 Good morning and welcome to the ninth meeting in 2015 of the health and sport committee. I would ask everyone, as I usually do at this point in time, to switch off their mobile phones as they can sometimes interfere with the sound system. You will also note those who have been with us for the first time that we have got members in, if I was using tablet and this is instead of the hard copies of our papers. I should start with a policy of sort to delay this morning. We had a private session on one of the committee's reports and that's delayed us a wee bit, but I'm pleased that we're here this morning for this roundtable. And as usual, although I look around and see some familiar faces and old friends nearly, I would invite everyone, as we usually do, to be able to introduce themselves for the records. My name is Duncan McNeill, MSP for Greenland and Verklyde in the convener of the committee. My name is Kenric Lloyd-Jones and I'm from the Chartered Society of Physiotherapy in Scotland and I'm representing the Allied Health Professions Federation. Bob Doris, MSP for Glasgow and deputy general of the committee. Sandra Melville, I'm a pharmacist working in hospitals and a member of the Scottish Pharmacy Board of the Royal Pharmaceutical Society. Mike McKenzie, MSP for Highlands and Islands region. Good morning, Dennis Robertson, MSP for Aberdeenshire West. Harry Stevenson, president of Social Scotland. Good morning, Colin Kear, MSP for Edinburgh Western. Good morning, Frank Dun, president of the Royal College of Physicians and Surgeons of Glasgow. Good morning, Richard Lyle, MSP for the Central region. Richard Simpson, MSP for Mid Scotland and Fife. I'm Helen Richards, I'm policy officer at the RCN Scotland. Rhoda Grant, Highlands and Islands, MSP. Peter Benny, I'm the chairman of BMA Scotland. My clinical job I'm a consultant psychiatrist in Paisley. Nanette Milne, MSP for North East Scotland. Thanks to you all at this page. In the Russia for all, usually a committee member asks a question, so just to get us going. The Royal College of Physicians and Surgeons of Glasgow urges Scottish and UK Governments to remove the inequity of care at weekends and public holidays. Does everyone agree that there's a lack of parity or inequity of care at weekends and public holidays? Everyone agrees, Peter? Yes, but there I think will always be a degree of inequity between working hours Monday to Friday, weekends and overnight. In particular, when it comes to elective services, it seems to me that there should be a lesson until we have a hugely increased resource both in terms of money and in terms of all staff, not just doctors. We would very much see the focus here being about ensuring that we have good quality urgent and emergency care right across the seven days of the week, whatever time of day or night it is, but we would not be at this point pitching to try to make an exactly equal service at three in the morning on a Sunday compared to during the week. I agree largely with that. Our thrust from the Royal College of Physicians and Surgeons was inequity of care for patients who are admitted urgently or as an emergency situation. We cannot have a situation where if you are admitted as an emergency on a Monday to Friday, you will get more likely to have a chance of survival than on a Saturday, Sunday or on a public holiday. The particularly vulnerable times are on the holiday weekends, where there is a Monday as well, so there is a huge build-up Saturday, Sunday, Monday of a lack of resource that is there on a Monday to Friday. Our main thrust, and I agree that the elective situation has to be looked at differently, I do not think that our resource would allow seven-day working for everything, but we must initially make sure that patients who are admitted for unscheduled care are treated and get the same standard of care throughout the working week and at weekends. I think that it is similar that we believe that if a patient has clinically urgent healthcare needs, they should be able to get high-quality care when and where they need it irrespective of the time or day of the week, so it is less about routine elective services being available whenever, but more about the urgent healthcare needs. When looking at what services should be made seven days a week, it has got to be evidence-based, so there has to be proper analysis about what is best for patient outcomes, as well as best use of resources. Following on from what you said, you are talking about services within hospitals, but it is not just that when patients are admitted to hospitals, they have to look across the whole system, so hospitals, community, social care and then look at the whole multidisciplinary workforce behind that. Yes, please, Arlie Stevenson. Okay, in Scotland, what you find is that there are seven-day services 24 hours a day, but there will not be the level of consistency that you might want to find that can match what is required for people, because some of those are essential services in terms of personal care, and they make sure that they are at the right times to provide that, but the challenge will be stepping forward together in relation to this agenda of seven-day working, and the workforce itself in modernising the service to be available still requires some work in relation to relationships with trade unions, for example, to make sure that we get to gear up in that way for the public. I think that it's maybe worth just taking a moment to think that the cohort of patients that come in at weekends isn't the same as the ones that we have Monday to Friday, and especially when we're looking at where we should target the finite resources that we have and where extra resources are required. The patients that tend to come in at the weekends tend to be more sick patients that haven't gone through the natural GP referral system, emergency admissions, they tend to be frailer patients with comorbidities, with more complex medicines, and, certainly from the pharmacy point of view, that's where we feel that we can have a very valuable role in sorting out these problems right at the start of the patients' admission out of ours, and we do that currently Monday to Friday, but not at the weekends, so I think that that is a definite gap in patient care. Just to follow on absolutely, I think that the rationale there is that this is about unscheduled care and it is about making sure that services are designed around the patient and in the best interests of patients and where the evidence is to support that, and clearly there is more that can be done. I need to open with that question and just try to pressure on that one again, because there has been some debate at least in the political sense that the situation is different from here as elsewhere and whether it's a priority or not, but I think we all agree with the but, but we all agree that there's an additional risk if you find yourself in that emergency situation, public holidays, weekends, or indeed out of ours is an additional risk there. We all agreed about that. No, Peter. The research on that tends to show that you are more likely to die or suffer complications if you're admitted at the weekend compared to admitted Monday to Friday, but there are confounding variables with that, in particular what you've heard already about the cohort of patients who are admitted at weekends are different from those who are admitted during the week and are generally more ill to start with. It's straightforward to agree that we must ensure that we've got good quality care around the clock, but there are some uncertainties about the exact meaning of the research because those who come in at the weekend are more unwell. It may be that the reason they have a worse outcome is because they were worse to start with, at least partially, rather than because we don't have the right services. Generally, the people who present at hospitals now are more unhealthy. In general, that's one of the problems that our health service has. In general, wherever the weekend, during the week, the people who arrive at hospitals are more ill than they used to be. They've been kept in the community longer, and when they get to the hospital they are vulnerable, they're older, comorbidity, all of that. That's a general hospital demand, not just at weekends. If I may, as far as we can understand from the research, it's the case that that's more so at weekends. Maybe the way to look at this is to be as sure as we can be about the evidence base. If you look at page 2 of the interim report from the task force, it outlines the four areas that the task force is working on, and they are, define what we mean by seven-day services, map the current service levels across those clinical areas, then define the requirements for seven-day services, and then identify the steps needed to ensure that that happens. We're very clear that that's the right way to go about things. Our perspective at present is that part 1 of those has been delivered by the task force, that part 2 is at best only partially delivered. We don't yet have a real meaningful baseline of what's being provided at present, and we certainly don't have clear definition of the requirements because we don't fully have the baseline yet. The task force is doing good work, but it's some distance away from being able to be getting down to the important part, which is number 4. I worry that there's a danger that you might try to push us to tell you what the answer to four is before we know for sure what two is. We'll get to the wider discussion of all the problems, but I'm just looking at the written submissions. There's loads of challenges in there about how difficult they are. That's not unusual when we talk about changing the health service, the committee is used to that, those sort of submissions. When I look at it, I know it's going to be very difficult. If it's not clear, as you have said, that there's a lack of parity at weekends and holidays, if it's not clear that people are more at risk, why are we doing it? I think that there is some degree of debate about whether the patients are more ill at the weekend, but there's been numerous studies not just in the UK but in other parts of the world indicating this vulnerability of patients at the weekend. I think that it may be partly because they present at a different time, but I think that there are other factors. When you look at the hospital at the weekend and you look at the support services within hospital at the weekend and you look at the way the community services are stretched as well, I think that there is a whole raft of problems. I think that this is one trigger for it, but those of us who have worked for many years appreciate that over the years you've been working with much more of a skeleton staff at the weekends, and that has impacted on a number of different areas. I'd also venture that it's not just about patient safety, it's also about things like delayed discharge and the fact that there's enormous pressure on the system which could be relieved if systems were more fully operational at weekends. That is very much why it's related to a much wider question around prevention and supported discharge. It seems to me that I'm taking from the discussion that we already had just to ask the witnesses about data. Are we actually collecting the data? We did an FOI on the workforce at weekends, which we published and were told was rubbish. That was the information given to us by the health boards. We don't publish anything except what is given to us by the health boards. Do we have the data on the workforce during the weekend as opposed to during the week? Do we have the data with regard to the access to what the Royal College of Physicians of Glasgow have, I think, very helpfully listed as the tests that are required absolutely at the weekend? Are they actually available in every hospital that is carrying out admissions? To define it even further, if we take just two further elements, is there evidence that we're hearing that the weekend admissions are different to the weekday admissions, but is there evidence that some of the weekend admissions are not really requiring to be in hospital? The overall figure of that, I'm told, is that it could be as much as 30 per cent of people being admitted to hospital currently who don't absolutely need to be in hospital and could be managed elsewhere. Do we know is that higher at the weekend, or is it only complex cases? Does the data on anything specific show us anything, for example, a stroke where we're supposed to have admission to a proper stroke unit within 24 hours that isn't occurring in the percentage that we would like it to occur? Are there treatments for thrombolysis or the tests that would indicate that thrombolysis was appropriate? Are they being done at the weekend or are they being delayed? Do we have a hard database on this? That seems to me to be the starting point for determining whether we're going to make what is perhaps going to be quite a significant change in either the distribution of the workforce initially or, in the long term, the total workforce in order to cope with weekend working. Anyone want to respond? Helen? I've just done the data about the workforce, so the task force as part of the initial work did some baseline mapping of services and the workforce available during the week and out of hours and at weekends, which was an initial step, but certainly from nursing data, it wasn't enough to give meaningful data in order to do something with it. The way the data was collected was very broad on the nursing numbers and what you need to know from a nursing perspective as well as not just the number of nurses but the level at which they are and what level they're working at. At the moment, with the data that's held nationally and from the data that was collected through the task force, we don't have that data set ready in a robust way that we could do meaningful analysis with, so I think that there is more that can be done. I think that the situation of patients with heart attacks in Scotland gives us an example of what can be done. Now patients in the west of Scotland, the ambulance service is signed up, the technicians and the golden jubilee are signed up, the consultants work a 24-hour shift system and stay in the hospital at night. The support staff do the same so that every patient who has a heart attack and needs to have primary balloon procedure will have it within the specified time, irrespective of the time of the day or the day of the week that this happens and that's because there's been a huge resource put into that. If you take that back to other situations where all of these aspects, support staff, availability of transport etc, are just not available in the same way for other situations, for example discharging patients at the weekend, it's far more difficult to get transport home for them. It's far more difficult to get a care package started in patients who are discharged over the weekend than it is during the week. This is just because people are stretched already and there's just not the resource to do it, so there is an issue at the weekend. Again, we've talked to the pharmacists and they can speak to that as well, but there certainly is the kind of infrastructure that they see in these high-tech areas such as heart attacks and stroke patients are not being seen across the board in the vast majority and, of course, it's the frail elderly that need to have this as much as anyone. Yes, please. I think that you've raised some very good points. Some of these things could possibly be addressed by discharge planning in advance and setting up care packages in advance. From the pharmacy point of view, a lot of the preparation of the discharge prescriptions for patients can often be done in advance. What we're really saying is that we would like to see pharmacy at the front door when patients come in to try and solve the problems. Although we're talking about does the database show that there are actually worse outcomes for patients at the weekends and why is that the case of data does quite clearly show that there are worse outcomes for patients. There's a lot that we could do from the pharmacy perspective, not just in helping with the discharge planning, but in sorting the medication issues out at the patients as they come in. Throughout that patient's journey, as a sick patient comes in and deteriorates the medications that they're on, they become less appropriate. We have a very big role in preventing avoidable harm for patients, as well as facilitating and helping to facilitate the discharge of those patients by making sure that the medicines that they're on are correct for them right the way through their journey so that it's much easier to discharge them when they go home. That can be done with pharmacy technical staff as well, but it's overseen by a pharmacist. There's a lot there that we could do at both ends of the right through the patient's journey to facilitate the whole thing. First of all, Sander makes a very good case there. Second of all, it seems to me reading through the interim report of the task force that the data is a bit piecemeal. We know a lot about some services in certain areas. What we don't know is what's the availability of similar services elsewhere in the country. In order to make the right decisions about this, we've got to have a broad baseline because any decisions are ultimately going to be about prioritisation. We're simply not going to be able to provide all of the services that everyone around this table would want to provide unless there are substantial changes in the resourcing. Anything that we provide at weekends within the current resourcing means that you're going to be reducing the input of those same staff during the week. I realise that I'm banging on about it a bit, but that's why I was hoping that the task force, certainly fairly soon, will have a much broader, much more effective database of what's being done just now. Until we know what's being done just now, we're not going to be able to map across and take Frank's example in Glasgow and say for certain that that does or doesn't happen in Aberdeen or elsewhere in the country and decide should it happen in all parts of the country and if it should, then where does the resource come for that and what do we decide not to resource in order to achieve it? That's the core of this, and there is good work in this interim report from the task force, but I would expect the next report to be much more broad-based in telling us exactly what we've got just now and making some recommendations about what are the priority areas for improvement. Yes, please. You'll see from the evidence. In Scotland, where areas have tried to have more service availability at weekends, there's just less discharge activity as part of the issue, so that comes in overhead where the staff are now to use the availability there. Again, point me there, it's not consistent though across the country that is one of the challenges for all of us, but again I'll make the same point that unless we move this all forward in step with good anticipated care plans there will still be an issue, but the systems join up well together, I think. But there are certainly challenges there, but I think there's a willingness and I think we identify where the issues might be, but we would need to be discharging 70s a week. But there seem to be a disconnect, I mean your evidence and people mentions that there are social work teams and they're there over the weekend. There might be an issue of it in the public about when people are discharged, you see stories about people being discharged at eight o'clock at nine and people not happier services, but there are some areas where you went to the extent where you were sending letters into wards and hospitals reminding people that social services were available. I mean if that is not, you know, I commend you for doing that, but I mean is that the extent of the disconnect where the local hospital doesn't know what the local services might be available on a Friday afternoon, for instance, which is just as important as the Saturday, Monday or the public holiday? What I would say maybe if it's okay to continue is that I don't think that that's a criticism of the fact that folk are trying to make it happen, but it does raise questions perhaps about how well it was planned, but clearly in our evidence we're saying there is an issue about communication, a very busy district general hospital and how people on wards know what's actually available and that view can be about what they did compared to what happened just now. I think that the reshaping care for other people money gave partnerships lots of opportunities to try new things, to be innovative, be creative, and I think that some of that's actually worked very, very well, but we still have this challenge I think about communication. You don't mind maybe go back to this issue about discharges. If we plan admissions well, there's a better chance that the discharge is planned early and it shouldn't be delayed any longer than is necessary. There have been workforce issues in some areas, there are issues about resources at times in different areas, so there's no doubt that these have been factors that have been worked on, but if we get that admission correct, one of the issues that I pick up in my own area and others may be able to comment on this is also about out of hours key decision makers, who are they, do they feel confident, as a risk averse practice perhaps, because they don't know about resources, perhaps they're locums, not a criticism, an observation of some of the infrastructure issues that may affect our ability to make sure that journey is a smooth one for patients. Thanks, honey. I'll tilt them up a side. Richard, do you follow up with your questions? Yes. I mean, I think that Dr Benny has made two very important points that, you know, we're having a sort of almost theoretical discussion about changing the system to 24x7 across-the-board, even service, but it'll take years to create the staffing level for that, unless there's a redistribution from the staff during the week. That seems fundamental to me, so, you know, if we need to know, is there evidence, for example, that if I have a heart attack in the west of Scotland, I'm going to be treated in the Golden Jubilee with, by this 24x7 service, this, you know, gold standard service that gives me the best chance of survival, whereas in Aberdeen and Edinburgh I'm not. I mean, if that is the situation, that's a serious issue we've got to address. But it may be the answer is actually not to open up Aberdeen and Edinburgh at the weekend, but to fly people to the Golden Jubilee. So, you know, there are, you know, is the Golden Jubilee's 24x7 service fully utilised? So there are different approaches to this and how we work it. The other thing is we should remember, in realistic terms, we have the highest number of consultant vacancies that we've ever seen, and we've got a very significant and growing, quite rapidly, number of nurse vacancies with a reduction in nursing student intake every year over seven years. So, you know, that was done on a work-planning basis that may well have been appropriate. I don't know, but, you know, the fact remains that you will not create staff to have a 24x7 service, even covering the seven or eight 80s listed in the interim report. So, I mean, my question is a really difficult one, which is if we're going to actually move, do we need to move towards this? If we do need to move towards this, does this mean that we really need to revisit as a Parliament on a collective cross-party basis the whole issue of targets? Because the system is target-driven from a management point of view at the moment. And as long as we have to reach these targets Monday to Friday, we're not, in my view, going to be able to extend this in the short term without a major change. I'm going to get confused whether you're giving everything, Sir, asking a question there, Rich. Well, the question is... Yeah, no, I got it. I mean, I think the question, you know, the hard question is that, do we need to do this? I was trying to get out of this at the opening of the... Is there a priority? Is there a drive to do this? Is there a... Does a risk exist? Where is the cost-benefit analysis? What are the outcomes going to be? And how do we achieve that? And distortion of targets, I think, was the other question. So, I mean, I'll go down in that. And I think Sandy was wanting to, in the earlier as well, so I'll take you, if you want to wrap up and then I'll take the others. Okay, two points, if I can, just very quickly to answer some of the things that Harry had said about discharge planning and getting it right from the start. It's maybe useful to consider some of the models of practice that exist in existence just now. In the hospital where I work up in Oban, we have the social worker every day at what we call a board round. The board round, as opposed to a ward round, is where we all stand in the room together. Everybody in the multidisciplinary team, and we just make a very quick summary of where each patient is in regards to their discharge, when is their discharge to be planned. We do this Monday to Friday, but it does also include planning for the weekend, and social worker there, so that everybody is aware of the challenges that we need to overcome to make sure that that. I think that's... You mentioned the C-word, communication, and it's crucial to NHS as it is in so many things. So, I think that that's something that could be rolled out wider that would really help this kind of thing. The more tricky areas that Richard had brought up were very interesting. I do think that we do need an even service seven days a week, because we're not going to do all the elective stuff that we do Monday to Friday, but we do need to have a service that is as safe for patients at the weekends as is possible. I really don't think that we have that, and it's not just whether I think it or not, but there is evidence to suggest that the outcomes for patients at weekends aren't as good as they could be. They're worse than they could be, and I think that there is something that we could do. Targeting where the resources are would be most usefully used, because they are finite resources, so it's where do we actually need to put in the extra resource to make outcomes better for patients? The very, very tricky question, and I admire you for bringing it up about should we be target-driven. I don't know that it's for me to answer that, but I think that maybe being patient-driven would be a better way to look at things. Peter. First of all, you were smilingly congratulating the evidence from Richard Simpson. I would agree with the evidence that he gave you in terms of his questions. Should we be doing this and should we be looking at the current targets? This needs to be about the quality of care that is provided to patients, and there's no getting away from it. The current targets are much more about arbitrary measures, like four hours' wait in A&E, which, as everyone around this table will know, is driven as much by some of the things that we've been talking about already. The ability to discharge patients who are ready to go is one of the major areas that causes that, and waiting list targets for elective surgery. It's easy to measure that, and we've got into a situation where, perhaps inadvertently, we seem to be prioritising elective surgery over urgent and emergency care. For me, that is not your top priority when you're looking at the quality of care that you provide for people, and yes, I would like that revisited. We covered the quality of data, but I think that there are some fundamentals to the system as well, and, certainly, speaking on behalf of the allied health professions, the allied health professions are not employed on a 52-week basis, so there is no, unlike other clinical staff in the system, there's no backfill, for example, for annual leave or for sickness absence, etc. That needs to be addressed if we're going to look to that. The second more central issue to this is that, if you simply look at spreading services more thinly, you may actually be providing a worse service, because unless things are co-ordinated, then you will end up with, for example, allied health professions at weekends but unable to refer on to social services or to community setting care. We know, for example, again, quality of data, that the Scottish Government has pointed out that there are virtually no community setting AHPs with some notable exceptions. There's virtually no community AHP provision at weekends. There are some fundamental aspects to address, as well as looking at the quality of data and what we might prefer. The issues that Dr Simpson was raising relate to the sustainability of the NHS as a whole, and I think, over time, they'll have to be difficult decisions made about where we prioritise resources, where we can make changes which will have the best outcomes for patients, but we need to be careful because there's so many different areas of work happening now at a national level. There's so many different task forces. We've got the seven-day services task force, we've got the unscheduled care work, we've got the out-of-hours review, we've got delayed discharge groups, so we're really co-ordinating it all together so that we can look and have long-term discussions about the sustainability of the NHS as a whole. I think, as well, there's no getting away with it if we are to move towards seven-day services, that it will cost. We need to have proper evidence base and analysis of where any changes to services have the best outcomes for patients and make best use of resources, and when you were saying, do you think we should do it, move to seven-day services, I think it is about parity of outcomes for patients. So, if the evidence does show that you do not get the same safe, effective person-centred care at weekends or overnight, then yes, we do need to change the way we do it, but it needs to be part of wider discussions and it needs to be about sustainable services. Just to reassure Richard, I did focus on architects in the west of Scotland, but this is a gold-plated service that really is throughout the country, and there are five centres. I think that wherever you are, given the fact that travel can be a bit difficult at the time, but, apart from that, that is an example of putting resources into service Scotland-wide that has worked. In the situation of unscheduled care, I totally agree with the situation that we need workforce issues here, because I know examples of physiotherapists who come in on a Sunday, they do extra work and they have to take the Monday off because of that, because of their work. So, there is this danger, as you mentioned, of spreading the workforce, so workforce issues are very important. The final point is outcomes that you mentioned. What is the best outcome for a patient? It may be a peaceful death in their own home with all the support that they need. Because we cannot necessarily measure outcomes in the same way as we can measure for our waiting lists, that does not make them any less important, but it is how we often do measure them and make sure that the patient is cared for in the right place, in the right way, with the confidence of their family as well. Thank you for that. Bob, can you take us on? It is really interesting discussion. I actually went to refer to our witness, Richard Simpson, co-exit earlier. It is really interesting about consulted vacancies and nursing student intake. Peter Bennett was talking about baseline. There is a current baseline of 1200 more consultants than there was before and 2300 more nurses and midwives than there was before, but I want to kind of widen it out. That is the context by which Dr Simpson was talking about. It is about having the right workforce with the right skills in the right place at the right time. I do not want to get focused on consultants and nurses because the whole point around this table is also about physiotherapists and it is about social workers and it is about OTs and it is about a whole gambit of people. I am just interested to know about wider workforce planning because yes, we can have more nurses, but if actually the need is to have a pharmacist doing a pharmaceutical care review at admission and to make sure that there is no delayed discharge because medication is not there at the right time, then pharmacists might be the best spend investment and it is trying to make sure how we get to see where the correct pressure points are. It goes back to the baseline argument. Some general comments on that would be quite good about, I know that it is a complicated system, but we all mentioned priorities, where would the priorities be, but also a slight fall-up to that convener about is there buy-in from all the various stakeholders that we have here, for example, if I was a physiotherapist, I had my physiotherapy clinics Monday to Friday at times where I knew, and the Institute of Health and Social Care says, actually we want to restructure that, you are in a Saturday and Sunday now Kendrick, and that is a seven day contract, you have not a Monday to Friday contract, is there buy-in or is there financial consequences to that, likewise for pharmacists and other professionals, so is there buy-in to do this because it has to be done, are there financial consequences just to restructure contracts irrespective of whether we increase headcount, and where are the various stakeholders on that, but back to my original question, where would you prioritise? Any takers? Sandra, and then I see Harry indicating there. I think that that brought me some very good points, but if I could just add one point to that, I think that what we should lose sight of and it was a common theme from a lot of the submissions is working together, and it is about the different skills that each of these professions can bring to the patient, but as part of the multi-disciplinary team, and certainly on the consultant-led ward rounds that I go on every day, every day Monday to Friday, the feedback that I get from them is that they miss that service at the weekend, but it is working there as part of a team and bringing the pharmacy skillset to the benefit of the patient, and the same is the case with the physiotherapists and all the other team players, so I think it is maybe worth considering it in that context. I was going to speak at the point that there already is an infrastructure in Scotland in relation to both health and social care, and certainly social care services are required to be there, but it is alert services for planned and unplanned events in people's lives because of vulnerability, and some of your description may not be here at my hospital, which I deal with most of my job. We have a hub that involves OT, physio and nurses, social work staff, looking at the discharge arrangements, home care, being a key part of that. One of the things for me, though, is that we should not be assessing people in hospital beds, we need to get them home safely and then look at how the lives have been affected by the need for a hospital admission, but certainly I think that the workforce is there. Evidence shows, convener, that in some areas we are trying to move forward with residential type conditions of service, but it does cost more, but it is 24 hours a day then, and we need to again take this forward across the country to make that effective. However, I do believe that the health and care partnerships have a real opportunity in their commissioning plans to begin to reshape services for the future and to make them available when they are actually required. Bob was asking about buying. Doctors are well used to providing a 24-7 service. We have done for certainly as long as my career and well before that. Provided that there is a clear need for medical input, that medical input will be there. Yes, there are resource implications, primarily about moving people from Monday to Friday to the weekend, but the vast majority of doctors are working weekends already. It is a good point about the integrated joint boards. It would be very helpful for them to have a bit of a stronger evidence base than the task force has been able to provide at present, so that they can run comparisons and be aware of what should be the baseline requirements. At present, I worry that they will be working in a bit of a data vacuum and therefore possibly run the same risk that we are doing a little bit of of going, well, we could do this or we could do that. In order to make sensible decisions, you have to have that broad view of everything that is currently being done and make decisions then on what are your priorities. Haley, please. I think that the points that you are making about workforce are really important, and I think that you need that long-term integrated workforce planning that will support these multidisciplinary teams that we have that are so important. I think that integration will help to do that, but it was clear when we looked at the joint strategic commissioning plans for older people services that partnerships had done, whereas they recognised that integrated work planning was a priority. They were struggling to actually get the plans underway, so I think more support, more work is needed around that. I think it is also about trying to maximise the contribution of each profession in multidisciplinary working. If you take, as an example, decision making in order for patients to get the care that they need and for them to flow efficiently through the health and care system, you need skilled clinicians who are able and empowered to make decisions about their care, whether that is diagnosis, treatments, referring to tests, submissions, discharge. Historically, clinical decision making has been seen as the role of doctors, whereas it is now more accepted that nurses or allied health professions can also be doing their senior clinical decision making roles. We have got many fantastic examples of nurses, such as advanced nurse practitioners, working in these roles often as part of multidisciplinary teams. We have got lots of goods, intermediate care services, such as hospital at home service in Lanarkshire, which is a completely multidisciplinary team—consultants, nurses, physiotherapists, pharmacists, and links with social care. Especially in the community setting, they are the ones who are preventing the patient going into hospital in the first place and supporting them to be cared at home. We need to consider how these decision making roles from other professions can support patient flow, can support seven-day care, support patients to get the best possible outcomes, but we need to think about what is needed long-term around the sustainable workforce planning so that we have that workforce that we need to make those decisions and deliver those services. I will briefly follow up on that and let my other committee members in. The more I can hear the evidence, the more I am thinking of politicians of which myself and Dr Simpson do this a lot. We set targets, and a thousand more nurses and a thousand more doctors. We keep hearing about multidisciplinary teams. I am just wondering if the politicians are a bit more young than having a headline commitment of one clinical discipline or one allied health professional. We stop making these headline commitments to x amount of doctors, nurses, midwives, allied health professionals and start saying what does this multidisciplinary team need in this community and resource that. Of course it makes election manifestos a lot less exciting, but it may be a lot more meaningful. On the ground when we start to deliver joined up health and social care, I am just wondering is it helpful or unhelpful? There is nothing political as my party does it as much as the Labour party does. Can it be a bit unhelpful sometimes to have these headline figures where we pick one discipline and go, that is the target? Does that sometimes miss the bigger picture of these multidisciplinary teams? Harry? Well, we are an infrastructure issue with particular disciplines. I am not able to comment on that, but certainly, as I said, have you looked at the infrastructure that is there already? If, for example, we do this differently, we do it well and focused on early intervention prevention, then there is a chance to have success through that, I think. If we discharge someone from hospital admission, 50 per cent of those individuals will be known already to whole care, for example—that is my local area again. If we get someone and support them through a reabilment programme of six weeks with our whole care staff, we will reduce the whole care by about 27 per cent following that. Those are quite starting bits of information to have at a local level, and everybody will have different bits of information about the impact they have. I think that also focusing on some issues that are identified through ISD now will help us focus on those people who use, require and benefit from the most intense services, whether it is pharmacy or whether it is medicine or nursing or social care, and we will know those individuals. There are not a huge number of people in Scotland. We could focus on how well we support them. We now support many, many more people now to end their life in their own home, actually, a point made earlier on. The skill required for that is huge for social care staff as well as other disciplines in the health and social care sector. We need to recognise that there are a lot of good things going on while there are significant challenges. I think that the vehicle is health and care integration, and I think that the direction that I travel there, the support to that and the leadership that will be required to make those changes are very, very important for the next five years and ten years. I am delighted to hear what Bob is saying there, because I think that the general public and, indeed, the allied health professionals are bewildered by the information that comes out from different political parties in terms of point-scoring, you know, 700 more consultants, but there are 7.5 per cent vacancies, so what does that mean? I agree that what is far more important to look at systems and systems involves looking at the whole pan and play of allied health professionals, and it would be far more valuable to the public and, indeed, to the allied health groups to hear. We have now got a system in place that involves examples that have been quoted from Lanarkshire, for example, but we now have a system in place that is going to allow elderly patients to get to their own homes at the weekend, as well as during the week. That is a contribution that we have now made, and now let's look at the next contribution. Although that may seem piecemeal, I believe that all of these small cogs are very important. We have seen this in Lanarkshire and other places of examples of excellence that we need to build on, but that is what the public would really like to hear, is a combined operation that leads to a clear end point in terms of the right location, for example, for an elderly relative. Go on, Henry. Just to respond to some of that, certainly on the question of buying the allied health professions, professional bodies, we are absolutely supportive of the ambition that people should see an allied health profession when they need to, and that this is an ambition for all of them. I think that the question that you raised is really about integrated planning. Even when you refer, you know, is it an A-H-P or is it a nurse, but even the term A-H-P, there isn't a single A-H-P, that covers a whole range of professions. The question you have to say is not how many A-H-P's, but how many speech and language therapists, how many occupational therapists, how many radiographers. That is why the issue of leadership is so essential in all this, and that is why we think that the question of the decision making process by which services or plans needs also to be inclusive and involve the strategic input of the allied health professions of the nurses or pharmacists of medics to ensure that we are operating optimally, because otherwise, yes, you absolutely have the danger that you get physiotherapists or OTs somewhere in a Saturday so that they're not there on a Monday, and that simply provides a worse service because on the Saturday, even though there is an allied health profession provision, there aren't the other interlinked services that you can refer on to. It's a reduced service at the weekend, and yet those staff are not available during the week. I'd back up the evidence given by the other witnesses, but just to add to that, Bob seems to be asking us what we would like politicians not to do. There's only one thing on my list, and reading through the report of the task force, they're not at the stage yet of starting to make recommendations, but they are reporting on the number of units that do acute surgery across Scotland and more than hinting that there are probably too many in terms of providing good quality care. I would quite like politicians not to do is to campaign to keep a hospital open if the conclusion of this work is that the best way of providing good quality care is to be moving some of those resources into the community and to be reducing the number of acute units in order to ensure that the actual quality of care produced to patients and the outcomes for them has improved. I probably don't need to go over the track record on that kind of issue other than to say care report. I've got, just to let members know, I've got Rhoda, then Mike, then the net and then Dennis, just to let them know. I'm Richard Lyle, and I've got half an hour to do that, so Rhoda. Sitting aside, I think the staffing issues that we've covered, there are surely advantages to moving to seven day care in that all elective surgery is done Monday to Friday. Most people's lives would lend it to having elective surgery at the weekend because of childcare and work commitments. If you were having day case surgery, for example, much easier to go in on a Saturday, get that done in your back at your desk or you've got family to help out with childcare, would that not then create, and obviously it does have staffing implications, but would that not allow hospitals to be staffed cost effectively to deal with emergencies of the weekend? There is a point here on the one hand that the reason that the hospitals are more resourced during the week is that there is a lot of elective activity and I think unscheduled care patients benefit from that, but the view of many of the health professionals is that that's a step too far at the moment because again we've got the health professionals to think about as well. Are they going to want to come in, are they going to have the resource to come in with all their family pressures and to come in every weekend for elective activity as well, so I think that very much the drive here is to make sure that for unscheduled care patients we do the very best we can to have an even service throughout the seven days. The elective, many of us feel, should be something that comes at a later stage depending on resource and everything else, but I certainly think here and indeed in conversations we've had south of the border as well, that to go to seven day elective service would be a huge step and one that would for my point of view just be beyond us at the moment. I was trying to make the point that this would have staffing implications of course it would, but if you're looking into the future would this not be something that would be desirable given that you would have to increase staffing and training and the like to do it, you couldn't do it tomorrow. I would love to see the unscheduled care even and I think once we did that then we might have a platform to look at the next step, but I think that's such a major challenge for us and the whole issue of unscheduled care is dominating what we're doing at the moment. The elective activity of course is very important and it's important for patients' quality of life and everything else, but we have such a huge issue now with the frail elderly population that I think that's become and it's an issue that embraces primary care, the community and the hospital, we're all in this together and that's why some aspects of training of young doctors are being changed to make sure that we embrace their skills both in the community and in the hospital environment. Peter's suggestion about care and focus on certain units like Clive Bank as you suggested but earlier, it doesn't necessarily mean that profession working any more weekends and they're currently working because if they were based on a particular area of activity they might only be working one in 20, you know one in 30 if there's a sufficient team to carry on. It doesn't necessarily equal those professionals working more weekends than they do now or indeed in the past Peter. I think that the key thing to get across is that the NHS in Scotland is very, very stretched at present. We've got to keep a focus on making sure that we've actually got a sustainable and working NHS going forward into the future and at its heart the urgent and emergency care is absolutely essential. It's what the health service is there for whereas elective care at weekends is primarily I think about convenience and we've got to ensure that the health service is fully effective at doing what it has to do before we start trying to improve the other aspects of it. But if they were there, it wouldn't be the NHS to have them underutilised at weekends. That you've got consultants there and you've got them in, you know, and the insurgents there are waiting, I suppose, waiting around for somebody to come through the door. That's my point. I mean, I'm not aware that there's any major issues at present in terms of underutilisation of NHS staff, quite the opposite, certainly if you look at doctors. The vacancy rate, the amount of extra hours that people are working on paid, we're not in a situation where we've got people twiddling their thumbs just now and it's likely that we're not providing as good care as we should be in terms of urgent and emergency and that therefore has to be our focus just now, surely? The former cabinet secretary will get a chance to speak to the new one later. Since we're paying them anyway, we often triple time to be on call. It should be far better use of their talent resources to have them working, for example discharging patients who are really discharging. I mean, they seem to be from the previous cabinet secretary that was not using them effectively in a sustainable way and I can't provoke you to respond to these intelligence. You can probably see from this distance the various responses that I might make to that. Perhaps the first one is to point out that actually at present doctors who are in doing the urgent and emergency care consultants are not paid triple time to do that, they're paid time and one third and the cabinet secretary simply got that wrong. It just isn't the case that people are twiddling their thumbs. The health service is extremely stretched already and what we're talking about round here is trying to ensure that it provides the best possible care for those in an urgent and emergency situation and it's been a very much a kind of baseline acceptance within the task force that that's the focus. I think it's a distraction to start talking about elective surgery on Saturdays and Sundays when the risk is that we're not providing good enough care in the urgent and emergency setting. I think my point was that if we're doing elective surgery of the weekend we would be providing better care in the emergency setting because we would have those professionals, we'd have the radiographers, we'd have the doctors, we'd have the nurses, we'd have the staff in to do that work who could then be diverted to deal with the emergency. It seems to me certainly on the FOI that we did. Staffing at the weekend and staffing during the week is chalk and cheese. I mean it seems almost incredible that they would be able to deal with an emergency, the numbers that are rostered on, whereas if you had people on they could deal with the emergencies. It's under Enric, anyone else? Just looking at using existing resources, there was an article on the BBC News this morning, I don't know if anybody saw it, about NHS England utilising pharmacists in the community and we're talking about whole systems approach. I'm sure nobody around this table is surprised to hear that we're way ahead of that in Scotland already and we already have that system in place and have had for many years where community pharmacists work closely with GPs and provide the minor ailment service, which is something that the Scottish Government put in place a while ago. Through the minor ailment service, pharmacists deal with a lot of patients that have minor ailments, they stop them troubling GPs but they also at the weekends and community pharmacists are open every Saturday and a lot of them are open on Sundays, that resource is there already. They prevent admissions into A&E because patients will rock up to A&E because they can't get to their GP surgery and it's far easier than phoning NHS 24. What is that phone number again? I'm not quite sure, just rock up at the A&E surgery. If that minor ailment service, there are currently 890,000 patients in Scotland registered with the minor ailment service but those are only the ones that are eligible for it, which are the ones that had previously been eligible for free prescriptions. 80% of the population of Scotland aren't registered and if we were to extend that service to everybody, I think that there's a huge difference that we could make. In taking the pressure off, as Peter Sturrightly says, the NHS staff in hospitals are not sitting there twiddling their sums quite the reverse, that could help alleviate some of the pressure through hospital doors out of ours. I think that the issue that everybody is possibly struggling with is the prospect that if you move from a five-day to a seven-day service, that's an extra two days on top of five days, which is a 40% increase, so you're either going to achieve that by a 40% increase in funding and or you're going to thin services out during the week and I don't know if there is evidence that it would be better to thin services out completely evenly but I think there's the fear that that wouldn't necessarily be the most efficient use to have everybody go home at three o'clock so that they can be there on Saturdays as a wild kind of argument and I think the other question is if you were to increase resource, is it really best devoted to acute care for elective surgery at weekends when there is so many other ways in which that money could be spent to reduce pressure on the A&E, to introduce preventative measures, to support discharge in the community, surely that is where the extra funding ought to be devoted rather than stretching services more thinly to cope. Harry, yes, please, go on. It's just an observation, it does seem to again be like you focus very much on acute hospitals when in fact if we were to get more capacity, more services, more flexibility and community in health and social care that would make the difference, I'm quite sure, to what happened in a hospital ward and how we're able to get people back out again. I think you're right that we focus on that and of course the written evidence is much more broad and so we've got that written evidence thankfully anyway but if we do look up, I was with my local pharmacist on Saturday so that's evident, dealing with other things, dealing with care workers at the weekend, social worker at the weekend, phone numbers, there is a degree there which is still lacking but if you look at the acute sector it's not as apparent, indeed it's apparent that weekends, only in recent, the long weekend at Christmas, there doesn't seem to be in the acute sector the degree of flexibility that is in some of the other sectors and primary sectors so I think it's quite natural that we sort of skew a bit to that because an arc quite obviously and apparent to us, some of those flexibilities where we are, where we want to be there or not but it would seem that in the acute sector that is not as evident but as he, Peter, is girmas in that, go on Peter? I think you're in danger of paraphrasing slightly beyond the reality, I mean certainly the acute sector at present provides very little in terms of elective surgery, not nothing at all but very little compared to during the week but in terms of emergency and urgent work, every single hospital in Scotland is working flat out every weekend and every night caring for patients coming in with severe illnesses, what we're looking at here is how do we improve that further, not how do we start an emergency service at weekends because we've got a fully functioning emergency service at weekends, we're just looking at how can we improve that more. In comparison to what's already happening in other sectors No, absolutely not. You wouldn't agree, Peter, there are some good examples out there with social work, with pharmacies and others that your profession can learn from. Let me try and answer that because you're trying to box me into a corner it seems to me. No, I'm not a box you into a corner at all, you're not to recognise maybe what Styrn is in the face. Right, what I'm saying to you is and you may have noticed me nodding when colleagues have been giving evidence about the need to continue beefing up our community services. What I'm saying is that there's a danger that you're drifting into a mindset that says that the only area in which there are flexibilities and in which people are working outside of normal working hours for most other people is in the community. In actual fact, the developments in the community are relatively recent compared to the hospitals that have been providing acute urgent care right through and are continuing to improve what they do. I'm a little wary of us concluding that the current service doesn't work. You know the defence of it, Peter, but we'll leave it at that. I'm asking you to recognise it in the community that there are some very good practices that the acute sector could possibly learn from. That was my basic contention. If you're saying that you've got nothing to learn and you've heard of that then. There's no way I'm saying that. That's an outrageous thing to say. I'm saying that there's nothing to learn. I didn't say that. Do you accept that there's some good practice in these other sectors that you could learn from? I go much further than that. I agree that there are excellent practices outside hospitals and in hospitals. I'm not in any way suggesting that there's nothing to learn from in the community. But we all need to make progress. We'll make progress then, Helen. Just a quick point on that, I think. When we start talking about acute and community, there's a risk that we're just separating them out, whereas we've got to think of the flow of patients from the community into hospital out again. I think we need to look at the system as a whole and look at how community services, acute services impact on each other whenever we're having any of these conversations. I think community is really important looking at some of the seven day care agenda when we've heard some examples of really good community services, but we need to look at the system as a whole and understand how different areas of the system will impact on each other. Mike McKenzie, I'm sorry, but we'll let you get back in. You might be able to pick up on something like that. Thank you, convener. I should probably first draw to the committee's attention the fact that Sandra Milvo is my sister-in-law. It's not because of the affection in which I hold Sandra or indeed the professional respect that I accord her for her professional abilities, but I was very struck by the written submission from the Royal Pharmaceutical Society because it seemed to offer possibilities of low-hanging fruit. I think that Sandra's already outlined that, how the minor ailments service could perhaps be increased. It strikes me that there will be other opportunities, other low-hanging fruit that can be picked. Again, going back to that written submission, that Glasgow pilot suggested that there is low-hanging fruit in terms of improving clinical outcomes. I just wondered, from the various other witnesses, where there may be low-hanging fruit that could be picked before we have a full-blown review and so on. The second aspect to that is that in terms of preventative spend, if I were to go and speak to John Swinney and attempt to convince him that there is low-hanging fruit, there are preventative spend aspects to this and that Mr Swinney you could spend £10 here and save £20. Bearing in mind the context of the austerity era in which we live, how would you make the case to Mr Swinney for this preventative spend and are you able to put some numbers on that? I will take that point first. When we are talking about preventative spend, the Child Society of Physiotherapy has just produced a false prevention economic model, and false prevention is a clear way in which, if you look at the cost of the impact of falls, not just because some of those are very serious falls and you end up with hip replacement surgery, which is extremely expensive, but also the cost of rehabilitation, also the cost of social care when an older person has had a fall. Prevention is a bit of a no-brainer and we have put figures on that for every health board area in Scotland and I would recommend you, I will see you later to give you some more details on that, but what that requires is that money is invested in preventative services. When we were speaking more generally about the acute versus community, I think that it is absolutely the case that you need to think about this in terms of patient flow and I would absolutely go with what Helen said. Let's bear in mind that the Government paper that went to the task force says that the provision of seven-day services are almost non-existent in the community setting for AHP's with some notable exceptions, and there are some fantastic notable exceptions, but that's what they remain. The potential, therefore, to improve this patient flow is tremendous, but it requires investment in the kinds of examples like the hospital at home services in North Lanarkshire, where you have multidisciplinary teams providing care outside of hospital, preventing the need for acute care, because ultimately acute care is very, very expensive. Anything that we can do to reduce the demand on acute care and to prevent people and to get them out of acute care more swiftly is to the benefit of the entire NHS, so it isn't just acute versus community in that context. Thank you, Mike, for bringing up the report from the Pharmaceutical Society. It's a very good point that you make about low-lying fruit, because the pilot that was done in Glasgow, in Glasgow Royal Infirmary clearly outlines, and it was only a month, a month's pilot, when you put clinical pharmacy in at the weekends to actually improve patient outcomes, and they have the statistics there of the drug therapy problems that were identified, dosies that were omitted, those adjustments that were made because of the patient's deteriorating clinical conditions. Those are very, very easy outcomes to achieve simply by putting that clinical pharmacy service there, and that has been demonstrated not just in Glasgow, but in various pilots throughout the country. However, the one recurring theme across that is that, in order for that to be sustainable and equitable across the patch, as so many of my colleagues have said, it's not a case of stretching what we've got through the week too thin, it does need to be resourced. I think that John Swinney would be very receptive to that. In one else, Helen Peter. Just an example of low-hanging fruit. I mentioned advanced nurse practitioners earlier, so looking at the types of nursing role where nurses have the clinical skills and the decision-making capability, where advanced nurse practitioners are in a whole range of different settings at the moment in the community, in the acute. Sometimes they're attached with GPs, sometimes they're working as specialist nurses in the community and mental health, but there's some fantastic examples of how advanced nurse practitioners can improve outcomes for patients and can keep people treated in the community so that they don't go into hospital. There's an example in NHS Tayside of specialist heart failure nurses who manage patients within the community, they follow the sign guide down so patients don't have to go to their GPs, they can be managed in the nurse-led service and they've got good savings because they've avoided admissions to hospital. But with advanced nurse practitioners and their specialist, there is patchy across the country, so there needs to be more national co-ordination, longer-term workforce planning to try and get a sustainable workforce of those roles that can help to support wider multiple disciplinary teams. Peter. I'll support both of those examples. In fact, Sandra has spoken a few times in her evidence about the potential value of having pharmacists available on ward rounds at the weekend, and I think that that's a very good case and I'd agree with that. Having said that, I am slightly wary of the low-hanging fruit question because it often comes up and it always feels to me that there's a danger that that's quite short-term thinking. This is such a broad subject that we've got to get it right, and each of the low-hanging fruit that we've heard so far would cost money and would be a decision that was made about resources, which would then mean that you would be restricting the overall resource that you've got available to you. It's this great difficulty of do we think short-term or do we think long-term? In answer to the question about where's the most value for money, I would say that it's most likely to be in primary prevention of ill health, so that's reducing smoking, reducing drinking, improving the diet of people in Scotland and balancing up as much as possible the social inequities in Scotland. It's a widely known statistic that the life expectancy is 15 or more years better in the leafy suburbs of Bearsden compared to just a few miles away in the east end of Glasgow. That's where spending money makes the biggest difference to those kind of scenarios, but it doesn't do it in the kind of timescales of low-hanging fruit. It actually makes a real commitment to improving the health overall of the people of Scotland and reducing the demand as things go on. Arnie, I was going to ask a point that can be in relation to the things that you know already, in relation to health inequalities, the impact of that in people's lives, the ageing population, poor health in ageing as well and the challenges of all of that. It does seem to me that the intention behind the integration boards is that they have in scope elements of unschedule care. If you really transfer from, as we know, emergency and acute type services to those based on a preventative approach to them, you need to shift the resource. Bridging that is part of the challenges and we know that it will be part of the challenge, and this is the opportunity with the integration fund, I believe, and I'm optimistic about all of this because I think it can work. That would be one of the mechanisms that we should be looking to in order to begin to make that shift to a place and look at that and how you blend in where there's new investment required over and above the things that we currently do or need to do differently to redesign, and all of that, I think, relies within the scope of the new integrated bodies. I have to thank Kenwick for his answer because it seemed to me that, and I haven't read the report and I hope he'll share it with the committee, but it seems to me that's an example of what I was looking for, and perhaps I should have articulated that a wee bit better. Maybe low-hanging fruit was not the best description to use, but it seems to me that there's a case for some rather obvious things that we should perhaps do right now, but what I was really looking for is perhaps getting beyond anecdotal or the pilot studies in terms of the health economics attached to this discussion. Can any of the witnesses guide us to a health economist that's published work that considers the kind of matters that we've been discussing this morning, so that we're taking decisions based on something that's beyond just the anecdotal? Can we add on a question that we've asked as a committee before? What would we stop doing to allow us to do better things? Maybe it's the wrong question that you ask at this stage over the cabinet's regularly hoffing about giving in for the next session, but you know, throw it out there anyway when Mike's important question. Frank, did I see you? Make it a point earlier that I spoke to some members of the Royal Infirmary and Glasgow staff yesterday in advance of this and it was quite interesting just to hear from one of the consultants in unscheduled care. This is acute medicine consultant. There are five consultant physicians on every Saturday and Sunday at the Royal Infirmary and Glasgow. By the time they have dealt with the acute patients, it's probably early afternoon, and by that time they then go to the downstream wards, so-called wards where there may be some patients in the wrong ward, a surgical ward because they don't have beds in the medical ward, and then other wards where the patients have got over the acute incident and are perhaps ready to go home. So while they're waiting, the junior meddics don't feel in a position to make the decision about discharge, and if the consultant's too busy with the time they make that decision, then it's late in the day to try and get transport. They then find difficulties in getting transport, but even if they did get the transport, then they wouldn't be able to have the care package appropriate enough for that patient. So from the medical staff right through the whole system, there are areas where more support is needed, and for us I don't think they can focus in any one aspect and say this is working well, but the rest doesn't. I think they're all working to their capacity, but every segment needs to be improved to help with that whole process. Although it may seem getting patients home doesn't affect their outcome, of course it does. The older the patient is, the sooner you can safely get them home, and that is the best outcome for that patient. Any other responses to Mike? I'm worried that I have to go on in the net. Briefly, convener, I think it's been a fascinating, very wide-ranging discussion this morning. Clearly a lot of thought has been into the great deal that needs to be done. One health professional that really has only been mentioned in passing this morning is actually the GP. Given the importance of integration of adult health and social care, I sat in the main grid during the passing of that legislation as did other people in the committee, of the importance of the GP in a leadership role within particularly locality integration boards, and how important it is. I hope that we haven't deliberately sidelined the GPs, but I think that they have a key role to play in that. I married to a retired GP of the era when he went in on a Saturday Sunday and he never dreamt of having surgery premises closed at the weekend, not completely closed for the whole weekend. I'd make myself very unpopular with the modern GP if I suggested that they should go back to working on Saturday mornings and even on Sundays to see their own patients. I wonder what comments are around the table. I accept absolutely that nurses have a huge role, and other health professionals have a huge role as well, but I do think that the GP has an integral role within that, even overarching. Part of that role could well be at weekends, as I say, at risk of making myself very unpopular with such a young and very good colleagues. I thank the net for bringing GPs up. It's late in the day, in fact. Technically, after the session, it was due to finish. First of all, what she's saying about the importance of GPs having a leadership role on the integrated joint boards is very true. We don't have any grave concerns about GPs not doing that. The places are there, and we expect that they will be there. Although general practice itself is very stretched, there may be difficulties in getting to meetings, especially if they are called at short notice. There is also a place on the IJBs for a secondary care doctor and a leadership role. That is crucial. As the BMA, we have had little difficulty in persuading GPs of the need to be very on board with the agenda. It's a bit more of a challenge for us to get colleagues in secondary care to be fully aware of the changes that are coming and how that will affect hospital practice as well as general practice. In terms of GPs working at the weekend, well, of course, like all other doctors, GPs are providing a medical service 24-7. They're not providing it as they used to to their own patients. I would hope that most people around the table understand the reason for that. It's simply that it was an untenable model. It's much more sensible to have services provided in a more centralised way at weekends and at nights. There's a whole separate strand of work being done by the Scottish Government with a report due later this year on out-of-hours GP services. I think that it might have been in the interim task report. There was a mention of a model of care in Fort William, where the GPs are very much involved. One of the things that the task force mentioned was the challenges in remote and rural areas, which we haven't had time to touch on this morning, but that was a very good solution of having the GPs in the hospital and using the skillset that they have in an integrated way in the acute setting. So that's maybe something that could be explored as well. Just briefly, chair, you mentioned what could we do or stop doing. I think that one essential factor for the whole system is that we need to incentivise prevention better than we do at present, because I think that the funding models, even over a two or three-year period, you may well not get the money back from the investment that you put into a preventative care scenario for five or 10 years. The fact that that money could come back, but it doesn't solve anybody's immediate problem. So I think that incentivising that long-term care would be an excellent way of doing it, and the other one would be to fund some research around the economic viability of preventative care, because the evidence base and the economic evidence go hand in hand, but they can be very expensive to secure. So maybe some support to get that health economic modelling up and running, because at the moment it's done very piecemeal, and I think a lot more effort needs to be done to look at exactly how we should be spending money more effectively for better decision-making and better care. Thank you, Dennis Robertson. For me, there's been a lot of good evidence this morning. It's a point that Helen made about the patient pathway. We're just wondering sometimes if we're concentrating too much on the sort of sectoral aspect rather than the patient pathway. For me, I'm not sure enough is being done, and I probably welcome your opinion, on preventing the patient actually getting to the hospital in the first place. Harry was talking about the discharge and the multidisciplinary approach. My thought is that if we can prevent the patient going to the hospital setting in the first place and provide that service in the community that they need, surely we're better doing that than maybe having a patient going into hospital perhaps, and Richard Simpson made a point, maybe 30 per cent of those admissions should really be admitted in the first place. So are we doing enough, and if we're not, how do we actually address that problem and I know the preventative aspect as a good argument? In terms of getting people to either go to community pharmacy or stop them going to the hospital, but ensuring that the community care, and it could just be the appropriate care package that they're needing at that time. That comes back to the obviously social work provision. It is a complex issue, because among other things in a community would be access to the GP, pharmacy and other types of services. Many people are known to all of us already anyway, as you well know, and I think it's about the ambition that we would have to make that a better journey, and maybe somewhat clumsily I was trying to get focused on the community. I do think that prevention and gender is really important here. What happens in a hospital is key to you if you arrive there, but there are a number of reasons why you end up at the door of a hospital and then why you're admitted following an attendance at an E&E. So it is very complex, and there are excellent examples of good work across Scotland. I think you've heard some of that today. The question is how do we learn from that and do more of the things that actually work and make a difference to people's lives? Helen? Just quickly, I think, as you're right, there are many good examples of that preventative community-based work trying to avoid people going into hospital at the first place, but what was also clear from the reshaping care for older people, the Audit Scotland report on that programme, was not enough, was being done for shifting resources into the community to actually support those services to run. I know that the Scottish Government's response to that report, I think, said it's not just the case of shifting those resources, but there will need to be new resources going into the community to support those services. Peter? In particular, to echo what Harry was saying earlier about bridging finance, because it's a difficult one. It's a chicken and egg. Do you close the beds first, or do you beef up the community service first? In my experience, when psychiatry hospitals were downsizing substantially, there was, generally speaking, where I was in the west of Scotland, sufficient bridging finance to allow the community resources to be up and running and functioning before the bed closure process. If you don't do that, that falls at the first hurdle. Do we need to increase the primary care resources across the board in this multi-disciplinary aspect, not just in terms of ensuring that GPs are available or the appropriate specialist practice nurses or whatever, but we need to ensure that the social care packages and the staffing is available to resource that as well? Absolutely. There are certain key areas where we know these are blue light accident and emergency risks, such as respiratory conditions, heart conditions, and we know that we can place services in the community that can support people and prevent the likelihood of people being admitted to accident and emergency, particularly at weekends, but throughout. What that requires is investment for that prevention, but, unfortunately, that requires a shift from acute to primary care, and therein lies an issue that has long been in place. Richard Lyle Firstly, can I say that I think that the national health service in Scotland is excellent? I've always said that, but I want to come on to and touch on an appointment that Milne made that I may offend also. I believe that we've actually got to change our work and practices. With the greatest respect to Peter and Helen on our edge of your submissions, BMAs say that GPs are also providing a seven-day service out of our service run by health boards. The Royal College of Nurses basically say that nursing has played an increasing role in the delivery of out of our care in the community, so you both are claiming credit. Can I tell you that I actually worked before I came in, became an MSP, I worked for the out of our service in Lanarkshire as a driver, and saw there and then what was being done by doctors. A small band of doctors came out at night to work. I saw the same doctors every week doing to me. Not every doctor in Lanarkshire plays their part in providing an out of our service. In fact, NHS Lanarkshire, out of our service at this moment in time in Lanarkshire, can't fill the shifts, so they're having to shut down centres, left, right and centre. I worked out at Wisha, Hearmeyer's, Monklin's and also Lockhart hospital in Lanark. GP surgeries shut at six o'clock at nine on a Friday. Don't open to eight o'clock on a Monday morning, you know. So there we go. Doctors, I got my doctor once every seven years if I can help it, but people go regularly every week. Saturdays and Sundays, everyone else has changed their practices. I used to be a grocer. Shops now are open 24 hours, go to all the different big stores, I'll not name them, and you can go and shop, whatever. So with the greatest respect, I believe that we have to look at it in reverse. We have to see what we can do. Because a doctor is not open at the weekend, everybody goes to the out of hours or they go to A&E. In fact, they don't want to wait at A&E for a couple of hours so they phone up out of hours so they can get an appointment at any time during the night, and I was there three, four o'clock during the night. So basically, and also with the greatest respect, doctors were getting between 80 and 100, when I was there, between 80 and 120 pound, an hour, an hour. So I think they're well paid. So I believe that we have to look at weekend working practices, work and see what we can do best, and also I don't need to wear glasses as much now because I get cataracts during the weekend. I get two cataract operations done at weekends at two different hospitals in the last couple of years. So I believe we have to look at and would you not agree that the point that I'm making is that we have to look at it in reverse. Doctors to provide more services locally that will then take pressures off hospitals, A&Es, et cetera. I'm guessing you'd like me to respond to that one. I think that Richard is in many ways talking about the same things that we've been talking about during this session about the need for looking carefully at what all professions within the health and social services are doing and could do at weekends and overnight. Now, there is an out-of-hours GP service. It's not the same as the out-of-hours GP service 15 years ago. That's because the out-of-hours GP service 15 years ago consisted to a large extent of every single practice trying to cover their own patients, which was never sustainable, never sustainable and arguably also was part of the reason why general practice was struggling to recruit enough doctors at all. We've got a review of what's good to happen with out-of-hours GP services. I'm not even going to begin to try to suggest that Richard is entirely wrong about this. The out-of-hours GP services are struggling and stretched across the country, but we've got to think about this in terms of who's best place to do what at the weekends, and that's what I think the task force is about. Anyone else? The point I'm making, you know, everyone else has changed their working practice. Do doctors have to do the same or will doctors do the same? Doctors, as I said earlier, have been working out of hours and weekends long, long before Tesco's and the various other shops came around that were open all of the time. Doctors are well used to providing the service that is required for urgent and emergency care, and we're still doing that. However, yes, there's a real need to look at how the out-of-hours GP services are running just now and that's happening, so let's wait and see what comes out of that, please. Yes, and Gennric, Frank? Just a brief point to add. I fully support looking at the whole out-of-hours service for general practitioners. I think there is an issue, which again we're recognising in the training of young doctors that the whole general practice move has been more towards looking after chronic illness rather than acute illness, and that's partly a GP's have selected that, some have selected it, some still enjoy the acute work, and there's no doubt that a GP who knows his patient during the day, and when that patient becomes unwell, that is the best individual that can decide the best place for that patient. However, there are resource implications and I'm hoping that Lewis Rich's report will shed light on this, and bring us to a situation where there's more interaction between primary and secondary care, that some GP's actually have spells within the hospital environment and some hospital doctors are trained to work both in hospital and in primary care. I think that will bridge very well that chasm between them. Nick? The first point I think is that although GP's are always going to be very key to the system, the health system has moved on, and there are other health professionals. We now have physiotherapists and podiatrists with prescribing rights, the prospect of other allied health professions coming on, so that they can, for example, prescribe antibiotics to somebody with a respiratory condition at the weekend or out of hours so that that will prevent the chances of it becoming a chronic condition where they get blue lighted to hospital. I don't think that we should stretch the algae with supermarkets too strongly because ultimately supermarkets are trying to attract customers and hospitals are very much trying to reduce demand. I think that we can all agree that we, I think that it was an RCN that said, we're not looking for the Tesco model for our health service, but we've had a good debate discussion here this morning, wide-ranging though it was, I'm sure that, like I do, that the other committee members appreciate the time that you've taken to come along here this morning and engage with us, and indeed the written responses that we've had from the participants here this morning have been also greatly appreciated, and I'm sure that we will go on to have this discussion because it can't be divorced in any shape or form from the future development of the health service that we were all committed to here this morning. Thank you all very much, really. Much end of that point and get the Cabinet Secretary in. Number two on 70 services and reconvene with an apology again for keeping you hanging around outside the Cabinet Secretary. Apologise for that. So we welcome, of course, the Shona Robison, the Cabinet Secretary for Health and Well-being and sports, Shirley Rogers, NHS Scotland workforce director, Ian Finlay, senior medical officer health workforce, and Akin programme director sustainability and 70 services, and Liz Portafield, head of planning and clinical priorities of Scottish Government. Do you want to make a short statement, Cabinet Secretary? If you do, please continue. If I could, just briefly, I want to thank the opportunity. This is a big area of work that has the potential to make significant improvements in the care provided to patients across the whole week, and, importantly, to ensure that our health services are sustainable for the future. In setting up the sustainability and 70 services task force just over a year ago, we recognised that the NHS is already delivering a range of services across seven days. However, we accepted that we could do more to ensure that those services are readily accessible of high quality and are sustainable. As you will see from the definition agreed by the task force, what they have been focusing on is removing inappropriate variation in the care provided overnight and at weekends for those who are acutely ill and for those who are already in hospital and need support to progress through their pathway of care. Sustainability is also crucial. The work that the task force is progressing is looking at how we can make our workforce and our services sustainable for the future. We do recognise the challenges in remote and rural Scotland in this respect, and the task force has already started looking at ways to support those areas. We have also initiated some specific work around the sustainability of services in our six rural general hospitals, and there has been some early success with that work. It is not a quick fix, it is complex and some of the changes will take time to work through. However, that does not mean that we cannot take action now towards our aims and I have been encouraged by the progress made by the task force to date and welcome the next steps that are set out in the interim report published on 6 March. One key theme that emerges from the report is about people receiving the right care from the right clinical team at the right time. For the majority of conditions or illnesses at care, that care is best provided locally by community-based healthcare staff. That means that our next steps need to look at enhancing those local services by exploring new models of care such as community hubs and the greater use of community hospitals. Where more complex specialist care is needed, the service model may be a regional or even national one, and the report sets out the example of major trauma services where we are putting in place a network of care, including world-leading major trauma centres to provide the best quality specialist care for those patients with such severe injuries. This is absolutely also consistent with our work on integration of health and social care and the emerging national clinical strategy, all aimed at improving services and clinical outcomes that will benefit patients and make the best use of our resources. We also need to make the best use of the skills and capability of the entire healthcare workforce. That includes nurses, allied health professionals and our so-called backroom staff such as those who are working in the labs, including healthcare scientists. One of the next steps that is identified in the report is a review of the role of district nursing. Our nurses working in the community are crucial in caring for adults and children to provide care at home, particularly those with long-term conditions. We also intend to look at what more can be done to enable advanced nurse practitioners to act as decision makers and to look at how we can make ward rounds at the weekends more effective. We know that there is already some great work going on across Scotland. We need to build that and we need to spread it across all areas. Additionally, the task force is looking at new models of care. The demand for diagnostic services has increased significantly over recent years. Through the first tranche of the performance fund, we are supporting increased diagnostic services at weekends. Alongside that, the task force is specifically looking at new ways of reviewing and reporting diagnostic imaging and at the provision of interventional radiology. With a wide range of work, such as this, it is vital that we link and build on the range of national work that is already under way. Against the backdrop of integration, we have got our engagement around the 2020 vision and beyond that. We have recently announced a review of the out-of-hours primary care services and the national clinical strategy, which is at an early stage. I hope that I have given you a flavour of some of the work that is already under way, but also the early priorities for the task force in their work going forward. Thank you, cabinet secretary. We will go directly to your first question, which is from Bob Doris. Thank you very much, convener. Good morning, cabinet secretary. We are almost at midday. I was interested in the comments that you made about the effectiveness or the efficiency of wardroins, particularly at weekends. I think that, to Evan, it is perhaps from Frank Dunroyle College of Physicians and Surgeons of Glasgow, who was talking about wardroins not necessarily being able to then facilitate when someone should be discharged, because perhaps the pharmacist is not available for given medicine or perhaps we heard from—who was the gentleman here? Harry Stevenson is from Social Work Scotland, but perhaps there is no connectivity care packages available to deal with delayed discharge and that kind of thing. We also heard in relation to perhaps more junior doctors holding off from making key decisions, because they wanted to be to the consultant come round and about capacity building with the right medical professional at the right time, making the right decision, but also the allied professionals that need to be part of that team. You mentioned in your opening statement about needing to be more efficient and take forward wardroins, particularly at weekends. Is there any more information that you could give us on how to progress that? This is a key priority, because if you take one performance measurement and that is any performance, you look at where the spikes are in terms of delays. They tend to be at the beginning of the week, Mondays and Tuesdays. Part of the reason for that is the delay in beds becoming available, because weekend discharging has not happened and therefore discharging begins to happen at the beginning of the week, but that is where the system becomes most under pressure. We absolutely need to get that right. Part of that is about who can make the decision around discharge and there is a lot of work going on around the training of nurse-led discharges. Pharmacist availability is a key, so there is work going on about how we can make sure that that is available so that people can go home with all of what they require, including medication. That work is on-going. Shirley-Anne, do you want to say a little bit about some of the detail about taking that forward? I think that there are a number of elements that contribute to high-quality wardroins. Some of that is about the appropriateness of the decision maker and availability of senior decision makers. As you are right, there are a number of factors around care packages, pharmacists, junior docs. One of the principles that we are trying to walk towards as part of this work is about encouraging people to work to the top of their licence. That is really partly about the delayed discharge issue, which everybody is very familiar with. It is also about the opportunity to intervene when a patient needs it rather than having to wait a period of time before they see somebody who can help them. The work that we have undertaken so far is still early days. We have been looking at a number of hospitals and trying to make a qualitative assessment about those wardroins. Not surprisingly, we are demonstrating through that early work that the quality of work of wardroins make a real impact on delayed discharge decisions, but more importantly, make an impact on the quality of care that patients receive. Can I move forward to that? I know that these things take as long as they take, and I get that especially when you are trying to develop working practices and capacity build with professionals. When do you think, for example, some of that work would come to fruition in terms of this committee or, indeed, a successor health committee looking at some of that work and seeing how it has developed, hopefully, successfully and more importantly, how that has then rolled out across the wider NHS. The Cabinet Secretary, I think, in her opening comments made a point about how there are a number of pieces of work that are coming together. The ward round initiative is already out there with boards now as one of the top six priorities for unschedule care. The work that this group is doing is contributing the qualitative assessment around that. If I could typify unschedule care at looking at the flow, time of discharge, accessibility to pharmacy services and some of the things that you talked about, this work is also working with the clinicians to look at what they find helpful in terms of ward rounds, decision making, confidence building around that, deployment of senior decision makers. It is already out there now as one of the six priorities of unschedule care. We will continue to supply this qualitative data to support that. Certainly, boards are expected to get on with those six essentials in pretty short order, and we certainly, over the next few weeks and months, want all of that to be in place, not least before we get into next winter's territory. There is a lot of work going on around that. I suppose underlying the question over timescale community round, I will make this my last question to let my colleagues in. In my initial question, I mentioned pharmacists have been keen in relation to that whole process. Again, with Sally Melville from the Royal Pharmaceutical Society in Scotland here giving evidence this morning as well. It is about how we roll out best practice and the independence of health boards under strategic guidance from the Scottish Government to get on with the day-to-day job of running hospitals and ward rounds and everything else. Greater Glasgow and Clyde, for example, this committee knows because we visited a pharmacy to the clinic there where they have centralised some of the dispensing facilities of pharmacy in Greater Glasgow and Clyde and doing so. I forget the numbers, but maybe they have released about nine or ten clinical pharmacists to be on the ground doing clinical pharmacy reviews with patients at the outset of their visit to hospital and they are more likely to be available ahead of discharge as well. It seemed in face value an example of good practice, whether it is best practice if nothing to compare it with, but the reason for putting that on the record would be if that is best practice, how do we roll that out across all health boards and make sure we get a high standard of service across the entire NHS? The ones for Scotland approach is exactly that. It is about if it works well, then that is what we should be doing and that is very clearly communicated to boards. Now, there might be some issues around what works in a rural general hospital and a district general might be slightly different from a teaching hospital, but nevertheless, if something has been proven to work, then the ones for Scotland approach is that that is what should be rolled out and boards are far more receptive to that. Now, because it is efficient and it actually means in terms of discharge, it has a huge impact in being able to do that, so the logic is pretty compelling and the evidence is compelling as well. Can I just ask, now that I can back and say that that was my final question, but I was just wondering in terms of that. Who would go, this seems like a really good model, it may or may not be suitable for your health board area, but would you like to consider it? If you do not decide to adopt it, that is fine, but please give reasons for not adopting it. Who pushes forward some of that stuff? I will surely say a bit more about that in a minute, but I guess part of the reason is that I have a regular meeting with chairs and that is an opportunity for me to disseminate some of those key messages around priorities, but we have a performance management arrangement where we have a lot of very experienced people within the Scottish Government who have daily contact with boards around many of these matters. Essentially, if something is working well, we would really expect a board to get on and do it unless there were really important reasons why they could not. Cabinet Secretary has given a general context for it. If I might say that there are certain things that need evidence and piloting and that is sensible, there are certain things that are no-brainers and where we have got something that is so evidently sensible to do, one of the things that specifically underpins the task force around this is a board operational leads group, so they get that information directly from the task force and are empowered to go back to their boards and see whether or not that can be implemented at pace within them. There are some things about this where evidence is lighter because there are innovative models that are being developed, but there are some things where it makes sense that we want to ease the flow of a patient through the hospital and if it is as simple as when they get their pharmacy kit supplied, then board operational leads will take that back from the task force and see whether or not that can be implemented and we want to hear from them if they come back saying it can't for whatever reason. Some of those reasons might be legitimate, if they are not, then again we'll pose the question about how that good practice can be deployed across the service. I presume, my cabinet secretary, that the motivation of this policy is a reflection that there are variations in outcomes between someone who is receiving care at weekends and out of hours. We've had some discussion earlier on about what's the evidence base of that and I'll pick up on your points there that the evidence base and that might be variable in itself and that if you present at a general hospital somewhere in a rural area rather than the central bell or the classic example that I think we heard this morning was the jubilee, then you'll get best practice, but if it's somewhere else it may not. So what work and research has been done around those variations and what did that research tell you? Well, I suppose there are some elements that are very clear. So if you look at the six essential actions on unschedule care, that was a piece of work that was undertaken by those who are experts on unschedule care around what are the six things that all our, not just our new departments but our hospitals, have to do to make sure that the most efficient and effective use of resources and people mean the better outcome for patients. So that work was done and those six actions are now expected to be delivered and that is about looking at the fact that the evidence says that if you don't discharge people at the weekend you're going to have a clog in the system at the beginning of the week and that is shown by the fact that you have beds taken up by people that don't need to be there at the beginning of the week and that means that the A&E performance at the beginning of the week is affected because they can't move people through. So some of that was just very, very clear. There are other areas that are maybe less clear in part of what Shirley was saying, we might pile it, some of that in terms of testing out but some of it is a lot clearer in terms of what we know is not working well and the evidence there and what has been tested, the word rounds as mentioned earlier on, some of it isn't rocket science, it's just things that we know will make a difference and should be happening everywhere. Some of the other areas are newer so it might be things that are new and innovative and we have to test those out because the evidence base is maybe not as well developed as some of the things that we know are more evidence based. I was thinking more of the quality of outcomes, mortality and other things that you may run a higher risk if you find yourself in the sector out of our weekends, public holidays. I was wondering, I presume that that's what sets your priority, there is a variation here, we need to deal with that, we need to reduce the risk to that individual, risk which still exists while we are having task force and whatever. So what did that type of research tell us in terms of hospitals in Scotland and in terms of the level of risk and quality outcomes that people are experiencing or not? Okay, I mean there's not a huge amount of evidence in Scotland itself around issues of mortality variation, there's more from down south. But I think, as I set out my opening rematch, the crux of the work here has been how do we make sure we deliver a safe and sustainable service, the best possible service, the best possible outcomes for patients no matter when they're in the system and that is about making sure that, and that why the early focus was on those who are already receiving services within a seven day context, so whether they're admitted over the weekend or whether they come through A&E in the evening, that we have to make sure that the services for those people are safe and sustainable and have a good quality everywhere. So that was an early focus of the task force. I think though where the task force has also began to look as well, what are the opportunities to do more diagnostics at the weekend. So I guess that's why the task force has looked at different elements. Part of it is about reassurance that our services are safe and sustainable for patients no matter when they come into the system. The other part of the work is what is the opportunity and capability of doing more across those seven days that would be more elective procedures. I hope that we presume that the international evidence of the Netherlands and the downside has accepted that. I'm just wondering why we haven't carried out that research to ensure that, given the international research and the research down south, that patients in Scotland were not at risk as a result. Surely we should have been establishing whether they're at risk, whether they're at higher risk and doing something about that situation. Well we have this statistical information and mortality rates and ratios and what all I'm saying to you is they don't show a significant cause for concern but nevertheless it's very prudent of us to make sure that we and the task force, that's why it was an early priority, to make sure that what we have is a safe and sustainable service. So even though there was nothing alerting us to a particular problem with weekend or evenings, it was prudent for us to have that as an early look from the task force. Do you want to add in? Ian's probably best place to take that. You're right. The reason we're doing this work is because there was evidence of self-swerve and mortality was much higher at the weekend, as you've said. It was at least 10% higher. The initial look at Scottish data suggested that that probably wasn't the case and Scotland's cabinet secretary has said. Nevertheless, we broadly accepted that there was a risk that that could be the case. We have a smaller system and it may be statistically the data from elsewhere may be more apt. For that reason, we broadly accepted that that risk may well exist. That's exactly why we've developed a bit of scientific rigor in terms of how we've undertaken this work. That is that we have agreed to map the situation in Scotland at present and then look at what we need and then bring forward to your proposals thereafter for that very reason. We've been mapping a range of the priority areas as outlined in the report for the last year. We've been mapping what the service looks like and what's happening. That brings you to some of the actions and conclusions. Well, it will do. The next step of that work is to identify what constitutes a safe, sustainable service at weekends and then look at the difference and see what we need to do. That will be the next stage because this is really an interim part of the process. It doesn't sit on its own. There's work around very early days around a new national clinical strategy, which will be an important component of that in terms of safe and sustainable services going forward. We might come back. We want some of that at this time. There seems to be lots of task forces in groups and lots of discussions going on while the situation hasn't changed. The risk still exists while we have spent over a year. The risk that you broadly assumed was evident. You know, you accepted what may be there a year ago is still there because there's not been any change in the system that would alleviate that risk or reduce that risk or hazard to patients. Well, I guess that's an interpretation. Sorry. I think it's important to say that hospital standard mortality rates are one piece of evidence in a very complex picture. There are a number of factors that would impact on whether or not a patient dies in hospital. Some of those are about the patient's condition. Some of those are about access to other facilities. Some of those are about a whole range of other factors that come into play. The other thing I would say is that I don't think what we were looking for was a digital solution. What we weren't trying to do with sustainability and seven-day services is say there's one thing there that we can do that will fix this. What we were looking to try and do was to look at a range of measures that would improve the quality of the patient's care and experience of the seven days. You were right, Mr Doris was right when you talked about variation in practice at the beginning of some of the questions. There were some variations in practice and we've been very blunt with boards about how we're being asking them to remove some of those variations. So, some of the things that have been overspoken from the patient safety programme, for example, things like surgical checklists, those good practices. We haven't waited to the production of a report to go out to boards and say we found this. This seems to be beneficial. This seems to reduce risk. We need you to be doing this now. So, I wouldn't want to create in the committee's mind an impression that we did something with now just thinking about it. There are an awful lot of actions already underway to try and both improve hospital standard mortality rate but also to improve the quality of care decision making and overall patient output. I'm looking for a general context because I do think it's very important from a political point of view that we were proposing dramatic change as at least been reported to us from people who will be affected by that change early this morning and the evidence etc. It's important that why we're doing this is pretty important. You know, there was a confused message from the previous cabinet secretary as I used his quote this morning about using the services in the workforce more efficiently at weekends etc etc. So, you know, I think there's a different type of imperative that you can get a lot more people on board with if we're dealing with best use of services in the workforce, of course, but in making the health service safer for people when they get into hospital. That's a different type of challenge for those people. So, it's the context I'm looking for. I'm not looking, you know, I wish we did have clear research that showed that we were prepared to accept that because that's a priority here about the outcomes. Shirley's point about the patient safety programme is absolutely critical here because we have a world-leading patient safety programme that has absolutely not waited for the reports about patient safety issues. It absolutely has got on the front foot to look at the best and safest practice across a whole range of mechanism, whether it's about how the front door of the hospital organises itself to make sure that the communication is right to hospital-acquired infection, all of that. So, we haven't waited for this report. What this report does, though, is to look at those two things that you've identified. How do we ensure that we continue to deliver safe and sustainable services for everybody no matter when they come into the system, but also how can we make better use of the workforce and the resources that we have over a seven-day period? Dennis Robertson. Good afternoon, cabinet secretary. I understand why we can focus sometimes on the acute services, but it's part of the initiative to try and ensure that we're looking for person-centred, safe, effective and sustainable to use your terms. We could be looking at how do we prevent the person going into the hospital in the first place. How do we use our community services much better, whether it be a community hospital, whether it be our community pharmacies? How do we actually use those services much better to prevent the patient getting to the hospital in the first place? Especially with remote and rural, are we using things like for instance the technology, the digital technology that's available, so we can actually do quite a lot of the work remotely as well? Your question is really key to how we go forward with the health service generally in Scotland. We focus a lot of our time and attention on one small bit of the picture here, when most people get their healthcare from the rest of the picture, which is primary in community service. I'm very clear that we need to start spending more time and attention to that part of the system. The task force is looking at that in the context of some of the challenges, so we have the out-of-hours challenges and Lewis Ritchie's work on that will be very much aligned to the work of the task force as well. Huge opportunities, yesterday I was in Oban and Loch Elthead, where you have a rural general hospital model, which I think can teach us quite a lot around how we might deliver services in a different way within an urban context. You have GPs who are very much working to the top of their licence with additional training and skill level, and in Loch Elthead they have had a tremendous response to their advertising for vacancies, because it's a very attractive proposition for GPs who want to do a variation of work during their week. Huge excitement from the GPs involved there about what more they might be able to do. There are some lessons that we can learn from that model within an urban context. We are working and looking at the task force recommendations around that and some of the other work that we are doing about how we might begin to look at how we can provide more care and treatment within a community setting in hours and out-of-hours that can prevent people where they need to go into the secondary and tertiary healthcare system. That is a huge potential area here. Obviously, there are going to be challenges in moving from the system that we have at the moment, but I think that those opportunities could be very attractive to general practice, where at the moment they are struggling to recruit in some areas, but young doctors are choosing not to go into general practice, and they want to have more variation in the work that they do. I am keen to create those opportunities. The benefit from the patient in all of this is that they get more of their care closer to home. Are we doing enough to ensure that the patient is getting the appropriate service by the appropriate resources within the community and that they have the confidence in the person? You mentioned the GP, cabinet secretary, but quite often the patients perhaps have greater confidence in their nurse practitioner, for instance, or even their community pharmacist. Are we doing enough to try and get the message across to the patient group that those people within the community are as essential to their particular care and wellbeing as they can get in hospital? The GP is only a part of the team. If you look at the team in Lockgilthead and Obent, again, advanced nurse practitioners, AHPs, paramedics are all part of the team that delivers in hours and out of hours care. If you look in the semi-urban context, the Clatmaninshire Health Centre brings together GP practices with nurses, with AHPs, with dentists. It is a one-door approach working with social care very closely as well. They have developed some very innovative working which, for example, has identified the cohort of people within that area that tends to make the most use of unscheduled care and have managed to dramatically reduce admissions to hospital because they are keeping people safe in their own home. There are a lot of good examples. The challenge for us is how do we spread that, because we have a system at the moment that does not look like that generally speaking in urban Scotland. We have some good examples of where it works. The challenge is the next stage of how do we, if we decide, if we agree, and I think there is a general consensus that that could be a better model, how do we begin to shift from where we are at the moment towards that type of model? Convener, finally, Cabinet Secretary, you are asking the question, how do we, can I ask the question, how do we? Well, we are looking at the moment around testing out more of this model within an urban context. We know that it works well in a rural context. We have some examples of it working well in an urban context, particularly in Clackmannanshire. What I would like to do is to test it in more of an urban setting, and with a coalition of the willing of folk who want to be part of that, I think that we could demonstrate that this is a model that would deliver a very good level of patient care, but it would also be sustainable going forward. We are on the case with that, and I am very happy to come back to the committee to share more details as we take that forward. Thank you, cabinet secretary. In the name of the moment. Yes. I found this very interesting, as our previous session was as well, because it is clearly a huge area that many things have to be considered. Clearly integration of health and social care comes into that as well, I would imagine, in rolling out the possibilities of seven-day care. I presume that we will be getting an update on that on Thursday when there is a debate on the integration of health and social care, but it would be quite interesting to know how things are going along those lines and the sort of buy-in of the various people who will be involved in that. That is my main question. The other one is that we know that there is a great willingness, particularly from pharmacists, to be more involved with seven-day care. Presumably that means re-negotiating of contracts, because they are currently on a five-day-a-week contract. I presume that that would be the case, and any information as to how easy or difficult that might be. On integration, this is a critical part of the way forward with new models. It is critical that we have not just integration between health and social care, but that we have better integration in the health system as well. There are opportunities for that to be far, far better than it is at the moment. Again, that is a critical part of it. The high-level agreement between us and COSLA around integration has been important, but what is probably more important is the partnerships on the ground getting on with the job in hand. The signals are very positive. Where there have been good working relationships, you can imagine that they have been first out the stall getting on, but even in areas where there might be traditionally not been such great working across the systems. That has really focused people's minds because it is a legislative requirement, but there are also some additional resources behind it that have helped to oil the wheels and helped people to look at new service delivery models. We do not want the same old, same old, so just two systems coming together, but the same services. We need them to think differently about prevention of admission to hospital as much as making sure that there is timely discharge from hospital. Those early wins are important. We have asked the new integrated joint boards to focus very much on their equivalent of the 2 per cent of the population that use about 50 per cent of unscheduled capacity at the moment. That is what they have done in Clifmanushire. What we would like is that the joint boards everywhere to focus on their 2 per cent. You can imagine that that would be quite an early win of helping to keep those people safe at home and avoid hospital admission, avoidable hospital admission. In terms of contracts and conditions, we are not in that territory at the moment because, obviously, there are processes and procedures for that and those will be respected and recognised. It is fair to say that Agenda for Change recognises seven-day working hours, and that is good and positive, but we would absolutely respect the normal processes and procedures for taking this forward with other groups. I hope that people see the opportunity here, and I think that for GPs particularly, there is an opportunity to do things a bit differently and to really give the profession an opportunity to develop and change what it does, but we need to do that hand in hand. I hope that people will seize that opportunity and take it forward, but we need to go through the proper processes of discussion with them around that. From the first panel this morning, there seemed to be a degree of unity that there were disparities in service between evening and weekend and during the day, and that needed to be worked on. Is this report, or is this piece of work, about evening out those disparities for emergency care—not for scheduled care but for emergency care—or is it about moving the NHS on to a 24-7 basis altogether? The NHS is not Tesco, so the idea that everything that is done at the moment is done 24-7, there are good patient safety reasons to not be doing elective procedures at 4 o'clock in the morning, let alone some of the complexities of when you would discharge people if you were doing that even if you wanted to. We have to be clear what we are talking about here, and that is that we, first of all, and the task force is very clear about this, make sure that we are already working across seven days, but making sure that that is safe and sustainable. Then, looking at the opportunities for additional diagnostics, for example, the weekend has already worked going on around that with using the performance fund to have additional diagnostic opportunities at the weekend. There are clinics happening at the weekend already, but there may be scope for more of that. I think that we have to be very clear what we are talking about here is not trying to do what we do in the NHS 24-7. I do not think that that is realistic or desirable, given what I said earlier about the patient safety issues, but it is about making the system ironing out some of the disparities, making sure that what we do across seven days is safe and sustainable, but looking at opportunities to do more, and I think that diagnostics is a good example of that, and the area of discharge at the weekend. Some of the things would have big impacts on the system, making the system more efficient and effective. Actually, it is not that difficult to do. It is about the way people work. It is about having the right people at the right place at the right time to be able to do all of that, including the pharmacy. It is not rocket science, though, about bringing that together and making sure that that flows over the weekend so that patients can flow out of the system over the weekend. Because you have got weekday working, it seems that outcomes for patients during the week are better because you have a critical mass of staff who are in there unable to do the diagnostics, the whole range of things that somebody coming in needing in schedule and schedule care would need, and the weekend it seems to be the same range of staff, especially diagnostics, radiographers, pharmacists. That whole written labs, porters, the whole thing are not available. How do you then create that seven days to make sure that someone coming in requiring that service gets it and make that cost effective without looking at some elements of elective work as well? I will ask Shirley to say a little bit the detail on what Glasgow is doing around some of the radiology and making that far more effective in working over seven days so that they can turn around results. Do you want to say a little bit? I might pick up a couple of issues from the things that we have been talking about. One of the questions that was asked by a colleague who asked about rurality pointed me to rural sustainability, which is a huge issue in respect of this work. There are two things that I wanted to give us illustrative examples of things that are already happening that are helping us towards sustainability. One is the community hospital that is developed for the western house. That uses a range of clinicians and other NHS staff, advanced practice nurses, paramedics, GPs in the overnight hours and a number of other colleagues who come together who provide that service. We know that GPs have exceptional patient assessment skills. As a result of that new method of working bringing together that multidisciplinary team admissions into the western house hospital have reduced by 17% as evaluated. So that means that reassures me that patients are getting a good assessment because they're getting somebody, a clinician with good experience who sees them when they arrive at the hospital and they're getting pointed in the direction of the right kind of care. It also means that rather than discussing the sort of inelegant delayed discharge which are people, we're talking about not having so many people going into hospital inappropriately in the first place. We talk a little bit about the sustainability of remote and rural workforce and the example that I would give, and there are a number of these things already happening in Scotland, but the example that I would give is an initiative at which we've undertaken with working with colleagues in Fort William. They had a couple of consultant posts that they'd had vacant for some time. Unless you have particular lifestyle or clinical practice choices, those opportunities are not always those that generate a huge number of applicants. Working with colleagues in NHS Lothian, we were able to put together an educational experience and support package into Fort William which meant that we went from having no applicants to seven suitable appointable applicants. It is quite a thing in some of our vacancies to have that kind of number of applicants and that was about making sure that people who were drawn to remote and rural practice didn't feel that in choosing that they were abandoned to nothing but remote and rural practice and that I think is something which is really innovative and is starting now to bear shoots across the piece. In your question as well, you also mentioned the use of digital support and there is no doubt that we are doing more around that, but we're also starting to see some real benefits in things like, for example, the development of Scotstar and our ability to retrieve patients and take them to the place that is best able to treat their needs. Scotstar effectiveness is, I think, going to be something that we will doubtless come back with further evidence in due course but is already starting to show real clinical effectiveness in respect of that. Coming back to the point that you were making about variation in the week, there is no doubt that there is some variation around some of that and there is no doubt that we will, as another colleague mentioned earlier on, in due course come to a negotiation of terms and conditions around that. What we've been very clear about from the outset of this work is that it would be the service models, the patient requirements that would determine the shape of those negotiations and I think that's really important. That's really important partly because that's what we're here for and partly because all of the clinicians that I've ever met wanted to come to work in the NHS and do a good job. They want to be able to play the fullest possible part and we want to be able to give them a service model that they can pin their professional coattails to. Some of the work that has been seen through the task force have been proposals from the RCN about the extended role that nursing and medwifery staff could undertake as part of this work. You've already heard, I think, quite persuasively from pharmacy colleagues who've got a huge role to play in respect of this and a number of others who will come together, not least the ambulance service in terms of the paramedic cohort. We've got examples of that work happening all over remote and rural Scotland, from Bucky to Fort William to some initiatives in the island communities and to the model that the Cabinet Secretary described in Clackmannanshire, which just for general information is a facility now that has within it three GP surgeries, two inpatient beds and 24 additional services that are available through advance nurse practice and some work from social care partners in terms of psychiatry support and those kinds of things. So not just the tube that used to be a fence that you couldn't climb through, so that's really, really important. In Glasgow, the radiotherapy services have not really been redesigned so much as reorganised. It's been bringing together a group of disparate services that mean quite frankly that you've got a bigger rotor. So you've got the opportunity to run those services and make diagnostic support available to people in a wider range of times than just Monday to Friday, 9 to 5. Again, that comes back to your point, Mr Menill, which is not just about the mortality stuff but the sheer effectiveness and efficiency that goes together to make a better patient outcome. Can I just ask one final question? Part of the evidence that we also received this morning was that people are sicker at the weekend, which seemed to puzzle me slightly. Has any work been undertaken to see why people are sicker at the weekend? Surely weekends are good for you, not bad for you? I'm not so sure that I would say that the human heart necessarily knows whether it's going to have a heart attack on a Friday or a Sunday. I'm not so sure that I would necessarily say that people are sicker. What I would say is that on a number of occasions some of the services that might help patients who experience difficulties at the weekend are more difficult to access. Any of you that have been involved in mental health care perhaps might be familiar with that. There is some evidence. There was some evidence when we saw the spike in Lanarkshire's HSMR figures last year. There was some evidence posed about the availability of care home facilities at the weekend and access to care support. And whether or not to be frank, sadly, patients were taken into hospital because they were going to die and there was nowhere else for them to be. So, I'm not sure that I've seen evidence that suggests that people are actually sicker at the weekend, but I think the infrastructure, which is why I made the point about the complexity of HSMR, the infrastructure that is necessary and various other factors. There are factors that would suggest, for example, that we with fragmented families, people go and visit their parents at the weekend and they notice that they're poorly and they've probably been poorly for a couple of days. So, there are a number of factors that come together in that respect. What we're trying to do through this work is make sure that the patient experience and the patient outcome is as good as we can make it and that we give the opportunity for the whole of the clinical team to be able to be involved in the decision making that essentially means that patients get a better outcome and reduce variation where we find it, where that's possible. Richard Lyon. Thank you, cabinet secretary. You said that the NHS is not Tesco. I couldn't agree more, but Tesco a number of years ago was now opening on Saturday and Sunday and are late and now most foot. Sorry? That was a few years ago. Yeah, a few years ago. Well, I worked in the grocery trade away at the very start of my career and never worked on a Sunday, but now you can get into most shops now, 10 o'clock at the right bit. That aside, Dr Surgey's shirt, generally on a Friday at 6 o'clock, don't open up again until 8 o'clock on a Monday morning out of our service, as they cope with it. We're coming up for Easter Friday, Saturday, Sunday, Monday, Easter weekend, which again, possibly out of ours, we'll need to cope with. So when do you think we'll ever get a seven-day service from our doctors that we could get an appointment on a local Dr Surgey or rather an attending A&E out of ours on a Saturday or a Sunday? Do you ever think we'll get to that? Yes, but it might be a multi-disciplinary team. It's not just about doctors. It's also about advanced nurse practitioners. It's about the role of paramedics. It's about that skill set that can build a safe, sustainable out of ours provision that doesn't rely on one health professional for its sustainability. Now, going back to 2004, when GPs were, when the responsibility for out of ours was removed from GPs and health boards took that on, what we've seen is a growth of various models that health boards have developed to try and provide that out of our service. There's a number of reasons, but the primary reason that I felt that it was important to review those set of circumstances is because, 11 years down in the line, boards are continuing to wrestle with how they provide a safe, sustainable out of ours service. What I felt was important was to look at how do we take a more coherent approach to that. Now, that might not be that the exact same model that works in Glasgow will necessarily work in mull or Tyree or whatever, but nevertheless, Lewis Rich's review will look at the urban and rural context, will look at who does what at the moment, but who could do what with the right skill set and training and support. In some ways, rural Scotland has got to grips with this a bit better. I'm not saying that there's not fragility in some areas there is, but some innovative solutions have been borne out of necessity in parts of rural Scotland. For example, the extended use of paramedics and the use of advanced nurse practitioners is something that's more well advanced in parts of rural Scotland, providing out of our services than perhaps the case in urban Scotland. Lewis Rich is getting ahead with his work. There's a lot of good people around his review group, and what we need it to do is feed into the agenda of seven-day working. The out-of-hours issue isn't just about GP out-of-hours. It has to look at in-hours services as well. It has to look at the ambulance service. It has to look at A&E. It has to look at NHS 24. Of course, it will be speaking and looking closely at working with all those organisations to make sure that the recommendations that come forward can help us to get on to a sustainable footing with out-of-hours services. I want it to be something that can go through into the long-term, and it's going to have more robustness and resilience behind it. I'll try not. I know that other people want that. I agree with me that if people could go to their local GP on a Saturday and a Sunday, that would relieve pressures on A&E and out-of-hours services. It might not be just a GP. It might be a GP if that's what's required. If someone needs to see a doctor out-of-hours, then clearly it should be a doctor they should see. If that is a requirement, but quite often someone can be equally seen and treated and satisfied with an advanced nurse practitioner or a paramedic. It depends on whether it's about getting the right health professional to the person and making sure that they get the right support that they need. That might be about bringing in social care support to the person concerned. If we look at how the service in Clip Manager operates, it's a multidisciplinary team that is a kind of rapid response team that is formed around that cohort of people who are the regular users of our services rather than the occasional user. That 2 per cent of people, remember, use 50 per cent of unscheduled care capacity. That is huge. There is a service developed specifically for them, which is rapid. It's responsive. It gets the right service to those folks. I don't want to be back looking at out-of-hours in a couple of years' time. I want to get a model that is going to stand the test of time that gives patients what they need but uses the skills of the wider workforce, rather than just being about GPs. Although GPs will always have an important part to play, it's not just about GPs. Just switching to the hospital-based service, you've made a decision on major trauma units, which are very much welcomed that that decision has been made, but it's really about the numbers of services that we've got. Your interim report refers, for example, that we're going to have four major trauma units. I know that the College of Surgeons said two. I think politically that would have been impossible, but four is the evidence base there for expenditure. The same with the mapping exercise that's shown that we've got 29 sites for acute general surgery, acute urology, 21 sites, and I'm sure it varies for the other things like orthopedics and the rest. If we're going to have a service that is effective, then if you take a population like Greater Manchester, they would probably have maybe two or three services. Now, I know that our geography is a problem, and I know also that the politics are a problem. But really, if we're going to have effective weekend working without having people that are present for elective surgery, then having people there only for emergency surgery on 29 sites might not be very cost effective. How is the workstream addressing this very difficult balance between what people want locally and what is actually effective, efficient, will save lives and is also sustainable in the long term? The work of the national clinical strategy will influence a lot of that thinking. That's not about the national clinical strategy saying, therefore, in such and such a location you should have. What it will lay out is looking at the evidence base around what the best outcomes for patients will be across various specialities. That work is an early stage, as you know, but it will be very important in determining some of those things. There are other ways of delivering some of the services. Part of the difficulty at the moment is around recruitment and retention of some of the specialities, particularly within our district general hospitals. Obviously, patient safety comes first, and we need to make sure that all of our services are safe. However, the way that we recruit and deliver services needs to change, and the use of the network, for example, shortly earlier on described how we were moving to sustain some of our services within our rural general hospitals by linking some of those doctors, particularly within specialities, to the teaching hospital, and various networks are being established around that. However, there is no reason, in my view, why some of that wouldn't work effectively within our district general hospitals, that you could have a far more attractive process of recruitment to some of those specialities if they knew that they would be working part of their time within a teaching hospital environment, while also providing support to the district generals. I think that there is an opportunity to do far more of that across Scotland. We need to allow the national clinical strategy to get on the way to help us formulate the thinking around some of that. Part of it is also about making decisions that can overcome some of the recruitment and retention challenges that we have within our system, and we need to be far smarter when recruiting to those posts that we develop. We recruit to a network rather than a particular position in a district general hospital, and the fact that we have vacancies still within some of those specialities that are incredibly challenging to fill means that we have to look at that in a very different way. You are right. Scotland is a big place, and Scotland is also a small place. In recruitment terms, from the pool of population, it is a relatively small marketplace that we operate in, and you will be aware of that. It is also geographically a very spread place, so we do always have to play access and the accessibility of services, particularly emergency services in life-threatening circumstances, into that space. The game is changing a little bit. We talked earlier on about Scott Star and those kinds of services around retrieval and those kinds of things. Cabinet Secretary has talked about recruitment. I think recruitment has got to have some regional context to it and some national context to it. If we are talking about profusionists, for example, where we have a tiny workforce, it makes little sense to me to have boards competing for that workforce. It makes much more sense to do that on a national basis and try and increase the numbers overall. So there are recruitment propositions that will come forward as part of this work. Cabinet Secretary alluded to the point that I made earlier on about the relationships between hospitals. We are also doing quite a lot of work at the moment in expanding the approach around clinical fellows, for example, to give people exposure, to give people an opportunity to look at things and to work in a specialist context. Perhaps even looking at some specialist GP stuff, there are now a number of universities who are starting to talk to us about whether or not there is a specialty about being a rural GP. That seems to me to make a lot of sense. You are right. It will always be a balance between the bigness that is Scotland and the smallness that is Scotland in terms of its population. Our role, I think, is to provide evidence about what is the best service for those patients, what is reasonable for us to be able to do in terms of that staffing model. I sadly cannot knit consultants any better than anybody else can. We have expanded that workforce considerably, but it is finite. Our job, I think, is to present Cabinet Secretary with evidence to options of ways that the service can be made more sustainable. It will be for others to decide what the acceptability of those options are, but that will be based on the evidence of what we have seen. We know vascular surgery needs a population of seven to eight hundred thousand people in order for it to be at its optimum efficiency. That would take you to an answer. Whether or not that is going to be an acceptable answer will be for others to decide, I think. If the outcomes are better, then it will be acceptable and we have to demonstrate that. I am very aware that the model in Scotland that we have adopted, which has managed care networks, is one—although the King's funder said that the jury is out on it, I am convinced that it is going to deliver in the long term, but that is at the moment about the elective procedures. It works well. When I had my cancer, it was operated on in Glasgow by the 4th Valley consultant going into Glasgow, and the team there of backup that he had meant that his skills were managed well. Two other health boards in the west of Scotland do not buy into that, which means that the outcomes, inevitably, I think, are going to be poorer. But that is elective. I do not know how it is going to be really difficult to get that into the non-elective, the unplanned emergency side. I just wonder whether you have got any examples at all so far of taking things of that sort. For example, the vascular surgery, which is the part of the most developed, is that working well with the five centres? That might be the best place to— It is working well in two areas. It is not as advanced in one area, but it is actually developing, and it is developing on a regional model. As for the network, one of the ones that is successful around the emergency side of things as opposed to the elective, is the network model in Fife and Tayside, which is part of that overall development, and also in the north, where they are coming together to do that. The west of Scotland is the area that had to look at where would be the optimal place for provision, given the paradigm of the population model to have enough skills and maintain and sustain the expertise. They are still looking at it. Again, that partly is about where health boards want, where the pathways naturally go for patients. However, it is being looked at, it is under way, and I expect to see more progress in the west, which is a bit further behind than the other two. We do keep asking about progress. That is in what particular field? We heard from Frank Dan, that the west was very good on it. That is in vascular. They do well, but there is more that could still be done. The national planning forum keeps asking about how it is getting on. That is very helpful. Just a brief for others. We have spoke lots about nurses and clinical profession, all of that, led. However, the whole question of slowing down those who are in the hospital and getting them out quicker is a tremendous burden on community-delivered social services. I suppose the question I want to ask is at no time that we actually considered health and social care service, rather than just a health service, because it seems, you know, in terms of, you know, it raises the obvious, and I think we all appreciate here about that, you know, how are they going to pick up this additional work? Will it be funded? But the other question, I suppose, is that lots of this burden has been taken up with a lower-skilled workforce who are working in very stressful situations, to also affect the outcome in patients that don't get to that hospital. You know, I don't want to be, but the 15 minute visit, the task-based approach, dealing with a myriad of people now, motor neurons, alcoholism, dementia, and all of the other things that is a big pressure on professionally trained people. You know, what in the workforce planning are we doing to reshape that workforce, develop that workforce and, you know, give them the status maybe that they are due, you know, in this process? Yep. Well, integration, I think, is the best chance we have of bringing those two systems together, and that's, you know, the course of travel we've decided upon is that, you know, through legislation they would be brought together, and I'm optimistic that that will remove some of the perverse incentives that we've seen within those systems of pushing in and pool. However, you raise a very important point about where within that team the care staff sit and, you know, there are issues around their paying conditions and training and career opportunities. So one of the things we've been talking to with COSLA is around how can we help local government and the sector to raise some of the standards and quality there, and those discussions are on-going about the best way of doing that. I think there are opportunities around career progression to remove some of the artificial boundaries between whether people can, with the right training and qualifications, perhaps move into jobs within the NHS far more easily from starting off perhaps in the care sector or, indeed, the other way around what, for example, nurses do within nursing homes, for example, there's the opportunity for those skills to be developed and to be far more developed than they are at the moment and to be more attractive as positions. So it is a challenge, I think, being part of a wider healthcare team will help. So the model in Clintmannanshire that we've talked about a lot today doesn't just rely on the care staff picking up the cases. It's also district nurses, it's also advanced nurse practitioners, it's also a range of other staff that are there to support someone with dementia or quite complex care needs within their home. I think that's important because you're right. Asking care staff alone to manage very complex care needs at home isn't a sustainable thing, which is why they have to be part of this wider team and to be supported. So that's what we want to see happen and we, as I say, we're discussing with local government about how we can play our part to make that more likely to be the outcome. The opportunities to develop that workforce and support that workforce better are there and, as I say, we want to play our part in doing that, shall we? A couple of quick things, if I may. Part of my responsibility is to lead something around health and social care workforce integration. So we have regular dialogue with partners from local authority, care home and other suppliers about what other things that we can bring together and one of the things that we're in the early stages of now is looking at that workforce planning, making sure that we've got data that allows us to compare apples with apples and so on. We've also just recently launched a career framework that does exactly what the cabinet secretary says in respect of giving an educational ladder for what are the better word to try and give people the opportunity to expand. Two other groups that we haven't really talked about that much have been fundamental into the taskforce work. One of them has been the representation around patients. They've actually been describing for us what they want to see and really what you were describing was about what it feels like to be at the end of a service. So that's something that has been really important to shaping up that work. The other, and I'm very happy to acknowledge the incredible contribution of our trade union partners, they've actually been prepared to look at some of these models, help develop some of these models. Now that isn't to suggest that I think we're going to hold hands and walk off into a glorious sunset in negotiation terms. There may be some very difficult conversations around that but actually these models are supported by the trade union partners and that's terribly important in terms of demonstrating the case for change. Yeah, they've got that sort of voice, but I suppose the general point that I was making, that we've got a service in the National Health Service, but we look at care where a lot of these people are going. You've got the private sector, the third sector, local government, different employers, whatever, whatever. That isn't a system. You're absolutely right and I'm not suggesting that because we've got these inputs that all of that will be very easy, it won't, but there are a number of things that we can do together that starts to make that feel like a real cohesive service for a patient or a service user. But those people at the bottom are the people who are dealing with me every day, they're not dealing with the social work manager or the district nurse team. Anyway, I don't think there's any other questions. We need to move on. Thank you all for that. We need to move on quickly to the next item of our agenda, which we hope to dispose with fairly quickly. We go back on the record then and move to agenda item number three, which you'll be grateful to hear is our final item on the agenda where we consider subordinate legislation. We've one affirmative instrument before us today. As usual, as a reminder, with affirmative instruments, we will have an evidence-taking session with the cabinet secretary and her officials who are with her now. Once we have had all of her questions answered, then we will move to the formal debate as necessary. The instrument before us today is a public body's joint work in Scotland at 2014 consequential modifications and saving order 2015. The cabinet secretary is joined by Alison Taylor, head of strategy and delivery integration, and Claire McKinley, solicitor, food, children, education, health and social care Scottish Government. Cabinet secretary, you wish to make a shorter opening statement. Very briefly, this order makes minor amendments to primary and secondary legislation, all of which are in consequence of changes made by the public body's joint work in Scotland at 2014. It also makes a saving provision to allow the integration arrangements already operating in the Highland area to transition into arrangements under the new legislation without a gap and at a date that is locally determined. The order will firstly ensure that integration joint boards, once established, have similar duties as health boards and local authorities, such as a requirement on them to give certain information to the provider of the patient advice service as a result of an amendment to include them as a relevant body under the patient's rights Scotland at 2011. Secondly, it will ensure that certain other pieces of legislation will continue to work properly when functions are delegated under the public body's joint work in Scotland at 2014. Thirdly, it will make the necessary changes following repeal of section 5A of the Social Work Scotland Act 1968, which made provision for local authority plans for community care services. That updates the statute book to remove or replace out-of-date references. Fourthly, it includes a savings provision so that the arrangements made under the Community Care and Health Scotland Act 2002 sections 15 to 17 Highland may continue until replaced with integration arrangements under the 2014 act. Fifthly, members will wish to note that the order does not take forward any new policy. However, I would be happy to take any questions on any of the modifications that it contains. Are there any questions for members? Does that suggest that the legislation that we passed in the public body's bill is not flexible enough to allow local arrangements to come into play where people can find a good way of working together? I know that Highlands is probably the only one that has gone down the road with integration, but is the legislation flexible enough to allow local arrangements to come into play where that works? It does. Alison, do you want to… Absolutely. The provision in terms of Highland is actually just there to make sure that it can continue to use the arrangements that they have already put in place until they move under the auspices of the new act. So it does not have any bearing on flexibility for local decisions to suit local circumstances. No other questions for members? Therefore, they move to agenda item number four, which is a formal debate on the second of the affirmative SSI, which I have just taken. I do not know whether that is my script or definitely whoever did that. Anyway, we move on to the formal debate. I invite the cabinet secretary to move motion S4M12645. Do any members wish to contribute to the debate? None. It remains for me to put the question on the motion. The question is that the motion S4M12645 be approved. Are we agreed? Thank you, cabinet secretary, for your time with us this morning. That concludes our business for today.