't know if this individual has got a longer term. Would you be happy if they had? I would ask always that we would be looking to fill the post substantively. That would be the way to reduce these costs, have substantive positions in these hospitals and then these costs are immediately reduced. Because it's almost like this person, and we don't want to get into specifics, has been working here for a long time and is presumably quite comfortable with their relationship. I understand the point that you're making, Mr Bowman, and in fact, as I've said, we have the medical director overseeing the cost of locums and the way that doctors are being used. So he would continually be working with the local practitioners to decide whether this is important to continue with this position. Professor Mead, I understand that you're looking forward to your retirement. Is that correct? Thank you. I will be leaving NHS Highland at the end of this year. I'm not retiring. I'm simply moving on to two other things. Oh, I see. I wish you all the best in those posts. Can I ask you what progress has been made with the recruitment of a new chief executive? There is a process underway to recruit a chief executive. I understand that we've not yet secured a permanent chief executive, but I understand that progress is being made in securing an interim chief executive for NHS Highland. Okay, so you'll have an interim post. A director of finance, has there been much progress made with that? So that's under discussion currently. We are not out to advocate currently for director of finance. That's currently under discussion. Okay. Do members have any further questions for our witnesses this morning? Willie Coffey? Just a brief one. Thanks very much, convener. Professor Mead, at the beginning you said something about it. It can take us two and a half hours to go to wherever within the border area for a meeting. Do you know how you use IT and Skype and stuff to just have charts in meetings? How do you need to drive two and a half hours? We absolutely do. We're one of the biggest users of Skype and video conferencing. In fact, NHS near me is going to reduce our patients having to travel for outpatient appointments, but we were talking earlier about the importance of engagement. You'll know that actually the face-to-face engagement is absolutely important. So when we have those public meetings, we go in person. Okay, any other further points from members? Okay, can I thank you both very much indeed for your evidence this morning? We now move to the next section. Our next item of business is section 23 report NHS in Scotland. I'll just suspend for a couple of minutes to allow these witnesses to take their place. Thank you. Item 3 is the section 23 report NHS in Scotland 2018. I'd like to welcome our witnesses for this item to the table. Paul Gray, director general health and social care, Scottish Government, and he's also the chief executive of NHS in Scotland. Christine McLaughlin, director of health finance, Shirley Rogers, director of health workforce, and Dr Catherine Calderwood, chief medical officer, all from the Scottish Government. I understand that none of you want to make an opening statement, so I'm going to move directly to questions this morning. I don't know if you were watching Mr Gray the evidence that we just took on the two section 22 reports, but there are some very good examples there of some of the problems that the Auditor General touches on in her 2018 overview of the health service, which you're here to give evidence on this morning. We were just discussing some of the costs of locums in NHS Highland. I think that this committee is extremely worried because we have a situation in NHS Highland where two locum doctors costs the taxpayer a total of over £900,000. How would you respond to that? I think that, firstly, I think that I would acknowledge the concern. It is substantial some of money paid from public funds and I would ask if Shirley Rogers and Catherine Calderwood would say a little to the committee about what we're doing to address these sorts of issues, both through our workforce planning and also our approaches to medical staffing, because I agree that these costs are very substantial indeed. I mean, this is a big but shocking example, I think, of poor workforce planning in the NHS. We all know that we've got issues with workforce planning. You have admitted that before, but how do we get to the situation where the open market is determining an exorbitant cost of over £900,000 for two doctors to staff our hospitals? When the Scottish Government pays for the training of doctors right the way through, how do we get to that situation? Well, there are issues of rurality. There are also international shortages of certain specialties. We are not alone in that, but if you are willing, I can ask colleagues to give you some detail on what we're doing. You're right to identify that there are issues in respect of medical supplies. As the DJ has said, those are not unique to Scotland. What has the Scottish Government been doing? We've increased significantly the number of places at medical schools. We've introduced for the first time in Scotland a postgraduate entry medical degree. This autumn just passed, which is particularly targeted around those people who are a little bit more mature and might be interested in working in rural and general practice. We're looking at transformed models of patient care whereby general practitioners are not the only people who can provide healthcare services. There's a combination of increasing the supply being as attractive as we can be as an employer within the constraints of all of the international challenges that we've talked about and also looking at a transformed model around how we deliver services. Ms Rogers, if you allow me to interrupt, it's not just supply, is it? There are certain parts of the country, and rural areas are an example, but there are also areas of deprivation that struggle to get consultants in a wide range of specialties but also GPs into those areas. It's not just about supply, it's about getting doctors to the areas that we need them. How are you tackling that? We're tackling that by working very closely with the boards, by trying to make those roles as attractive as they can be, by trying to have a more diverse approach to workforce engagement and employment. It's not working, Ms Rogers, because I went to visit the CAMHS service in Dundee this summer. They're supposed to have seven consultants in children, adolescent and mental health. They only had four at the time, and they couldn't get doctors to come to Dundee to work. As a result, we only have 41 per cent of children in Tayside getting to see a mental health specialist when they can. It's clear to me that the Government policy isn't working to get these doctors in place. As you'll be aware, for the first time last year, we've been able to publish a workforce plan that starts to identify where there are particular challenges. We have worked through NHS Education for Scotland and my own team about looking at those shortage areas and what we can do to target in that particular regard. We've had examples of using bursaries to try and help in that space. We've had examples of trying to look again at how we particularly provide rural incentives and so on. We have a new GMS contract and so on. Is that bursaries to encourage people to train us doctors? That's to encourage people to train full stop. That's to encourage people to come and work in our health services. So are you saying that we're not training enough doctors? We're training more doctors than we've ever trained before. Okay, let me put this to you. We train many doctors in this country. You'll know the figures better than I do. But I hear reports and I can't get substanciation from the GMC or the BMA for this that we lose up to nearly 40 per cent of our trainee doctors. Those that the Scottish Government has paid to train through our universities and hospitals and they go abroad to Australia and New Zealand. The taxpayer pays for their training but in the NHS Highland we've then got to pay an additional nearly £1 million to get two doctors to cover the hospitals. So why is the Scottish Government paying all this money to train doctors and letting them go to other countries? Should there not be a clause that makes them stay and work in the NHS? There's an argument for what you're saying. To be fair on the numbers bit, we know that young people like to go and explore careers in different parts of the world and they do that. The vast majority of people who leave Scotland for a medical school go to practice in England and come back to be fair. So just the fact that people go doesn't mean that some of them don't return because many of them do. But there are issues about the international marketplace for medicine. There are highly intelligent, highly trained people who have skills that are entirely marketable across the world. So in trying to make a career in medicine attractive, we try and do all that we can to make that attractive to stay and practice medicine in Scotland and a large proportion of our medical students do so. OK, let me go back to the two low incomes. Have you considered capping the amount of money that they can be paid? Catherine might be in a better position to talk about the service impacts of that but we have given consideration to whether or not there are other ways that we can help the boards to manage those situations, whether that's around bank, whether it's around agency, whether it's about the establishment and reinforcement of Scottish arrangements around bank and agency stuff. So we know that for doctors in training we would give low positions for a limited period of time with the view that those posts then would be filled by somebody with a permanent contract. The doctors that you're discussing, I believe one as a surgeon, so the essential services that they were providing both emergency and elective work would mean that if that post was empty, there would need to be patients travelling. One would assume for elective surgery and it would mean that there was potentially a rota that was unsustainable for the other doctors to cover. Therefore you do risk with rotas perhaps only three or four people covering that even if one person is, that one gap means that the whole service then is very fragile. Nobody's disputing that they should be there to cover patient needs. It's the amount that the taxpayers having to pay. Should there not be a cap on this? The Scottish Government is letting market forces determine how much these doctors will be paid because they're not taking an NHS contract. In following up to what Ms Rogers has said, this is a marketplace so that if there was a job that said we're not going to pay you X amount, those people would go and take a job elsewhere. So they would leave that service if they could have money or a longer contract somewhere else. With respect, Dr Calderwood, I don't think that the public see our NHS as a marketplace. I think that they feel they pay their taxes and their doctors should be on NHS contracts. Why won't the Scottish Government enforce that? I think that we are in your point about medical students leaving. I think that we now understand that a lot better. So we in Scotland train a lot more medical students per head of population than the rest of the UK. We have five medical schools. So we have always been net exporters of doctors and actually you'll find Scottish medical students trained doctors all over the world in very... Is that a good thing when we can't staff our own hospitals? I'm coming to what we're then doing to attract people. We know that the single biggest factor in keeping doctors in Scotland is being trained in a Scottish medical school and where you went to high school. So we're doing a lot of work around encouraging medical students from all over Scotland, but in particular in remote and rural areas because we know that people will... They may leave at that early part of their career, but they will come back and establish routes around where they grew up. Do you think that if we pay to train doctors they should be made to sign up to a certain amount of time working for the NHS in Scotland? So this is something that has been considered. One of the difficulties for Scotland would be that if that was not the case in the rest of the UK we might find that our Scottish medical schools are less popular and in fact that would then have the knock-on effect of not having as many people training here and therefore not staying. Unfortunately that UK marketplace for medical student places would mean if we did something different we would be disadvantaged. Angela Constance. Thank you very much, convener. Picking up from where Dr Calderwood left off, I'm really interested in the very practical examples of the things that we're doing now to get out of the locum loop and address some of the broader workforce issues. Things like I'm aware of the refugee doctor and dentist programme, where for a modest amount of investment you're able to help people who are doctors in their home country to convert their qualifications to work in our NHS. I appreciate the issues to do with immigration and asylum are not in the gift of this Parliament but we could be doing more there, I'm quite sure. There are issues about, you touched upon this, I wonder if you could say more about the whole widening and access agenda because there are high schools up and down this country that have never had any kids go to medical school. If you could say more about the type of work, about getting more working-class kids at new medical schools and young people from rural areas. If you could say more about the upskilling of folk-like and a rose-advance nurse practitioners, what I'm seeking, convener, is can you tell us more about practical things that you're doing now, what are the barriers to doing more of these practical examples but also what are the opportunities? I'll take the widening participation first. We have a targeted number of places for medical students and we must widen this also to other university places but we're specifically studying medical students at the moment so that each medical school needs to have a 10 per year of pupils coming through from schools that would not have, as you've mentioned, ever perhaps had somebody at university or at medical school. We have also got gateway to medicine courses in Scotland starting last year. Glasgow gateway to medicine course has had 21 out of their 25 going on to medical school, the other four then will do paramedical science degrees. A very high success rate of people who've come in from schools where they wouldn't get through the medical student exams but they do a year to prepare them to get into medicine and that has worked extremely well. The widening participation more generally, going into schools, the schools that you talk about, the medical schools council has a scheme so I have been to several schools, in fact I'm going in January again so many of us and colleagues from the NHS are going to talk about careers, not only in medicine but in the health service in general. Edinburgh University medical school has a new programme taking in 30 medical students a year who have healthcare professional backgrounds. That starts 2021 and will expand if that's successful. What that is doing is allowing people to study part-time so they can still work as a nurse, as a physio, as whatever their NHS job is and they then study in the other half of the time. It's done online, obviously later years of that course they do need to be present for patient learning but we would hope that that attracts people who already know what it's like to work in the NHS, who then stay and because they will be likely to be more mature, the evidence is that they then don't leave the country. Those are very tangible practical issues. The second part of your question was about some of the reliance on medical rotas so there's a very traditional model of the medical consultant with registered doctors in training below and another level of more junior doctor. We realised that for a lot of those posts in fact other practitioners, in particular advanced nurse practitioners, are doing an extremely good job. There's supervision there because the consultant is on call and this reliance on this needing to be a role for a doctor. We've changed our attitude to that so I know you know extremely well the difficulties in pediatrics. You've also touched on psychiatry, those are real shortage specialties and so what we're doing is looking at providing services differently. Training advanced nurse practitioners in the NHS in Grampian with Dr Gray's hospital, advanced nurse practitioners are on a shortened course so that rather than taking two years they're taking one year so that they can come into the service more quickly. Colin Beattie I'd like to explore a few issues around governance and leadership. In the report there's a number of references here to the quality of board members, the lack of a consistent approach to achieving the appropriate level of knowledge and skills and expertise. I believe that the Scottish Government is developing a range of initiatives in regard to that. In the light of the Auditor General's report, do you think that the initiatives that are being undertaken by the Scottish Government are adequate to address those issues? In response to some of the governance issues in NHS Highland, we commissioned John Brown and Susan Walsh to a review of the governance. They produced a report on that which in turn produced a blueprint for all NHS boards in Scotland. That blueprint is now being applied to all boards and is to be fully applied by the end of this financial year. In other words, all boards should conform with the blueprint by the beginning of the next financial year. I think that that will respond to some of the issues that the Auditor General has raised. We have strengthened our support for induction of chairs and board members and the Cabinet Secretary has made clear to the chairs of the board that she expects the findings and good practice from that exercise done in NHS Highland to be a part of it. That is something that we will not simply take for granted, but we will follow up and assure ourselves about it. The blueprint that you refer to, I do not think that that has been shared with the committee, has it? I could not say if it has, but I can see no difficulty in doing so. I think that it might be useful if we saw a copy of that and view our concerns over governance in general. Obviously, you have used NHS Highland as an example. Here, as a committee, we only see when things go wrong, not when they go right. How do you transfer best practice one board to another? Addressing problems is one thing, but actually adopting the good practice from boards that are getting it right is really valuable. I think that that is part of the purpose behind this blueprint. We took the view that it was not sufficient simply for NHS Highland to learn the lessons of the review that John Brown and Susan Walsh did, but that those should be applied across Scotland. Again, the cabinet secretary has raised directly with the chairs of the health boards the importance attached to not only understanding and sharing best practice but implementing it, spreading and scaling it. I have discussed with the board chairs the ways in which they can do that through the work that they are doing on innovation. I think that I would say to this committee that there are pockets of good practice, but we need to get better at ensuring that they are embedded everywhere. That said, when issues do arise, we try to learn from them, but we also make sure that we use the board chair meetings to discuss the kinds of things that boards are finding to work well. For example, when NHS Lanarkshire went through a period of significant difficulty at the end of 2013, we put in a support team at that time. The findings and learning from that support team were shared with all the boards. I think that some of the governance support that we now put in to boards if they are experiencing difficulties is drawn from the good practice that we have learned from previous incidents. You are talking about NHS Lanarkshire in 2013, and you shared that with the boards. Clearly, some of the boards did not learn from the lessons there since we have had problems coming up subsequent to that. One of the things that we are committed to doing, and as I say to the cabinet secretary, is leading, is to improve that sharing of best practice to ensure that it is embedded everywhere and that we assure ourselves that it is being embedded. That is what we are doing. The blueprint, obviously, is something that boards can use, hopefully, as a learning device. However, the quality of NHS board members, as mentioned in the report here, is very variable. Again, we only see when things go wrong and frequently, not just in the NHS, it is weaknesses on the board that have exacerbated the issues that we are facing. How are you going to deal with that? Does the blueprint in itself want to address that? In terms of recruiting board chairs, we have moved in the last year to a process of values-based recruitment, which is much more thorough and detailed. It not only involves a paper submission and an interview, but a battery of psychometric tests, conducted by someone who is qualified to do that. A role-play exercise, again, can be overseen by people who are qualified to do that. From those elements of feedback, we get a much better picture of the skills and capacities of the individuals who are coming forward. The commissioner for ethical standards in public life in Scotland, who oversees the public appointments process, has been very supportive of the approach that we are now taking. That is for chairs. I want to be clear with the committee at this stage, but I believe that there are elements of that that can also be applied to board member recruitment. Further, I am clear that the quality of the appraisal of board members needs to continue to improve in light of what we are seeing. That said, I do not want to leave the committee with the impression that we do not have some very good board chairs and board members. However, in paragraph 69, the Auditor General talks about the need for a more effective challenge within the board members. That has consistently been a weakness that we have seen in boards where things have gone wrong, or at least in NHS where things have gone wrong. How are you going to address the existing board members? One of the things that I have been clear about when recommending chairs to the cabinet secretary for appointment is that I take them through questioning on how they move from a process of seeking reassurance, which in my view is insufficient, to a process of assurance that involves testing the material that is put in front of them, and I think that boards are not swamped with paper but get the information that they need and that they have the time and the skills to interrogate that. Again, when we are recruiting board members, we are paying very close attention not only to the skills and capabilities that they bring but also to the fit and mix in the board. In other words, we make sure that we have people who are financially qualified and we make sure that we have people who are able to scrutinise the clinical governance arrangements that are in place. It is not just a baseline that every board member has the same approach but rather making sure that the fit and mix of the board is adequate for the needs of the board in question. I want to return to workforce for a moment and follow up questions from the convener to Shirley Rogers and Dr Calderwood. Shirley Rogers said that, for the first time, we have a workforce plan published. Why has it taken 10 years and the current level of workforce challenges that we have for us to finally publish a workforce plan? When we published a workforce plan rather than a comprehensive, integrated plan to have three separate plans going back to the old model rather than the more modern model that we want to project on the national health service and social care service? Workforce planning has been present in the NHS. I have worked in the NHS in Scotland for 23 years. Workforce planning has been present for all of that time. What became different was the elements that you referred to. We are doing so with partners who are not just NHS partners. We are doing so in a manner that reflects the holistic nature of the NHS rather than just secondary care in the hospitals, primary care outside, doctors, nurses or whatever. The plan was published in three phases that dealt with secondary care in the first instance. The integrated landscape with colleagues from COSLA and so on in the second instance. Most laterally, because of the negotiations around GMS contract and various other bits and pieces, primary care. It is our intention, as I think the committee is aware, to publish an integrated workforce plan and that work continues to be able to do so in the spring. That reflects that changing dynamic, which has not been the case and was not the case 10, 15 years ago, where we did plan for specialty by specialty for doctors and as a separate thing nursing and as a separate thing AAHPs. Was the comprehensive plan not meant to be published this year? The comprehensive plan is due—we have published the three elements that the plan has committed. Three separate plans though? Yes, based on the old model. Three separate plans based on the new methodology. That was another important aspect. In order to be able to plan with multiple employers, we needed to have a shared number of people to do it. Based on the new plan, when do you think now that we have a new comprehensive plan coming, we will have a manageable vacancy rate in the national health service and social care service? I think the vacancy rate in the NHS and in social care is always going to be challenging for us. We are always going to have to continue to make sure that we have a sufficient supply. As you know, in numbers terms, health and social care in Scotland employs approximately 14 per cent of the working population of Scotland. In numbers of that size, there is always a challenge about making sure that that is influenced by other factors such as the withdrawal of various other bits and pieces that we need to consider. There is always a challenge in making sure that that is the case. What we are doing, as the CMO has pointed out in the previous evidence, is targeting those areas where we know that we have a specific challenge. If I can give a challenge that is not medical for a second, we know that we have a challenge around healthcare support, and in particular those individuals who work within the care home sector. For the past two or three years, we have been developing an educational model that allows us to essentially have people learn while they learn. To give you some medical examples, we have three and a half thousand nurses in mid-wide vacancies, for example in the National Health Service. One in three GP practices is reporting a vacancy for a GP. We have one in three radiologists posts vacant. We heard that from Ayrshire and Arran and from Highlands. When will that be sorted? Based on your comprehensive workforce plan, when will we sort the radiologist issue? When will we sort the GP crisis issue? When will we get down to one thousand nurse vacancies rather than three and a half thousand nurse vacancies? If I take the radiology example, some of that will be about recruitment. As you know, there is some targeted activity in that space. Some of it will also be about finding different solutions to some of those radiology challenges. If I take the East of Scotland, for example, and look at how radiology services are being developed there using digital and technical platforms that allow films to be read appropriately by clinicians from every part of that region. It is not simply a number. I think the Audit Scotland report says that it is not just about money and supply. It is about transformation, how we use technology to better support some of those services that need to be supplied and are under pressure to do so. Frankly, a film can be read by a competent person in a number of different locations. That allows us to make the use of technology that we need to use. It also allows us to make good the supply issue. Can I say to you specifically that, in five, ten, fifteen years time, we will never have a GP vacancy? No, I can't. No, I am not saying never. At the moment, it is not sustainable. Health Wars tells us that. It is not managed at the moment. The vacancies are not managed at the moment. At what point will we get to where we have a transformation plan around service and a workforce plan around filling the vacancies that gives us a manageable situation in our health boards? You can give us a time frame for that, surely. A year, two years, five years, ten years? I think that it is going to be one of those things that is an incremental development. We now have a medium-term financial framework that allows boards to plan. We have a number of issues around access. That allows us to increase our supply. We look at training ratios, for example. We know for those areas where we have a shortage of supply, we are now training more than one-for-one. In pediatrics, we train 1.6 for one. That reflects the changing patterns of work that people want to enjoy. People don't particularly... You must have an ambition date. There must be an ambition. We hope to have it done by two years, five years, ten years. I think that you have asked Ms Rogers this question a few times now and she has given an answer. Liam Kerr. The workforce issues are hugely concerning, but all those people need to work somewhere. The report is quite clear that the capital investment is required in the estate. It talks about a backlog of maintenance of £900 million of which 45 per cent is urgent. It is significant or high-risk. First of all, what is the Scottish Government's response to that? Given the financial challenges that we have been looking at, how on earth is the NHS supposed to cover this? You are right that the level of backlog maintenance has stayed relatively static for the past few years. It is one of the factors that we look at in capital planning, but one of the most significant answers on backlog maintenance as well as making sure that the buildings are safe and able to be used is looking at our programme for replacement of facilities and looking at that as part of service redesign. The answer on backlog maintenance is not to spend £900 million as a sum to bring those facilities up to the level that you would want. The answer in some cases is always going to be some additional facilities. It is our capital investment strategy longer term to look at the priorities across the country. We have a national infrastructure board to allow us to try to make sure that we prioritise across the whole of Scotland and not just focus on particular parts of the country. We said in response to the report that we are developing just now a capital investment strategy that will look much longer term. We need to be able to look 10, 20 years in advance when we think about our infrastructure. As you know, a typical new hospital build will take around seven years from the very first strategic case that the board makes through to being in use. It is important that we look much further ahead on that. However, our investment on annual basis from capital is split between essential maintenance that we need across the service and investment in new facilities. We have seen recently the new Dumfries and Galloway royal infirmary as a good example of our answer on backlog maintenance in that particular situation. I hear the answer, Christy McLaughlin, but I then look at paragraph 33 of the report, which says, as the way healthcare is delivered changes, the existing NHS estate will need to adapt to reflect this. The Scottish Government has not planned what investment will be needed. In your response there, you were talking about a capital investment strategy. That report seems to suggest to me that there is no such strategy, that the planning has not been done. Has the Scottish Government really not planned what investment is going to be needed at all? In any event, how can the NHS continue to deliver services in the future without the buildings and infrastructure to do so? I agree. It is going to be one of the most significant areas for us to focus on over the next few years. Has it not been focused on already, Christy McLaughlin? If you look at the number of new facilities that we have had over the past few years, going back to Queen Elizabeth was £842 million investment in that facility. It is not that we are not investing, but we always need to be looking ahead and making sure that we are making use of those funds and prioritising correctly. The work that we are doing is building on the regional plans to make sure that we are looking at the right facilities across the whole of the country. It is not that things do not exist, but it is important that we are able to look short-term, medium-term and long-term. The strategy is all about the very long-term approach to that. Let me be clear that the Scottish Government has not planned what investment will be needed. Is that a fair statement? Is that the case? We have not planned, but we are doing work to make sure that the plans that we have regionally for the next 20 years are in place. The strategy that we are developing is a new strategy. I do not have a strategy to say that this is the one that we have just now for developing something for the future. When will it be developed? We are doing the work just now. We have said that we will have something published by the end of this financial year. By April, there will be something that we presumably can have a look at. That is what we are working to. Willie Coffey. Can you give us an idea if you have done any post-Brexit modelling on the workforce and its impact on NHS? Yes, we have. What is the message that you are talking about? Shevley has been leading on that. We have done quite significant work. Cable may be able to say more to you. I am sure that, around the table, everybody will understand that the model that is emerging for Brexit is changing at a fairly frequent pace. We had had a number of concerns around particular elements. Things like, for example, the mutual recognition of qualifications, whereby we needed to give consideration to whether or not arrangements would be in place to allow us to continue to deploy those people trained in EU 27 nations. We now have a position in respect of that. We are currently operating the advanced pilot of the settled status scheme to allow those EU 27 workforce members of our NHS and health and social care staff to apply for that settled status. We understand that people are starting to do so. Our concerns about the immediacy of the workforce that we currently deploy, accepting that there are some messaging issues that have been raised with us and various other concerns that have been raised with us around circumstances that we may or may not find ourselves in, depending on the nature of the deal by which we withdraw from the EU. Those issues are largely, I hope, in a manageable form. The bigger issue for us at the moment is the concern around supply and future supply of people choosing to come and study and live and work in the United Kingdom post-Brexit. The medical officer has already identified that the strongest characteristic that encourages somebody to stay and practice medicine is where they went to university, where they went to medical school. We know that there is a huge correlation, a very positive correlation between where you went to medical school and where you go on to practice. We are now starting to see some of those numbers and expressions of interest in medical places start to dip a wee bit. The committee members will be aware that we have now seen the number of applications from EU 27 nations to join the nursing and midwifery council significantly declined. We know that we went from approximately 8,000 to less than 100 applicants to the NMC register in the last year. There are issues around supply that are encouraging us to work very hard to try and grow our own, which is why some of the issues that Catherine talked about in terms of medicine are similarly replicated with extra effort around nursing, schools of nursing, and in particular around healthcare support workers, where we know that the proportion of EU nationals working in the healthcare support worker network is higher, that we are working very closely with colleagues in local government and in the other sectors to try and make sure that we have a supply pipeline in that respect too. There is a concerted effort to try and make sure that we are able to retain those EU national citizens who already work within our system to assure them that they are very much wanted to continue in that space and that the messaging around that is positive and to look at the supply pipeline going forward. The likely impact will be on NHS staffing and recruitment from the £30,000 salary limit that was announced yesterday in the new immigration policy. We know that £30,000, as a cut-off point, will impact on some of our nursing grades and will also impact on some of our junior doctors, but the biggest proportionate hit is in that healthcare support worker arrangement. That is a challenge to us and, of course, the narrative about low pay does not necessarily indicate low skill. Healthcare support workers may not be paid very much, but the skills and abilities that they bring are critically important to how we run our social care programmes. When I sat in the committee a number of years ago when Caroline Gardner's predecessor Robert Black was here, he warned us about these days facing the NHS and how difficult it would be to sustain and deliver the service as it currently was. We are seeing more boards reporting overspends, the numbers increasing and the size of those overspends are increasing too. This is despite record funding for the NHS and another £730 million in next year. My question is, where are we with the transformation strategy that we are pinning our hopes on? How consistent is it across Scotland and when will we begin to see some of those overspend numbers coming down because of the benefits of the transformation strategy taking place? I'll bring others in, but I want to draw out three things. First of all, the ministerial steering group has commissioned a review of health and social care integration. Sally Loudon and I are co-chairing the group, which will be reporting to the ministerial steering group on this in January of 2019. One of the key impetus behind that is to accelerate the pace of change through health and social care integration and to pick up the points that Mr Beattie and others have made earlier about sharing and implementing best practice. That is part 1. Part 2 would be useful for the chief medical officer to say a little about the work that she is taking forward through the realistic medicine programme because that again is genuine and sustainable change, which will make a difference to the way in which we engage with patients and the way in which diagnosis and treatment is done. I know that, for example, just recently, and certainly Rodgers may be able to say a little more about this, we are seeing a reduction in the rate of prescribing through the work that we are doing with pharmacists and patients to ensure that there is appropriate prescribing that people are not having, well, it's called polypharmacy, too many medicines. We can cover those points off if the committee would like. Dr Catherine Calder, would your take on transformation, is it going far enough, fast enough even? The realistic medicine that we are promoting has started in Scotland and is now all over the world, talking to people about what they actually want from their medicine. Just because we can do doesn't mean that that's the right thing. For somebody, somebody may want to run a marathon, somebody else may just want to be able to walk their dog in their garden. There is a real shared decision making and personalised approach to people's care that we probably haven't refined as well as we should have done. Within that, what we need is talking about value-based healthcare, so that's a value to the person. What we also need is value for the money of the public purse. For the first time, we believe that we are the first country in the world to do this. We have a training programme that matches clinicians and people from the finance department of their health board to learn together about what value improvement training is. It may sound naive when I say out loud that there isn't an understanding about the finances that goes through what doctors learn in their training. We know then that people in finance are working on a different column of numbers, so we have brought that together as something that then will spread. We have trained 200 people in the first year and we have funding to continue that training. You can imagine that small numbers of people in the boards train others. We are also working on exposing where there is variation in practice, which leads to variation in outcomes. At the moment, we have a rate of primary hip replacements across Scotland that varies by a factor of fourfold. Primary knee replacements vary by a factor of sevenfold across Scotland. The patients don't vary by that factor, so it may be that some people have procedures that they don't need. It may also be that in other areas people are not having what they should have. We have published three maps of variation in Scotland and we are planning to publish another 10 by the end of this financial year. What that is doing is asking the questions that I am not going to tell the orthopedic surgeons how many knee replacements they should be doing. It is exposing why there is practice in a small country that is so different. We are looking at rates of childhood obesity and the clinical community doctors that I am talking about. It is right across all healthcare professionals who are really welcoming this because these are the conversations that they want to have. They often talk to me about having not felt that they have had permission to talk in this way to people. I will be brief, but I must mention the citizens jury. The first-ever citizens jury in Scotland has just finished. We invited people over the age of 16 to come together in three weekends to talk about some of the very difficult questions that we are doing. We were a victim of our own success. We calculated the number of people we would need to invite based on voting and how many people turn up for ordinary juries. We were oversubscribed by 50%. We had to turn people away because they wanted to be part of it. I have seen a draft of the recommendations that the people of Scotland have come up with, and they are really supportive of these difficult questions about values and about improving how we are delivering our healthcare. That will not be quick, but I think that we have started the conversation. Bill Bowman, can we come back to the question of locoms and the costs there? One of the issues when we were discussing it was that we speak about agencies, but I am not sure that I or others know very much about these agencies. Who are they? Are they regulated? Do you approve them? How do you manage your buying power so that perhaps boards here in the rest of the UK are not just having a bidding war and pushing up the costs for the same people to nobody's benefit? I will bring Shirley-Anne in on that in a second. It is probably just worth saying to the committee that medical agency spend in NHS boards fell by 5 per cent between 2016-17 and 2017-18 and locom spend fell by 10 per cent between 2016 and 2017-18. On that point, Mr Bowman, although there are high costs that the committee has rightly drawn attention to, we are working hard to bear down on that, not just to let it run away from us. The use of locoms is really quite important. I do not want to re-open the point about Highland, but the two locoms in question were in the Belford hospital and in the Cathness hospital in Wick. Those were not large hospitals that could flex their workforce, particularly easily. It might be different in a big hospital and the local community, as the CMO said, would have had to travel quite substantial distances had these services not been available, and in particular given the types of skills, possible impact on emergency surgery as well. Shirley-Anne, you might say something about the way in which the medical agency staffing is co-operated. There is no reason for us to be concerned about the quality of the people who come to us from the agencies. They are run through commercial organisations, they contract with boards, there is a national contract that is used, there are a number of them. Roughly? I would probably say in regular usage, four to six, so not thousands but regular. There is a distinction between that and a bank, which is the NHS's own staff running in that space. I do not have anything that would suggest to me that there are concerns about the quality of what we get, though clearly all of our ambition is to try and have full establishments and to use our bank where possible. The point that I would make, perhaps more bluntly than the director general has, is that in the utilisation of these agencies we do so in order to preserve safety for patients. My point was really how do you manage the relationship so that you are in control? You are a large purchaser, I expect. You have some sway over them and setting the rates. There is a national prototype contract that is supplied from NSS to the boards for their use. They are not required to absolutely adhere to it but there is a national protocol contract that they can draw on if they wish to. To my witnesses, I am still not completely sure that I follow this issue about locums. Why would a doctor take an NHS contract if he can make £400,000 going through an agency to work in an NHS Highland? Security of tenure, views about their values, the desire to work in one place and be certain about it, the fact that you can settle your family in a particular place if you have certainty about the length of your employment. There are many reasons why a person might choose to, not just in medicine but in many professions, choose to go for a locum or agency type employment or to go for fixed and substantive employment with an employer. We know that there are many people who do, but the fact that the locum and agency option is open and working and thriving in Scotland means that they have an option. Does the power not rest with the Scottish Government to close this option down and to save the taxpayer a lot of money with the same service? The power rests with us to close it down. We could close every contract and we could cease to employ locums tomorrow and I would not like to estimate the number of people who might die as a result. I think that it would be a very dangerous thing to do. I accept, convener, wholeheartedly your point about the expense of some of this and the importance of bearing down on that. I have tried to give the committee some evidence that we are seeking to bear down on it. However, as Ms Rogers has said, and I am sure that the CMO will support me, there are significant patient safety issues at stake here. If we take someone out of the Belford hospital, it is not a big hospital. If we take people out of WIC, the good folk of WIC are not going to want to have to travel down. I agree with respect. I have already made that clear. I am suggesting that NHS Scotland, as the main employer for doctors in Scotland, manages its workforce and makes sure that those hospitals have doctors that they need. Clearly, those doctors exist, but the option is open to go through an agency rather than an NHS contract. That may be a lifestyle choice or a point-in-career choice. However, you have left that choice open to them. Indeed, we have. I believe that we should continue to do so. I am happy to say that that is unequivocally to the committee. I turn to paragraph 62 in the Auditor General's report. It talks about leadership. She has three, four, five, six bullet-pointed examples of arrangements at the top of boards where there have been struggles to recruit both chief executives and directors of finance. There have been various interim positions, a high turnover of non-executive members of boards as well. Do we have enough people to run our health boards? We have a chief executive in place in every health board, and at the moment— Some of them interim, is that correct, Christian? The chief executive of NHS Grampian is an interim position, and we took the decision, and I think that it was the right one, to appoint a new chair, because Professor Logan is leaving at the end of this year, to appoint a new chair and to allow the chair to oversee the recruitment of the new chief executive, the substantive recruitment of a chief executive. I think that that was the right decision. We have recruited to the state hospital. Shirley-Anne, do you want to give a list of the places that I can do it or surely can do it? The Auditor General has done it for us very helpfully. I think that my policy question is how do we get people in place that are there for the long term to run our services? That is a kind of hodgepodge of interim and struggling to recruit its paragraph 62. No, I am reading it, and what I am saying to you is that we now have a substantive appointment at NHS Orkney, we have a substantive appointment and have had for some time in NHS Greater Glasgow and Clyde, we have a substantive appointment to the Golden Jubilee National Hospital. The point in time at which the Auditor General wrote to the report, what she said was entirely factually accurate. The fact is that we have moved on since then. Do members have any further questions for our witnesses this morning? I had some questions for Mr Gray. I want to thank you first of all for the last two and a half years that you have been very open. We have had our first year of friendly arguments and discussions, but you have always been very open and I want to wish you all the very best for the future. I want to take advantage of you being here and maybe ask you a couple of questions now that perhaps you might be less on the leash in terms of some of the issues. If I can clarify Mr Sarwar, I am expecting Mr Gray to be back again before he escapes the Scottish Government. We look forward to it, but just a couple of points related to what we have discussed today. Ms Marra said about the number of people relating to health boards. Going back to the vacancy rate, the fact that we have 3,500 nurses, 900 GPs and so on, we are over 5,000 people short in the national health service. Should we just be honest with the public and say that we are not going to find 5,000 people and given the fact that we are not going to find 5,000 people, we need to change the model of our care and there being a real programme of reform coming from here, led by the Government. Would you advocate that? Do you support that? I think that there has been significant investment in primary care announced. I think that we should allow that to take its course. That was 250 million announced over five years. There has been an announcement about 800 additional mental health workers. I think that we should allow that to take its course. I think that there is an international shortage of radiologists. There is not actually something that we can do that prevents an international shortage, but as Ms Rogers had said, we do not absolutely need to have everything done by radiologists. They are highly skilled individuals. There are other opportunities for others to participate. Technology can make a difference. Overall, staffing levels are up. I can give you the detailed numbers, but there have also, in the last quarter, been a reduction in the vacancy rates for consultants, nursing and remifery and EHPs, so we are seeing that coming down. I do not make this just a flippant point. I make it as a genuine one. The 140,000 whole-time equivalent staff who work in the NHS did not come from nowhere. They came from the workforce planning that we have done. We have substantially enhanced that, as Ms Rogers has said. I accept that, Mr Gibson. I am asking a different question, which is not to say—I accept all the things that you have said about those recruitment challenges and what you have done to count those recruitment challenges. I am asking a much more broader point. Does there need to be an acceptance that we are not going to magic 5,000 people, that there does need to be a radical transformation in how we deliver services in Scotland, and that leadership needs to come from the Scottish Government setting out radical reforms and a new model of care that takes this Parliament and, more importantly, the public and the people who work in our national health service with us? Does that need to happen? There are—so, nobody is disputing that there needs to be radical change. Nobody is disputing that in any way whatsoever. The changes in the past few years—I am not making the point about particular terms of office or terms of Parliament—I am just saying the way that things have developed has been substantial. There are people now being cared for at home that would not have been cared for at home 10 years ago. There are people being treated in different ways. If you go to the Golden Jubilee National Hospital, you will see them having supported discussions with patients where you have a nurse at one end and a doctor at the other to make sure that people are appropriately cared for and treated so that they do not have to come back from ortony after they have had their surgery. We are making significant advances. I expect that the future to be very different from today—in the same way as today—is very different from 10 years ago.