 Ma willing everyone, and welcome to the 9th meeting of the health and sport committee in the Scottish Parliament fifth session. I could ask everyone in the room to ensure the mobile phones are unsilent. mejorol sleentäng roi i dda i amrydd o mobile devices for social media, but please don't take photographs or film proceedings. We have apologies from Donald Cameron. The first item on the agenda is two round tables on recruitment and retention, and the first panel will focus on general recrwpment a'r retensiw sy'n fawr o'r NHS. Rwy'n fawr, rwy'n fawr o'r recrwpment a'r retensiw. I welcome everyone to the committee. My name is Neil Findlay. I am the chair of the Health and Sport Committee and I am the MSP for the Lodians. I am not going to introduce the cast of thousands around the table. You are going to do that yourself. I think that we will start in this direction. Just a brief introduction, not your biography please. Good morning. I am Tisha Hall. I manage the Scottish Association of Social Work, which is part of the British Association of Social Workers UK-wide, and we are a membership organisation. I am Clare Haughey. I am the deputy convener of the committee and the MSP for Ruthergwn. I am Tom Arthur. I am the MSP for Round Fisher South. Good morning. My name is Adam Longhorn. I am a paramedic, but I am here representing the Allied Health Professions Federation, which is an umbrella organisation that gives some leadership for allied health professional bodies. Miles Briggs, I am the Conservative MSP for the Lodian region. Hello. I am Caroline Lam. I am chief executive at NHS Education for Scotland. We are responsible for the postgraduate training of doctors, dentists, clinical psychologists, pharmacists and others. We are also responsible for providing continued educational development for nurses, midwives, healthcare supporters and indeed anybody who works in or with NHS Scotland, including those in social care. Good morning. My name is Alex Cole-Hamilton. I am the Liberal Democrat spokesperson for health. I am also the MSP for Edinburgh West End. Oh, sorry. I am Alton Johnston, MSP for Lodian Green, health spokesperson. Hello. I am Shan Kiley. I am a knowledge and research manager for the Royal College of Nursing. I am Richard Lyle, MSP for Oddingston and Bilson. I am Dave Watson. I am the head of policy at Unison Scotland. I am Mary Todd, MSP for the Highlands Islands and I am also a pharmacist. I am Ivan McKee, MSP for Glasgow Proven. I am Candy Millard, Eastern for Sure, health and social care partnership. Although we have only been one year as a health and social care partnership, we have been integrated for 10 years. Colin Smyth will lightly join us. I am assuming that he has travel problems. We are going to move directly to questions. We have a large round table this morning. Brevity and questions and answers will be rewarded, not with anything in particular, just with more questions. Can we maybe just get into the discussion and could I ask first of all, over the past 10 years or so, since the health committee looked at those issues before, in your experience, are things getting better? Have they improved or are they going in another direction? I think that it is fair to say that they are definitely going in the other direction that you described in terms of the medical workforce. Focusing on recruitment and retention across the range of different, what we call, branches of practice, that is GPs. I know that you have heard quite a lot about GPs recently, but also the consultants, the doctors at work in hospital that are not consultants but are qualified, they are called SAS doctors, trainees even, in each of those different areas we are increasingly seeing growing numbers of long-term, difficult-to-fill vacancies. We have been having problems increasingly also in filling a range of different specific roles for trainees, which is a particular concern. We see a number of different reasons for that, but none of them are yet being tackled. There has been, I think, in the last 10 years an increasing understanding of the challenges that there are across the NHS and the reasons why posts are increasingly hard to fill and why supply has been slowing down. The main issue is that we have not managed to turn that around yet and take the action that is going to stem that tide. In terms of the direct and shortish answer to your question, Neil, I think that there is no question in our minds that things have got worse in 10 years, but possibly that the only positive thing is to say that understanding has got better. I agree. It is getting worse. The data that is available would demonstrate that. We must recognise that, while the data is pretty good in the NHS, it is pretty poor in social care, relying very heavily on registration data, which has a lot of gaps in it for obvious reasons that they are very fragmented provider areas. What we do know when we look at the array of data is that we have got an increasing vacancy rate in key areas, most obviously in areas like nursing, which is the big numbers, but there are proportional problems in occupational therapy and other areas. Also, we know from the limited data of particular problems of vacancies, thousands at the moment for social care workers in Scotland who need to be recruited to free up the NHS. Linked to that, we have also got problems of turnover. Some of the turnover rates in some of our social care organisations now, frankly, would make call centres blush. It is that bad 25% and higher, and that is some of the better employers. The other issue, which I think is there, which is getting worse, is that we are getting an aging workforce, and that is going to have challenges in itself. That is all before we start to recognise the future demand that is going to be placed by a growing elderly population. I will echo the points that colleagues have mentioned so far. Certainly within nursing, vacancy levels are increasingly of concern. The recent figures are showing that in nursing, vacancies have gone up again to 4.2 per cent, and more than 600 of those posts have been vacant for more than three months. We also echo the points around the retirement age, and certainly there has been an increasing effort in looking at what the potential is for recruitment over the next five to ten years. Certainly the age profile within nursing, and that is across nursing and healthcare, social care as well, is increasing. Looking back over ten years at that stage, maybe 40 per cent of the workforce in nursing were aged 45 and above, and now we are at a stage where well over half are, and the future retirals are of real concern. Certainly because over the last number of years, the number of newly graduating nursing students coming into the workforce has been the lowest since 2002, and there are a lot of lessons that can be learned there about what can be done around workforce planning to improve the situation. Adam. On the HBP point of view, we have certainly agreed that we would echo many of the comments before, but we would add that the data for this is really not particularly reliable for all-out health professions. So many work in private settings and public settings and third sector as well. Vacancies themselves do not tell the whole story. Again, we shared the comments about ageing demographic, but a large change in the staff demographic to a largely female-based staff has brought with it and interesting challenges as well. The need for workforce prediction tools that will reflect where we are going with a workforce rather than just replacing vacancies like for like is absolutely vital for us. We can, hopefully, like to give a number of examples of where we can do that. There are some particular challenges around about down-banding of staff roles from band six, seven, eights to seven, sevens to eights, which is disincentivising, recruitment and retention. And a particular challenge for smaller professions, we have in all-out health professions, we do have a number of very small professions, and it's very difficult for them to have any clear idea of what the challenges are for them and to be able to put this forward in a way that could be remedied. Thank you very much. You asked us to reflect on the last 10 years and I think in doing that we need to be really clear about the context because that has changed quite considerably over the last 10 years. So we've seen a huge growth in the more elderly population. So in Scotland, over the last 10 years, the proportion of the population over 65 has increased I think by something around 30, 35, 36%. We've also seen some changes in the way in which people want to work. So increasingly we're seeing a new workforce coming through who are much more interested in working part-time, who are looking for much more flexibility in the ways that they're working. And I think that the other thing that, particularly with respect to medical recruitment, is around the move away from visa-free training. So 10 years ago we were looking at about 4,000 applications per year into medical training from trainees who would require visas and that's now dropped to somewhere around 400 a year. So I think we need to be clear about the context that has been a rapidly changing environment. I think there are some opportunities for us as well. So I think that the national clinical strategy sets out a framework within which we can start to think about how services can be delivered in a way that is much more sustainable for the workforce and which provides a really good environment for us to be able to attract, recruit and retain people in the workforce. I think that the announcement of additional student numbers in medicine is very much to be welcomed. And I think that we need to look at the contribution that all our professions can make. So I think that some really great examples of pharmacists working alongside GPs in practices. So I agree that we are in challenging times but I do think that there are lots of opportunities for us as well. What kind of our social work intelligence which suggests is that that recruitment as such is not really a problem in terms of qualified social work. Retention is becoming increasingly a problem and I think a lot of that is due to what people tell us about their working conditions, hot desking, not being able to speak to other people, having to book a desk sometimes the nearest desk is 32 miles away if you're in a rural area. A colleague told me last week that he spends a third of his week now trying to find a desk to do his work at. Issues around having to work within a far more target-driven culture than social work traditionally is used to, particularly in terms of adult care social workers that have to work in health contexts. I would suggest that integration is nothing new, that's what social work has always done and it's still a very dedicated and passionate workforce. We had our mental health officers conference last week where we had representation from all 32 local authorities and it was really really encouraging to hear what people were saying in terms of the positives but in terms of the negatives and the reason people leave those kind of jobs is the isolation that people find themselves in, the fact that they want to do relationship-based work and end up writing reports and we have got some very passionate champions in Dr Morrow from the mental health tribunals is always advocating unique social workers to do reports. You cannot drive that down to a lower level, so-called cheaper. For us, that is a major issue, it's not the recruitment, it's the retention. Shan, can I pick up on one thing that you said? I think that you said that nurse recruitment is at the lowest level or training is at the lowest level. Could you repeat that? The outputs of graduating students coming out of university has been at some of the lowest levels in the last few years and this is going back to decisions that were made some time ago. For example, in 2010-11 and 2012-13 there was around 20% cut in nursing student intake numbers and really what we're doing at this point in time is living the consequences of those cuts because in recent years the lowest number of graduating students have been coming out into the workforce. Of course, while the decisions that are made, it takes four or five years from that point to when a newly qualified nurse will be entering the workforce and then subsequent training, experience to take on more experienced roles. At the moment, we're in that crisis point of the decisions that were taken some time ago, which were a result at the time of employers being under incredible financial pressure, flatlining their projections for nursing, without looking at the nurses that were needed to provide care and the actual numbers that were provided to enhance and provide different types of services. It's really a result of some of those workforce planning decisions that were taken some time ago that we're now experiencing those lower intakes. Alison Ewing will come in on related issues. Yes, thank you, convener. I'd probably like to direct this first question, if I may, to Jill Vickerman. Both the BMA and Western Isles, who we'll hear from in the next panel, have highlighted the sort of lack of clarity around data when it comes to recorded vacancies. We clearly are in very difficult challenging times when it comes to recruitment and retention, but I think that it would help if we knew what the challenges were. The BMA and the Western Isles have highlighted discrepancies between the actual number of vacancies in local services and the ISD vacancy statistics, which define a vacancy as a currently advertised post. It doesn't include unadvertised positions or those filled by locums. I just wondered if you could maybe describe what you think the ideal situation would be. Thank you for the opportunity to pick that one up, Alison. It is a serious concern for us on a number of different levels. I think that there is a reasonably wide understanding now that the ISD definition of consultant vacancies is a very narrow one and health boards are asked by ISD to return the specific measure on the basis of posts that are currently advertised. However, on the one hand, having a consistent definition across all health boards that they all return, you can understand what the rationale for that is. However, the reality on the ground is very different and it is really important to understand both the fact that if we are really going to tackle this problem and understand the scale of it, we need to measure the complete picture on the ground. However, there is also the other effect that we see, which is the impact that it has on those delivering front-line services when they are working in an environment where they can clearly see, for example, that there are 10 posts that are not filled by permanent staff. They may have somebody coming in on a locum basis occasionally or they may just not have yet been advertised and they are told that there are only two or three vacancies. That is having a negative impact on morale and a genuine sense of people being even more put upon in the workplace. We see that problem as a crucial one to resolve for a number of reasons. I suspect that there has got to be a difficult conversation about how we get over the hurdle of the fact that the vacancy figure that has been collected and published for a number of years now, if we are to change that, there is a political challenge in terms of how we present that. However, our view is that we need to get a collective agreement about how we measure the posts that are not properly and fully and permanently filled on the ground and how we describe them alongside and add to that very specific and narrow definition of vacancies that is currently collected. If we are to describe these vacancies honestly, it is going to make the situation look worse than is currently published. That is absolutely right and it is worse than is currently published. Sorry, do you think that that is why there is a reluctance to get to grips with this issue? It has got to be one of the hurdles and certainly in the discussions that we have, we do talk about how we would overcome the challenge of changing, having a step change in the number of empty posts that we describe. I think that that is a really important thing for colleagues around the table to think about how we support a change. If we do not find a way over that hurdle politically as well as practically in terms of defining the measures, we are not going to have that complete understanding of the reality on the ground. Thank you for bringing me in at this point. Good morning, everybody, because my question is direct corollary to Alison Johnstone's and Job Recommend's response there. In respect of training places, I think that there is also a problem as well, because we often trade blows with the cabinet secretary and the First Minister in the chamber about the number of training GPs on-stream and how many vacancies there are in there. That is a very thin veneer, because beneath that, we do not get to interrogate, A, whether those are full-time trainees, as in they will be going into full-time eight, nine-sessional places, and B, whether they are going to practice in Scotland when they do actually finish. We understand from the RCGP that we will be as many as 800 fewer GPs that we require in the health service by the end of the decade. Audit Scotland's report was very telling last week that it said that our workforce planning cycle, both in NHS Scotland and by extension the Scottish Government, is over five years, whereas it takes seven years to train a GP. I wonder, Jill, if you and perhaps other panellists could reflect on how we can get the right information to just establish how deep that training problem is, as in how many more GPs we need to encourage into training places, and what you would like to see in terms of workforce planning in the wider health sector, so that it is fit for purpose. Thanks, Alex. I have quite a wide range of questions there. You focused specifically on GPs and GP trainees. Some of that is obviously relevant across a wider range of medical training posts and, indeed, no doubt, across a wider range of health professionals. Earlier, we talked specifically with Alison about the consultant vacancies. We actually have better information on consultants than we have on most of the other branches of medical practice and health professional groups, and we do have in Scotland better information than in a number of other countries. It is a major challenge. If we are going to understand the depth of the problem, we need to set aside the hurdles of being honest about the data on the ground and just get on with measuring it. From our point of view, Scotland is not that big a country. It should not be an impossible task to get our heads around what the actual numbers are in post and what the number of vacant posts are. Our call is consistently to get better at measuring across all those branches of practice what the reality is on the ground. In terms of how we workforce plan in a better way, there is quite a bit of work at the moment taking place in Government thinking about how we improve workforce planning across health and social care. Our concern is at the moment, as Caroline mentioned, the national clinical strategy. There is clearly a big piece of work for us all to be involved in changing the way that healthcare services are delivered across Scotland over the course of the next five, ten, fifteen years. There is a major challenge here in terms of planning a workforce to deliver a different health service in, as I say, 10, 15 years time. As you say, the lead-in time for training a GP is a minimum of seven years for many other medecs—it is nearer 10 years. We need to be understanding now what that future model of healthcare looks like, because everybody is committed to changing it in such a way that we can deliver a workforce to create a sustainable healthcare service. However, if we do not quickly move on getting clarity about what that new delivery model looks like, we cannot train the right workforce now and we need to be starting to do that now. Our call is absolutely for a consistent and concerned approach to looking at the future of healthcare service delivery and then, as a result of that, quickly move on to thinking about what are the implications for the workforce and who do we need to be training and how do we need to be making them able to take on the different kinds of roles that we are establishing for that future health service. I will follow up on that and talk specifically about workforce planning. What is happening now, what has happened in the past and where we need to go with that? You are right, it covers more than doctors, it covers other professions as well, so it is interesting to get a range of inputs on that, because looking at this, having done this in a previous life in business, the end of the day workforce planning is not rocket science, you plug all your variables into a spreadsheet and it tells you what is going to happen and then you tweak it as you go and we talk about, yes, there are a lot of variables but you know what those variables are, you have to make some assumptions but you are always getting feedback on how those variables are tracking over time so you can tweak the model. Looking at it from now, it does not look like a difficult thing to do and given the importance of it, I suppose the question is, has it been done in the past at a national level and if not, what kind of data are we working on or what kind of the situation we have at the moment is that just a function of accidental things that have happened in the past or has there been any kind of plan or design to it? I wanted to comment on the supply side, if you like, of the workforce because I think we do have really good data around that, but maybe just to pick up a little bit on what you were asking around tweaking the variables. There has been some work done over the last year or so around looking at individual medical specialties and looking at the profile of the workforce there, looking at what we have in terms of consultant numbers and likely retirals but also looking at the, because there are differences between the profiles so pediatricians tend to see more of those trainees on maternity leave and working less than full time which might be a quite different profile to some of the other medical specialties. I think that that is helping to improve our sophistication in terms of planning the number of specialty training numbers that we have in the system for medicine. I think that getting the right supply through to fill those spaces is a separate and different challenge and that really has to start well with universities but also before university as well so we need to be making sure that the sort of kids that we want to be doctors have the aspiration and the opportunities to become doctors and is the case currently that in Scotland we train more, we have more medical undergraduate students and we also actually have more registered doctors per head of the population than the average across the UK but our medical schools currently have about 50% Scottish university students and it would be good to see that proportion slightly increased. I think one of the advantages of the new numbers that have been announced is that they're focused on widening access and I think that that's really important and I think that the proposals for the graduate medical school will also help to ensure that we're getting students who are Scottish and who are therefore more likely to stay in Scotland once they've completed their undergraduate training through into specialty training and through into becoming the consultant workforce of the future because we know that the main thing that drives people in terms of where they choose to work is their family and friends and that's very much based on where they grew up. Sorry, I'd like to pick up everybody else's comments but thank you Alex for the question. Yes, well we must look at ensuring that we have robust data around what the workforce looks like and where it stands. It's absolutely vital that we really look to what the models are that can provide the service that we need to deliver as well. We have particularly relating to primary care, we have examples of occupational therapists, podiatrists and propratys, physios, radiographers, all returning people, all providing fantastic services that are in some cases provided by GPs currently. Specifically, I might make a point very quickly but we have two, we have examples of paramedics for example replacing GPs one-to-one in surgeries in Aberdeen whereby looking at the entire system they're looking at what the acuity of the staff can provide allowing GPs to do GP work and out of solutions that are novel but are working very, very well. Dave? I'm talking more broadly about workforce planning. I think that when I worked in the health department as a comment for a couple of years I remember doing some work on workforce planning and one of the colleagues that was working full-time in that area described it as more of an art form than the science and I think that's probably pretty accurate at the time and I think we've done a lot of work. Part of the problem I think is that the data is variable and the data in the NHS is despite the I accept Jill's points on some of it, data in the NHS is at least the best we've got. I mean if you go into social care the data is very, very poor indeed as I said based largely on registration, all sorts of assumptions and definitions that are made there which don't help us a great deal in workforce planning terms. The problem I think in workforce planning terms is that there are a wide range of variables many of which we can only at best make assumptions about at this stage particularly when we're talking five or ten years ahead. It's not like other areas of workforce planning we can do a relatively short period. For example if a workforce plan has got to take account of the state economy frankly if they could do that they're probably earning millions of pounds of the city of London not sitting on the civil servant salary. So there are factors in relation to the economy. We don't know for example if we're going to make progress on gender segregation. Social care sector we're talking about 15% are men and we're clearly not going to be able to tackle the ongoing problems unless we address issues of gender segregation. We've also got changing delivery models and not all of those are fully understood and the pace of change not understood. So how quickly will we move from acute to primary care services? The government wants to do that, absolutely right. The speed of that change I think is going to be pretty challenging and then how much can we deliver through changing or expanding roles? We've seen it nursing, we've seen it at the point made about paramedics and others. There are real opportunities. We published a skills charter a couple of weeks ago where we showed ways which this could be expanded and done more quickly and that's even without entering Brexit into the into the calculation as well. So I think all of those reasons means it is challenging. I think we could do better but we need to recognise that there are lots of variables that we really don't know too much about. To comment further on workforce planning, the Royal College of Nursing has particularly been focusing on looking at ensuring that the wider health and social care workforce is considered within workforce planning. So far a lot of workforce planning has particularly concentrated on NHS. So in planning for future nursing places the focus has very much been looking on NHS employers and it's really important that the whole wide aspect is now looked at about a third sector around care homes, around the whole arena of areas where nursing and health care support workers are working and later on in the session note that you'll be hearing from Scottish care and the care home sector in particular is one where we're aware of very high vacancies and it's very important that workforce planning for nursing is looking at the breadth of employer areas and making sure that we're planning for health and care social integration and looking at all the aspects where nursing is needed in the future. Alison Johnstone Yes, I'd just like to Caroline Lamb, if I may, just ask for a bit more information about the refugee doctors programme because clearly there are implications of breaks on the discussion that we're having this morning but the refugees programme sounded a very positive thing? Caroline Lamb I think it is a very positive thing. It's a programme that we've been running for a while which is aimed at supporting refugees who have been working as doctors in whatever country they've come from and getting them into employment in NHS Scotland. I think I don't have the figures to hand but I can certainly get those for you if you'd be interested in that because I think it's important that we look at engaging the full breadth of the talent that we've got in Scotland around the workforce and that includes getting people who've got those skills and abilities back into the workforce who might be people who've trained in Scotland but have for whatever reason taken a career break so we also run a number of programmes aimed at encouraging people back into practice so GP returners, dentist returners, also nurses, we've been very successful in the last year in recruiting I think about 145 nurses into our return to practice programme so I think that's also really important that people may choose to go out of the workforce but we need to get them back in as well. Thank you. John Swinney For Blevarty, Caroline Lamb, to pick up on Ivan McKee's and Nelson Johnston's question, how many training places do we have in Scotland? I think you made a comment that anyone who's in Scotland should be allowed to train while I have a case where a chap who wants to train as a doctor, I can't get them in, how many people are rejected or how many applicants who apply don't get in. The Government said we're going to bring another 50 should we make that 250 and should, last if you allow me convener, I discovered that anyone who trains immediately leave and finish their training, they can leave and go to Australia, New Zealand, Canada, whatever, should we have a tie then contract that people should stay here for five years before they can leave? Caroline Lamb Okay, there's a number of questions there. I think the first thing was about how many applicants we have and I think you're probably asking at the undergraduate stage to the start of somebody's career in being a doctor and it is the case that all courses undergraduate level and medicine are oversubscribed, it still remains a very attractive subject to study and it is at the university's discretion to apply their application and their selection processes and I'm sure that's something that they would guard their academic independence very carefully around all of that but I think it's very clear that we don't have a problem in attracting people to medicine. I think that the fact that the Scottish Government are encouraging the universities to look at the additional student places around, particularly looking at people from a wider access background, I think is a really positive step and one that we should encourage. In terms of numbers, I think that's very difficult, I think that we probably need to look at how we do the most that we possibly can to retain doctors within Scotland and you're right that at the moment we're talking about young people who have lives and have ambitions and aspirations to do lots of different things so yes some of them may decide to go off abroad but many of them will then return and come back into NHS Scotland bringing with them a wide range of experience which actually I think benefits NHS Scotland so the length of training programmes for doctors are so long that I think it's quite hard to be very prescriptive about what we are allowing or not allowing people to do within that. I think we need to try to retain as much flexibility as possible. I'm sorry to press you on this but you didn't give me an answer to what I was asking. How many training places and maybe maybe you want to come back to... No no no I'm sorry I can give you rough numbers sorry I've missed that bit. In terms of postgraduate training programme places which is the element that my organisation supports we have around five and a half thousand training places in Scotland yes. How many of those people that five and a half thousand again to to get the answer how many of those leave during the course of their training programme 10% 20% 5% right I'm hesitating not because I don't want to answer your question here but because it is very complicated because the training programme is split into the doctors will do two years in a foundation programme and at that point there is a decision point for the individual doctors as to whether they go on to further training and some for some specialties that will involve core training and then higher specialty training for other programmes that will involve a run through. Many doctors during the course of their training will choose to take time out they may go off for family reasons for maternity or paternity leave they may go off to do research for a year they may go off to get experience in different organisations for a year or so and then come back so there is a whole wealth of different reasons why people and it's one of the reasons why it's very hard to answer that question I can try and get you some data on it. That's what you call life. Yeah it is people have complex lives. Thank you Trisha. Again within social work in terms of workforce planning we've known for a long time that particularly in adult care there are huge issues in terms of mental health officers because we've got a vastly aging population working with a vastly aging population and particularly in terms of the adults within capacity legislation whereby MHOs have to assess capacity and we are really in a quite difficult situation there social workers have to do what is kind of the equivalent of a master's degree to become an MHO and they have to be released from their substantive tasks in order to do that. Quite often these people working children and families teams or in other teams and obviously somebody being released from a busy workload has an impact on that workload and on that team so although you know chief social worker advisor to the government has commissioned reports on that and although it's been known for a long time it's difficult to say to local authorities you must do something about this because local authorities make their own decisions obviously I was very interested in that I think about one or two years ago NHS Highland actually ended up supporting five social care workers to undertake their social work degree so you know there are different models that that you could do that are quite imaginative and that I think could work very well to try and and address that problem but I think it does require some courage in order to do that. Miles? I wanted to pick up on Richard's point and Caroline was going to tell to what extent do you think the university and college sector aren't actually helping to address this problem specifically with the capped number of places we've got for medical students I think since this parliament was reconvened the number of Scottish domicile has gone from 65 percent study in medicine to around 50 percent constantly today so to what extent do the universities have to be doing more to make sure that we're accepting more students but also more likely students who are going to stay and live and work in Scotland and and also what else can be done and what else is being done to try to get people who have left Scotland to go and work in Australia and New Zealand to come back to Scotland to work within our health service. First of all on the question of universities I think that our universities in respect to medicine but also our colleges across the whole range of other professions have have a huge contribution to make and and I think that that's not just about where students come from but also about the experiences that they get while they're at university so I am nest together with Scottish governments working very closely with our universities at the moment to try and ensure that more students get an opportunity to experience remote and rural placements for example and also that more students get an opportunity to experience placements in general practice while they're studying because I think having good positive experiences in those areas is one of the things that then leads them to be able to express an interest in continuing a career around that so I do think that it's really important and equally you know I am personally I am absolutely committed to the widening access agenda I think I've mentioned it a few times already and I do think that that's one of the ways in which we could try and ensure that we are that we've got more eminently able Scottish kids coming through into medical schools. Okay, Joel and Adam then we're going to move on to another issue. Okay, I'll try and be brief. I wanted to pick up on a question that Richard set to Caroline around about the suggestion that we might consider effectively requiring doctors post qualification to stay in the NHS in Scotland. This is a really challenging issue and our view very strongly is that and as Caroline made this point as well that the most important thing to do is to make posts attractive for people to come and stay in Scotland. We're really concerned about any direction of travel towards forcing people to stay in the NHS post training because I think that's a really short term approach to take. The impact on the morale of the doctors, if that is the approach that is taken, is likely to be extremely negative and the message that it sends to those others that we're trying to attract to come to Scotland is not a positive one. We would not be at all confident that post five years that you would have somebody then who was committed to the NHS. However, you may well be aware of a scheme that's just been announced in NHS Wales where GPs are being offered a £20,000 golden hand cuff to stay in the NHS for a year and we will be really interested to see what the impact of that is and what the longer term benefit to the NHS is and I think that's something for us to watch very carefully. I also wanted to pick up a point that Miles made about shifting the balance of the number of Scottish domiciled medical students that we have and I think that there is a general consensus that that would have a positive impact on the number of medical students who would want to then continue to train and stay in Scotland. The message that I hear a lot of concern about that kind of change is the profile of Scottish universities and the sense that they need to have the freedom to select and choose those medical students across all of their specialties of course that will allow them to punch above their weight in the way that they do on the worldwide stage and that is what makes Scottish higher education such an attractive place for others to come to so we need to think carefully about how we play with some of these variables. Yes, yes. What extent though how we fund our universities in Scotland is that also impacting because a Chinese student coming to study medicine in Scotland at Edinburgh University is around £30,000, to what extent do you think decisions are being taken about where the students are coming up from in terms of financing the university rather than where they are going to work when they leave university, especially around medicine? Again, I would say that there are quite a number of different conflicting variables involved in the decisions and the discussions within universities about that. Absolutely, there is a financial incentive to attract and have a number of people coming from outside of the EU indeed, but there is the other impact that changing that balance would have in terms of how the university is perceived on the worldwide stage. Richard, you wanted to come back. I reply to you, Jill. Sorry, I don't want to hamstring anyone or tie anyone, but I believe that if a country gives you the opportunity to train to be whatever, you should at least give back to that country. With the greatest respect, if you don't like it well, go and train somewhere else. I have just a slight comment on that, just that observation. When the teaching profession brought in a one-year probation scheme after people trained, it did have an impact on morale, a positive impact on morale because people got a job for a year before they moved on. I do have some sympathy with that point. Adam. I have a couple of points from Miles's questions. The evidence that we are presenting today is compiled from 12 different allotelf professions and from allotelf directors. Some of the feedback from them said that there are very few training places for some professions and that some of those come from the rest of the UK who then return back to their homes once qualified. Quite often, there are vacancies at the time when people exit the training for those, which is obviously a difficult point to remedy. Another point that was raised by people was placements for students outside of the central belt because the problems outside the central belt are not just remote and rural for us. Funding for those placements is very important. They can cost individual students up to £600 a time for those things. The antithesis to Richard's point is that a point was made regarding professionals coming to the UK who need to register for the first time with the HCPC that process can take 16 weeks and can cost the individual £500. There needs to be some support for bringing people in, making it easier for them to come and take up posts for us. I want to ask about the agenda for change and the consultant contract. Adam, you mentioned that there were possibly some impacts on the allied health profession workforce from downgrading of bands. In the written evidence that we got, there was also a mention that it was perhaps a reason for drift to the rest of the UK that there was a perception that the agenda for change banding in Scotland was less generous than the agenda for change banding in the rest of the UK. As someone who worked in the health service and was well aware that in Scotland we actually implemented the pay recommendations of agenda for change so our bands do get paid higher than the rest of the UK, I was interested to know if there was any evidence for this and if there was any compensation or anything that could be done about it. The secondary question that I wanted to ask was to the medics in the room that I heard from the Royal College of Physicians particularly about the concern about the consultant contract, the 9 to 1 ratio, and I just wondered if there are contractual issues that need to be tackled in terms of workforce retention. Thank you, Mary. I'm afraid that I'm going to have to hold my hand up and say that I can't answer in-depth on that question, but I will do so. I will submit some supplementary evidence for you to answer that directly. My apologies. Picking up the question about the consultant's contract, Mary, there is an on-going issue relating to what was described as the 9 to 1 element of the consultant's contract. For those of you who perhaps aren't so familiar with what that terminology means, the current consultant contract is nationally agreed and allows for usually 10 sessions a week for each consultant of four hours each. The expected balance between the amount of face time that the consultant has with patients and the amount of time that they have to contribute to the wider development of the NHS, to teaching the up-and-coming medical students and trainees and to contributing to their own professional development, is supposed to be two and a half sessions for that wider qualitative contribution and seven and a half for direct patient contact apologies. The intention in the contract is that that should be the starting point of discussion, that that should be the expected balance between the various different types of activity, but that in certain circumstances and when agreed between the consultant and their employers that could vary in either direction. The reality is that what we have found in Scotland now is that consultants are being pushed to spend an awful lot more face time with patients to try and address the increasing demand challenge and that they have less and less time to contribute in these various other ways. That has impacts on both the training capacity that we have in Scotland and on our ability to innovate and change, which I think that we have discussed earlier is absolutely vital at this time. On top of that, it is having a very negative impact again on the morale of the consultants who are currently in post in Scotland but also really importantly the attractiveness of consultant posts in Scotland. It is one of the things that we hear cited most often by doctors outside of Scotland for reasons that they wouldn't want to come and take up a consultant post in Scotland. It is the sense that Scotland is a 991 contract country and I do think that there is a real opportunity for us to tackle that and it doesn't require changes to contracts, it requires adherence to the current contract as it currently is. I think that perhaps the trade unions wouldn't want to give the impression that that we think a gender for change is not properly implemented in Scotland or certainly that it is better done in England for a whole range of reasons. It is pretty chaotic down there so I think and that's not to say there aren't issues and in particular I think one of the issues with the gender for change is the very long scales which is there is some work being done under a gender for change for that. I mean it's the will undoubtedly be if it's not tackled soon equal pay challenges for that when people are sitting on scales for a long time not necessarily reflecting their duties responsibilities or their qualifications so I think that there is some work to be done there but generally a reason to have what we should also remember is that health boards have some control over banding under gender change because they control job descriptions certainly I've seen cases where the job scripts have been badly drafted and therefore you know they're probably not properly banded or different to that they might apply elsewhere in the UK and we should also remember that if there are real issues then they've also got the option of recruitment retention premium as well under gender change. Gender change is sometimes described as being too rigid etc actually it's quite a flexible agreement but he does depend on all the pliers to to be flexible in using it. Mdl Slate to come in on this is she? Colin? Thank you. Can I just follow up on a point that Jill made regarding the erosion of SPA hours has any work been done to really quantify the extent of that particular problem and for example how many consultants would be required to go back to this sort of two and a half figure? There's been quite a bit of work done in terms of looking at the new contracts which are being set up for people being taken into post and looking at the balance of 91 versus 827.5, 2.5 etc and we do see the continuing focus and balance on 91 contracts which is really worrying. In terms of the broader question there about what would be the total capacity required to free up a proportion say of those working on 91 to allow them to shift back to the 7.5, 2.5 arrangement. I haven't seen any analysis of that but there's clearly a significant piece of work that's required to do to understand in terms of not just the new consultants coming into post but those already in post what would be required to actually allow them and support them to make that happen. I'm sorry very quickly. Colin, thank you on that point and just to repeat my earlier point about looking forward as well, we have examples of particularly occupational therapy of whether the consultant occupational therapist is leading in stroke clinics and one particular exciting example of a project where they were unable to recruit a medical consultant to a rehab clinic and then recruited an occupational therapist and the results of the project kept increasing, kept improving. So there are future models, there are alternatives to traditional models that need to be used as well. Can I raise associated issues? Agenda for change obviously deals with terms and conditions to NHS staff but we're discussing this issue in very negative terms in terms of the workforce plan and the gaps that there are but for some people this is a very positive thing because for some people there appears to be a clondike going on. For those who run agencies, for a small group of senior consultants who are earning three times the salary of the First Minister, it looks as though if you're a shareholder and a nurse and the agency at the moment you're living it up large because of this. I don't know if Andy's got that information but the Audit Scotland report says that there's a salaried nurse, the average cost is 36,000 whole-time equivalent but an agency nurse is 84,000 that's the cost, the RCN might be able to help us. How much of that is just a clear profit for the agency? I don't have figures around the split between what's patchy paid and the agency fee and what the nurse receives and what the agency receives. However, the volume of cost and the increasing cost that's been spent on agency and local workers across the health and social care services is a matter of concern and particularly in the last year we've seen a very dramatic increase of nearly 47% increase in the cost particularly looking at nursing within the NHS only so I think it's very important that there's increased focus and I know there is work on going looking at agency and local workers that has been taken forward so I think it's a very valid point to look at because it's certainly a real indicator of pressure, the volume that's been spent and certainly the Royal College of Nursing would be making the point that if there's a demand for those nursing roles there should be the focus on looking at employed posts rather than continuing to use agency cover. Again, the report suggests that agency cover is being used for long term rather than just short term vacancy cover that's a concern and you know the increase in midwifery staff 4%, 47% for agency nursing and midwifery staff and then 33% for medical outcomes. Those are all big figures that appear to be continually going in that direction. I don't know maybe that we've not got the right people around the table to get right into the guts of that issue and maybe some of the committee has to think about how much of this is just pure profiteering and how much if it is actually legitimate costs. I thought I had to raise that. A number of the submissions that we've had to the committee, both written and oral, have raised issues about recruiting staff from overseas and I'm aware that both health and social care providers use staff from both the EU and from outwith the EU and some rely on those more heavily than others. Could the panel comment on how they see the changes to the immigration of the UK Government, how they have impacted on recruitment from overseas and also if they've seen any effect of the changes to the post study work visa? I think when I spoke earlier I did raise the fact that the move away from permit free training in the UK, which happened some years ago, has had an effect in terms of recruitment into medical training posts. I can't comment on the post study visa effect but it is the case that around about 20% of the medical undergraduate population in Scotland is from either Europe or overseas and I think it's probably a concern to us all around what might happen to that population post Brexit. The honest answer is that the data is very poor indeed. We don't know precisely. Someone asked a similar question in the previous evidence session and I think I said that the day after Brexit I was busily trying to find some data that didn't succeed so we've been doing some survey work of our members and it's only obviously surveys from that and what's very clear from that is that a certain proportion have already considered leaving. These are EU nationals predominantly not so much true for outwith the EU but certainly EU nationals certainly considering leaving because of the uncertainty and the lack of of a guarantee in relation to what will happen post Brexit which is why that's our number one ask of the UK government to provide clarity and certainty there and I think the other there's clearly from that survey and we reckon we've probably got about 6,000 members in Scotland in that situation so they're concerned obviously for their future. Some of them are considering returning. It's the sectors where it's most prevalent is certainly in the private residential sector that's where the bulk of the responses that we've been getting back from and it ranges from fully qualified nurses to other social care staff. Also in the home care sectors quite large chunks of staff there as well so I'm afraid it's not hard data plenty of anecdotal stuff plenty of survey type type response work that's been done but we don't have the hard data but what's clear is that this is the sector where we are struggling to recruit and retain at present so we can be pretty sure that given the demands on this sector in the future that we're going to have to address this issue and plugging the gap without overseas or EU nationals is going to be beyond challenging. Candy could ask us what your organisation is experiencing the same. Does that reflect what they've seen in relation to social care staff? Across within the health and social partnership we don't actually employ anybody obviously they're employed through the the NHS or the council or through third sector providers. I think we benefit a bit from being in the central belt which is probably that we retain people for longer because of that central belt area so the areas where we struggled the most with staff is particularly specialist roles so for example recruiting a consultant for our child and adolescent mental health teams has been difficult. Our providers again experience similar problems to the ones that you've been discussing in terms of recruitment and retention of social care staff. I was specifically trying to find out about non-EU nationals because it's been an issue that's been raised with me by constituents that is particularly difficult for them to and people that they know to get visas to come to work in health and social care in the UK but I was wanting to move on then obviously to EU nationals and how the panel felt in particular about the impact that that may well have on recruitment and retention within the UK post Brexit. Thank you for that question. Certainly the UK's exit will have a profound effect on nursing across the UK and in Scotland and they're all called nursing. We've published our unheeded warnings in a labour market review report and there is some data and information in there looking at both non-EU and EU nationals who are working in nursing across the UK and it's really significant at the moment looking at what's both happening in health employers and social care employers as well and certainly within the care home sector it's certainly an issue that's coming to prominence and we're hearing around what potential impact will be with the UK's exit but certainly our unheeded warnings report has got some detailed information. Just as a brief supplementary what the national organisations are doing to lobby the UK Government about this issue? We've done lobby, we've written a number of briefings to the UK Government, we supported the Scottish Government's initiatives in this area as well. We said that essentially our number one ask from the UK Government at the moment is to give a guarantee to EU nationals who are currently in Scotland and they've ended broader in the UK that they will have a right to stay post breaks. I think that's the absolutely essential thing because the longer that goes on the more uncertainty there is, the more likely we're going to lose those very key workers and in some sectors it's not just in health and care I can tell you in construction the number of other areas that we represent staff, there are big issues so that's the number one ask. We're lobbying loudly and hard on that issue and obviously we welcome all the support. We've had it certainly in Scotland I have to say and the opinion polls as well have been extremely positive on that, you know the public gets that so you know there will be absolutely even amongst those who voted voted to leave there's a very clear majority of those who believe that those are currently working in Scotland should have the right to stay. To concur with the points raised there that they're all clutch nursing across the UK has been very much focusing on the potential impact and it's very important and we've made the point at UK Government level as well around developing a coherent workforce strategy that preserves the right of EU nationals currently working in health and social care and making sure it's very clear what the huge impact could be so as a UK organisation we are very much concentrating on these issues thank you. Very similar to others the British Medical Association has been lobbying hard at both the UK and at the Scottish level on the point of providing reassurance and removing uncertainty about the future for overseas employees who are currently employed in Scotland. We are hearing slightly different perspectives within Scotland and from the rest of the UK because of the different messaging that is taking place about the position in Scotland and that is also creating some confusion and we have had now in our last few meetings with the academy of royal colleges an increasing focus on this issue is now coming part of our regular agenda of discussions trying to get a better understanding of the scale of the potential problem because the medical profession is at least as reliant on overseas medics than any of the other health and social care professions as you would imagine and we see the challenge not just about retaining the staff that we already have and rely on so much to deliver the NHS in Scotland but also the fact that we would have an expectation over the very near future in the next month in the next year that there would be people thinking about coming to Scotland to fill a number of the vacancies that they were so desperately trying to fill who will be looking at Scotland and the UK and making a different decision and that is an immediate and urgent problem that we need reassurances from government about and a point that we're regularly making so in terms of the impact of this I think we'll start to see that immediately in terms of the types of applications that we're getting for posts but also applications for places at university and in training posts which we were discussing earlier. Okay, could I bring in Miles? I might actually have a point. You were, what, raised the, later or have you already raised it? I didn't know that's what I raised earlier. Ah, that's fine, that's fine. Tom, yeah, yeah. A final supplementary, the UK government has characterised EU nationals as bargaining chips. Can perhaps system the panel comment on what the impact would be if we reached people who were denied the right to remain within the United Kingdom given that we have had no clarity from the UK government and they voted against a motion in the House of Commons to reassure EU nationals. Have we keen to hear what the actual impact would be if we were to lose these people? Well, I mean, I can be very clear in particular sectors. I mean, I think, you know, certainly in the residential care sector, the absence of overseas nurses and other care workers in that sector would be constantly devastating. I mean, you know, I just look at the numbers that we get in terms of cases we handle etc in that sector and, you know, almost the majority of certainly staff that you see come through are either overseas nurses or EU nationals. So, I mean, clearly, if that went, then that sector would have real problems. I'm sure Don Lleith would be happy to clarify that for you from the employer's perspective, but that's certainly our impression for it. I think, increasingly also in the home care sector, we're seeing issues there, the particular groups of staff that have come back in our survey, some of the numbers somewhat larger than I'd expected, to be honest. So, I think the impact of that. And clearly, the biggest problem with phrases like bargaining chip is that, you know, we're talking about care professionals who clearly culturally and behaviourally, you would expect to behave in certain ways. And when you treat them in a way, which is somewhat subhuman, frankly, by using phrases like bargaining chips, you then get in a situation where they say, well, you know, clearly, I'm not wanted here. And if I'm not wanted here, believe you me, there are other countries in Europe who have exactly the same demographic challenges that we have in Scotland, and they are going to go elsewhere. And that would have devastating impact on health and social care in Scotland. It's on a subject financial. I'll come back to you then, Joe. Just a quick point to follow up, because hopefully my previous answer reinforced what a devastating impact it would have on our medical workforce. One of the EU sources of medics, which people sometimes don't think about, is Southern Ireland, where there are a significant number of our doctors are trained in Southern Ireland, and the potential impact on reducing the flow from that source and causing the uncertainty is unmeasurable, I think, at the moment. So, I think that the response to that is your question, is that we all see a hugely worrying potential impact, both on the terms of the numbers of the people in post, at the moment, the potential flow into the country, but the morale of all of the other workers around about them as well. Just to concur really with what people have already said that, you know, our organisation from the British Association of Social Work's perspective has made representation in Westminster of Andy's already, because obviously it would have a huge impact on social work as well if a lot of the social care professionals left and, personally, as a bargaining chip, having been in Scotland for about 30 years, but that citizen, you know, I feel quite strongly about these issues, so, you know, I need to be careful not to get too involved in it. Okay, Richard, say you want to say something. Yeah, I can't, if you can turn to financial. When you're 20, you don't really worry about having a pension, but when you get to 50 or near enough 60, you start to think about it. Is the factor that changes in the pension arrangements and tax incentives for doctors who are getting, you know, in that age range, being a factor in getting doctors to stop working or cut their levels down? It could be for health professionals across the piece. Yeah, well, everyone then, but, you know, in regards to doctors, I believe in that, I don't know if I've got the figures right, but they can know that their pension pot can only be £1.5 million, and then, you know, if they work on, they can't make any more contributions. I may be wrong, correct me if I am wrong. Jill. The answer is quite straightforward. Yes, of course, it does have an impact on doctors' decisions about whether to continue working on and in what capacity, and the reality is that that is having an effect on the availability of our most experienced doctors working longer-term careers. We are seeing across the whole range of branches of practice doctors who are under significant pressure, who are very stressed or seeing an increasing demand on them, and then looking at their own financial position and they are being advised quite often that it's not the best decision for them to keep working. Sean, you? Certainly, the impact of pension consideration is a really important issue to discuss, and certainly in certain areas of nursing, where there are very large groups of nursing staff who are approaching retirement, the issue of working longer and potentially working many more years on nursing, which is a physically demanding job, will prompt and is prompting nurses to consider what their options are. Certainly, there are areas of nursing such as community nursing, mental health nursing, and there is the option for many to retire at the age of 55. With that scenario, we have concerns that more nursing staff will choose to retire. There has been raising staff as well, and they are working much longer on having to carry people up and down tenement blocks. The point is that the tax changes in relation to the annual lifetime allowance are capturing a lot of staff quite far down the thing, and it's an issue in discussion with the Scottish Government, who will be consulting as to whether they take up some of the UK Government's changes in England, which could have an impact there. Sometimes, these things look as if the policy aim was to capture some very high-pay staff and to capture some private sector practices, which are essentially tax avoidance. It was done for not bad reasons, unfortunately, as often with these things. There are unexpected consequences of doing those. I think that the retirement age point is an important one. We have recently had the Cridlain review of looking at UK-level, looking at the normal retirement age, the state retirement age. One thing that Cridlain identifies and can be very difficult to do is that there are different jobs that have different demands on them, and whether or not a single retirement age for everybody is necessarily the way to go forward. I have to say, in a lot of our areas, in the local government pension scheme, which covers all the people in social care, for example, the average pension is less than 3,000 per annum. I have to say that people are not leaping to grab that at an early stage. In fact, in recent years—I am the trade genocide secretary for the pension scheme—I would have said, 10 years ago, people would have said to me, how do I get early retirement, Dave? Today, I get far more questions about what happens if I carry on after normal retirement age, and this is largely about adequacy of pension provision, particularly for women who may have had career breaks, but also for low-paid men as well. I think that pensions are an important aspect of it, but we should also emphasise that a good pension scheme is a very important recruitment and retention tool in this sector and one that we should defend very keenly. We are almost at time, so I thank the world, Adam. I am supporting everybody else's comments regarding pensions age as well. I thank the convener for his point about amulant staff and pension age. That has been looked at and Westminster has felt that it was okay for amulant staff to keep working until 67. They weren't in a risk profession, so we thank you for your interest and we certainly would welcome any thoughts from Scottish Government on that. I thank everyone for their evidence this morning. There are some people around the table who said that they would contribute some further information, follow-up information. Can you supply that to the committee class via email or letter or however you wish to do it? Okay, thanks very much and we'll just suspend briefly. Okay, good morning everyone. This is our second round table this morning. We'll focus on rural recruitment and retention. I welcome everyone to the committee. My name is Neil Finlay, convener of the Health and Sport Committee and Labour MSP for the Lothians. As previously, I will allow you all to introduce yourself. As I said earlier, just a brief introduction, no biographies, please. I'm Jill McVicar, director of operations in NHS Highland. I'm Claire Hawke, the deputy convener of the committee and MSP for Rutherglen. I'm Tom Aferm, the MSP for Renfrewshire South. I'm Ron Culley, chief officer of health and social care at Western Isles. I'm Miles Briggs, MSP for Lothian. I'm Jim Cannon, director of regional planning for the North of Scotland planning group. I'm Alex Cole, Hamilton Libberdown with Grat Health, Spokesperson MSP for Edinburgh West. I'm Aaron Heer, on behalf of the Royal College of GPs. I'm Alison Johnstone, MSP for Lothian. I'm Donald McCaskill, chief executive of Scottish Care. I'm Richard Lyle, MSP for Oddingston and Belfast Island. I'm Gillian Smith, director for the Royal College of Midwives Scotland. I'm Marie Todd, MSP for the Highlands Islands and our pharmacist. I'm Stuart Ferguson, general surgical trainee at the Royal College of Physicians and Surgeons of Glasgow. I'm Colin Smyth, MSP for South Scotland. I'm Ivan McKee, MSP for Glasgow Proven. I'm Bill McKerrow, I'm an associate postgraduate dean with Ness in the north, and I'm here representing the Scottish School for Rural Health and Wellbeing. Okay, thank you very much everyone. We have an hour or just slightly over an hour for this session, so it's inevitable, we appreciate it. Marie, would you like to begin? Thanks Neil, where to start? One of the things that was striking to me, I guess, when I was reading through the submissions that came from the written submissions that came in, was the change that's happened in midwifery training. Now almost all of the professions said that one of the things that enabled them to recruit to rural areas was when people had experience during training of working during rural areas. So it struck me as an odd decision to stop training midwives in the highlands and islands, and I just wondered if anybody in the room could give me a little bit of background as to how that decision was made and when it might be remedied. I feel I've lived through quite a lot of the history of this, and the decision was made because they changed from double duties, midwifery, some time ago now, to single duties. So it was that midwives could concentrate on the care they needed to give women, because if you were looking after somebody who was, say, terminally ill with cancer and a woman who needed her antinatal visit, and your priority would perhaps go towards the nursing agenda and would not give the care that was really needed for the midwifery agenda. So they stopped doing the double duties some time ago, and the double duties were always really helpful for the highlands and the islands, but the difficulty wasn't replacing them when they went on leave or anything. But when they went from six universities down to three universities, and I think that's what you're alluding to, and where a Stirling had a campus in Vernace, Stirling University, Dundee University, trained midwives, and a Caledonian University was the other one that closed and left us, Robert Gordon University, Napier University and the University of the West of Scotland. So now they operate a hub and spoke model, and I do think that it's a really good question that you're asking, because I do think that that has an impact on how people appreciate the place where they're doing the clinical placement. Now I think a fantastic example of that has Robert Gordon University has been covering the highlands and the islands, and recently they placed two student midwives in the western islands, and they enjoyed, and I think that originally one of them came from there, and they enjoyed that placement so much that in October they will be taking up two positions there. And I think that if we're going to operate a hub and spoke model, then we have to make sure that we give people the opportunity to see what it's like to work in a remote and rural area, because it is quite different. Your time around your decision making has to be different, because if things go wrong in that environment then you need to be able to transfer quickly, and you need to be making the point of that decision around transfer really, really importantly. So I do think that there is an issue around that. I think that some of it was because we went from 220 midwives in training to 100, which was a very steep decline in the training numbers, and I heard Shan earlier on was talking about now three years later, we're getting out significantly less than we got out before, and some of that was in the back of an oversupply, and routinely the Cabinet Secretary, even before this current administration, would be getting, because I think it's about six, seven years, would have been getting letters in for parents, grandparents, aunties, uncles saying, how can you train people and then not give them a post? And that's actually when the one-year job guarantee started with midwifery and then coming to nursing. We are no longer in that situation. We are in a situation of difficulty in recruiting to midwifery posts, and it would be easy if we could say it was only the highlands and islands, but it's how big is the central belt. We know we're having difficulties recruiting to the community maternity units in Inverclyde in the Vale of Leven. We've really recently had to close Montrose because they haven't had enough. The Aberdeen situation I think most people know about is that they've had 26 full-time equivalents down and they've had to manage those services, and that puts stress on people left behind. And so how far is your central belt? Because Lothian and Glasgow don't appear to have a problem, but if you look at Glasgow, that it is also the Clyde part of Greater Glasgow and Clyde, they've certainly got a problem, and I worry about the future of the services in the more remote and rural areas. Could I ask you about that 200 to 100? What is that for? 220 down to 100. 220 training places a year for cross Scotland? Yes. Down to 100. Over what period of time? And that was done quite quickly. That was done over, I think at the most it would have been done over two years, but I think if I recall it was probably done in the space of a year because of the oversupply we had at that time. When was that approximately? Excuse me. I'll have to, I have to remember exactly when it was, I think it was around 2013, 2012, 2013. I remember being told when the numbers were dropping, I was getting off the train from Dundee, so I was kind of trying to remember when that was. I wonder if anyone else, I mean I wonder if Jo wants to answer. That's very important, and Gillian has been very comprehensive. Other than to say that we absolutely agree if you train in remote and rural areas you're more likely to come back, so operationally we would welcome clinical placements for students of all disciplines. See, in relation to the placements, do students get additional support to take up those placements? So, for example, if a central belt student, 11, let's say it was an Edinburgh student, wanted to take up a rural placement in Dumfries or in Highlands or whatever, would they get support to do that, as in for their accommodation and all that kind of thing? Yes, yes they would get support, but sometimes it's the difficulty of finding that accommodation, and in actual fact when we look at the students and what support they get, sometimes it's even more expensive to get that support for the central region than it is for the remote and rural, but when you have things like the summer holidays where you've got a lot of tourists up around the Highlands and the islands then it can be very difficult, so it is a difficulty, there's no doubt about that. Thank you convener, we heard in the last session in the panel before you of a commensurate drop in nursing places around that time or a couple of years before that. It strikes me as particularly myopic way to save money if across workforce in various aspects of the health sector we are storing up problems for the future by exposing ourselves to a much diminishing workforce as you're now describing. I think it was because there was a bit of fear around an oversupply because we had no jobs for newly qualified midwives, it was almost disingenuous at that point in training them and not having employment for them, so it was a real difficulty, but over the last few years the numbers have built up again and we're sitting now, at last year we took in 183, we'll be waiting to see what the numbers are in the group that's currently working with the Scottish Government to look at that. What I think, and I just want to come back on your point there, is that I don't think we had a robust workforce planning tool in place, I am still not convinced that we have a robust workforce planning tool in place. I reflected this last week at the Scottish Partnership Forum that we're into a workforce planning tool for midwives that is the third run of it, so if they're having the third run to test it they can't tell me it's robust, so I have concerns about that. I think Audit Scotland would agree with you based on the report that it published last week, that we have a workforce planning cycle of five years in Scotland right now and it's an indictment of the Government's approach to workforce planning across the health sector. It's very troubling what you're telling us. It's maybe to take a more general approach to this because what's true for midwifery is also true in other areas and part of the evidence that we've submitted around the recruit and retain project is quite illuminating about that. In particular, the degree to which having an experience in a remote and rural area as part of your on-going professional development or qualification, whether that's medicine, whether it's midwifery, whether it's dentistry, whether it's physiotherapy, it all has a positive impact on the degree to which you would then be prepared to take on a bigger commitment to go and work and live in that area. So I think that can't be underlined enough. It's hugely important and anything that we can do in support of that should be done. Ivan. I just want to go back and explore some of the issues around about the workforce planning and hopefully some others can come in on this as well. Because you're looking from the outside and having done this in previous lives if you like, it's not on the surface of it too difficult a thing. Yeah, you've got a number of variables. You've got to make some assumptions as to what they're going to be, what's going to happen going forward, but you can track how those develop and took the model as you go. So the kind of scenario you're describing, where you kind of get dramatic oversupply then dramatic undersupply shouldn't happen if you're doing the workforce planning correctly. So I suppose the question is what is there in place at the moment and how effective it is? Because at the end of the day it comes down to figuring out what the demand is going to be, how many you think you're going to need, and then figuring out how you're going to supply that. So to what extent are those processes in place and what's to be done with it? Sorry, we've kind of been concentrating on the midwifery aspect of that, but I think this is a general point. Absolutely. Please come in. Perspectives on it. By all means, John. I think it's really interesting because we're currently looking at what the numbers will be for the intake for next year. For the very first time and I was interested when Caroline Lamb was talking about it earlier on, we saw a scenario, a planning tool, that was being developed by NHS Education Scotland, and that's the first time I had seen a tool like that used and actually gave me a different approach to what I would be lobbying for. So I think that sometimes it's been done in isolation by boards and not even including the right professionals to input into it. I am seeing a change now, but when they say, and I think a big issue for us has been that 50 per cent of neonatal units have been staffed by midwives in the past because we were dual trained. We've done nursing and midwifery. That's no longer the case. And so we're having to see that there's this balance between neonatal units. And often when you get, and I was interested in the 4 per cent agency that you spoke of earlier on, because that 4 per cent agency, I suggest that quite a lot of them are neonatal units that they're going into because midwifery uses midwives banks that are employed by the health boards. And I think that there is a hidden problem in there because I don't think you get the right measure of what you're bank because it's not external, it's internal. And now the situation with the staffing in some areas is so difficult that even those who are on the bank are burdened out and they're not coming in for the extra shifts. And I think that's the difficulty. Donald, just to come back on the nursing issues, Scottish Care, our members employ about 10 per cent of nurses in Scotland. Three years ago we had a vacancy level of about 12 per cent last year, 18 per cent, and research which we will publish on the 18th of November will show that that vacancy level is now 28 per cent. We are faced with a critical situation and that has a compounding effect on the whole of the health fund social care system. Because if we do not recruit and retain the nurses in social care, then that has a profound impact and that report will illustrate reasons why that is the case. But one of them is certainly workforce planning. A few years ago, that 10 per cent, in other words, the contribution of social care providers was not included in the calculations which each year determined the relative intake into nurse training. That's now been remedied and in some parts some of the reason for the lack and shortage of nurses is because five years ago we didn't train enough. With integration we have a real opportunity now to develop an appropriately robust model and method of workforce planning. There is a real opportunity to evidence that shared training and shared placements. I have just been experiencing the first ever physiotherapy placement of a student about to finish his study. Half of his time he spent in a general hospital in Oben and the other half of his time he spent with a care at home organisation. That had huge benefits to the individual patients and the individual who were receiving that support in the community. There is real potential for us not just to plan appropriately but to learn some of the lessons from elsewhere about how we can co-train and co-locate individuals. How are your members covering a 28 per cent vacancy rate? They are covering it by using agency staff. That report will indicate that the agency costs on average are around £345 for a night shift but that can go up to £800 a night for a night shift and needless to say the individual nurses are not going home with £800 at the end of their shift. The exponential increase in agencies has deeply impacted on social care providers in the last 18 months, two years and is getting worse but paradoxically I heard the other day of agencies ceasing to trade because they couldn't find enough nurses and in some sense agencies are a manifestation of the problem and that is that we do not have enough nurses and certainly we don't have enough nurses who are willing and prepared to work in social care and there's lots of reasons for that and our report on the 18th will explore why social care nursing and particularly nursing for older people still remains an unattractive option. I'm not expressing an opinion on this, I'm just asking a question but do you think there is profiteering going on? On behalf of the agencies, I'm probably not in a position to comment on that but they are in existence to create a business and they have seen an opportunity and they've been exercising that opportunity but it is having a profound effect on the viability and sustainability of care home providers in particular whether those care home providers are private for profit or charities. David. Thanks, convener. Just to pick up a number of the points specifically going back to the idea of undergraduate involvement across all specialties, as a rural GP it makes no end of difference when I speak to someone whether they are in the secondary care in the south of the Queen Elizabeth university hospital in Glasgow, big hospital but they've had a rural placement or they know what it's like. Knowledge without perspective is a higher form of ignorance is one of my favourite quotes and a third of Scotland's population lives in a rural area and if that person who is working in any kind of sector whether they're actually based in a rural area or whether they're based in a city having an understanding of Scotland's demography is extremely important because we often find that the leaders of all sorts of all different professions the leaders of these professions who then go into managerial positions they also have to have that kind of perspective as well and there's sometimes a kind of a slight leaning towards people who are who are in kind of city based positions go into these management positions a bit more easily. One of the things that we've really been concerned about is this disconnect that we've noticed between strategic aspirations particularly of the government and the operational reality and one example is realistic medicine, fantastic report you know a lot of us clinicians across the board are reading that and thinking this makes sense this is fantastic but it's not being matched up with the realistic funding, with the realistic management, with the realistic expectations that come with that and that leads to frustration and that kind of frustrates that kind of disconnect even further. You know we're talking about connectivity as GPs that's the biggest issue that we face in being able to kind of pursue somehow and kind of take forward the innovation that happens in general practice, rural general practice in particular and just taking on that point about disconnect you know I kind of have to bring to the committee the aspect that the DHI have been rolling out, broadband connectivity across Scotland funded by the taxpayer and one figure that particularly concerns us because connect connectivity actually kind of makes the whole thing sustainable, actually connects us, allows that innovation to happen and despite the millions of pounds of DHI funding and the fibre that's going outside Brodic health centre and Shiskin health centre which would allow us to connect with our LAMLASH medical centre we've discovered that it's going to cost upwards of 115,000 pounds to get our three of our sites connected to LAMLASH medical centre. There's a complete disconnect on how this is happening, I get better connectivity to our server in LAMLASH in Tromso 500 miles north of the Arctic Circle than I do five miles up the road in Brodic so I don't mean to bring too much all at once to this but in terms of how we look at how the people's experience of rural practice is very important to have, people want it, last night I turned down the 82nd application for a student elective on Aaron in the last year we can only take two or three and there's no mechanism to allow those students to be kind of then signposted appropriately to areas who will take that on board but that connectivity and that disconnect between strategy and operational reality is a huge issue for us and causing us a lot of frustration. James, thank you, I wanted to make a point about workforce planning, in my experience workforce planning is quite a complex thing in the health service, it's not a binary replacing like for like and when you can consider it in I suppose in the landscape of the constant pressure to innovate skill mix to change you know when the pressures are around sustainability of services then workforce planning isn't an easy job to reflect in the fact that workforce planning is undertaken at different levels within our system we've talked in the main today about workforce planning at a national level and it's important that we consider that but it also happens at a regional level in terms of the work that James will do but it happens at a local level too and indeed one of the things that we as integration authorities have to give regard to is how we want to change your services over time to meet population need and by virtue of that we envisage a different workforce over time and so we need to make sure that the work that's done strategically at a local level at a regional level and a national level is being joined up and we probably don't have that arrangement in place just now. Can I ask in relation to the point that David made and I think that that's important certainly for our constituents and the issues that they come to us with in terms of problems and issues within the health and social care field is it a general feeling that there is a disconnect between if you like the policy strategy rhetoric you know all of that stuff and material reality on the ground or is David way out there on his own yeah William I would agree with that I think that the whole of healthcare planning has been bedeviled if you like by a series of different projects working in different ways not being joined up very effectively people in essence discussing the same thing in different rooms but not actually pulling their resource and their intellectual energy into moving things forward and the Scottish School for Rural Health and Wellbeing which I chair was really established to try to fill that gap it's a loose strategic alliance between our academic partners in Highland involving Ness also incorporating RGU incorporating NHS Highland health and social care and what I think we've been able to achieve and what we could achieve much more of is this collaborative environment where we are working together and not the world is another series of projects of course coming along as the Scottish Rural Medical Collaborative as I follow on to the being here project but these are all individual projects and require continuity if we're going to really make the big gains from it so just a plea in that direction anyone else get a comment at miles yet to what extent you know I was listening to David it was really interesting to to I think said 82 applicants you'd had just for the two positions and you didn't know how to or where to signpost them why have you as sort of organisations not been working on that and waiting for the government almost to come forward to say this is how you should be doing it because you know any other field I think would have said right we need to put together a framework to be able to do that we have and I used to for the month of my colleagues in Skye and Islay and they're in the same situation and at a college level we've tried to look at how we can invest and resource that the Rural GP Association of Scotland got a conference Thursday Friday this week there's no end of enthusiasm and we are doing a lot of work to try our best to do that the problem we have as gps is there's a day job and there's everything else and you know I'm this is my annual leave coming here and last night still I was you know going through dogman you know and it's just that there is a real pressure at the moment going through dogman which is probably get all the letters in from consultants share of information and you know we've I would love to take a week or two weeks out to solve this problem because I think we've probably got the answers in the ground as well but there is this how do you get that message up to the to the people who will listen and be able to take that forward and ultimately that's what takes kind of funding and resource can't just make one other point you know we've seen the Scottish Government put forward this 20 000 bursary I think that was 100 places 37 were taken up what would you say the government should be doing then to actually help support this telling us about it and I mean I think I don't mean to be too critical there's a lot of fantastic things going on just now in rural practice across education in Scotland being a GP in a rural area in Scotland I will stand up and say it's one of the best jobs that you can have but it does come with its frustrations and one of those frustrations is as I open the BBC news website and the BBC news website was reporting the targeted scholarship scheme targeted bursary scheme and there's a picture of Aaron because we've been quite vocal we've done the movies to try and attract people and people are not coming forward there's a picture of Aaron on that BBC news article places like Aaron are where you can apply for this this bursary and I emailed a lot of different contacts to find out how do we how do we engage because we could we could do something really powerful about this and it was really difficult to actually find out how to engage with that process so it's a great idea and I don't mean to be overly critical of those who've you know progressed these ideas but we and Aaron are sitting there with a picture of the of our island saying this is where you can come and do this and we're asking how do we engage with this how do we take this forward some people go to Benidorm you've come to the hill that's coming later that is commitment and james i was just about bill's point about connectivity of initiatives and I think there is an increasing number of connections between initiatives and I see an awful lot of connections being made a lot of streamlining of thinking and resources I don't think we're there yet but I think the national clinical strategy does give us that kind of platform to align everything towards it so it for me it's quite a positive message I don't think we're there there is I recognize the disconnect but speaking for the six north of scotland boards that I represent I know that the chief execs are very keen to build any new initiatives any changes from the bottom up from the services and not to be sort of top down strategic then run I'd just like to offer a wee bit of reassurance that the Scottish government is not responsible for the content of the BBC website of what pictures that they use but I'm a bit confused because we've been hearing about to attract people to work in rural communities we need to get them there to train and you're saying that lots of people are wanting to train there so where where is the disconnect why is that not happening if I can answer that is that okay I think there is a problem with looking at holistic recruitment there has been a pervasive sense of in particular in training programmes I mean the whole just to kind of brief off diverge slightly junior doctors is an incredibly misleading term we've got missed the junior doctors who are 35 40 still in those kind of training posts and I think that there's a degree of kind of assertiveness being placed about where people should kind of should train often by the time that people looking for GP placements or indeed to to to be employed as a GP there's other things in life life is complex there's other things in life that has to be taken into account now the committee is probably aware of confidential evidence that I've submitted of my own particular kind of experience of that and it's galling because it's not just my experience it's the experience of a lot of other colleagues that I speak to that we have to get grips with the fact that when people move to rural areas are keen to contribute to that kind of to that community and in a very effective way it's not all about the medicine the medicine is actually the fun part but there's often the considerations of family of spouses of employment of how you're going to live in that kind of situation and I think until we get that part right because it's not until we recognise that people are investing time and careers and because there's a lot of there's a lot of positive outcome potentially to gain from that until we get that better understand what you're saying here but this doesn't it doesn't connect up with what you'd said before if you've got 82 applicants for two posts and so there are people who want to go and work in a rural community or an island community what's what's the disconnect then in terms of getting them places to go and work because students will often be attracted to the medicine and then you then realise there's other parts of life that have to be sort of taken into account and it's why in the college's report of being rural connectivity nothing to do with any medicine connectivity was a highest kind of issue I'm maybe not being clear enough on what I'm asking here okay because you've all what we're saying is there are people who are putting their putting their hat in the ring and saying I want to move to Aaron as an example so they've already decided that the connectivity or the social life or whatever else is fine for them so where is the disconnect between them applying and them being able to find training posts in those days it's in the mechanisms that allow that to happen I've got a friend who was a who applied and was keen to move to Dumfries and Galloway as a rural GP had lots of reasons to do so Dumfries and Galloway is really struggling for rural GPs and they gave up because the process was taking too long through the HR processes the relocation kind of process was was not kind of living up to what they were saying they were able to do now you know that's one example we know by their examples as well but it struck me that for someone to want to move to an area which is crying out for GPs to be put off the process there's good things happening a single performers list great innovation that should hopefully kind of do something to help that but we need to be mindful that there's a whole process behind moving to somewhere and if that human resources process is enough to put someone off making a significant career decision that's what happened that that's my the honest truth about her experience I'm keen not to just focus on GPs or any one discipline but I think if these are general issues that are across the board then that's absolutely pertinent Ron and then Stuart and just just to come in on that specific question I think one of the things that we're maybe guilty of is to think of remote and rural as one thing the reality is that it's not and somebody who may want to to move to Arran to practices in the GP may not want to move to south east so it pertains to the individual in question and what motivates them to work in a particular area and that's more than just the the location is aware it's about professional development it's about the type of medicine they can practice in that context so we need to be very careful to think about this issue of remote and rural in a context where it can be very different across the big parts of Scotland which which are challenged in this respect I also wanted to come back on it on the earlier point because there's lots of collaborative work that's been done in Scotland but at the end of the day we still work in an environment which is competitive so ultimately if there is a GP up for grabs and Jill and I are both interested in bringing them into our partnership then you know absolutely we want to collaborate but there's a point of which we will want to put our own interests first so there is a competitive element which we still need to give thought to in the context of of the labour market whether that's in medicine or any other healthcare profession Stuart yeah thank you I just wanted to make a comment regarding the question of how aspirations towards training aren't matching reality so the context I understand is rural general surgery there are probably about 20 posts in general surgery across the six remote and rural hospitals 12 of which are filled at the moment and recruitment is always a problem I'd submitted evidence on a survey that I did with a colleague of all the Scottish surgical trainees asking what their attitudes were how interested they were in rural training and in working in a rural environment and what was striking was that 80% of Scottish surgical trainees say yes we should be training in remote and rural environments 43% of them said I would personally be interested in training in a remote and rural environment but of those six remote and rural hospitals there are only two that have a surgical trainee there so there's absolutely a lost opportunity there and having explored that a little it sounds like there would be additional funding required for those posts to be made available in a rural setting but all the evidence suggests that experience of work in a rural setting is one of the most positive things you can do to see someone eventually working there. Richard Sorry, did you want in? No, no. Okay, sorry, Colin. Thanks very much, convener. Those of us that live in the rural area, in my case, down in Dumfries and Galloway, I've obviously seen quite a centralisation of services right across the public sector whether that's policing, whether that's the health service, it is more and more services are obviously centralised as part of the part of the national strategies. How has that impacted on recruitment and retention in rural areas given the fact that the experience of an individual on their career pathway in a rural area is now something very different from what it used to be because of that centralisation? Donald, do you want it? Yeah, it's a problem that particularly affects surgeons because there has been a lot of literature published about the relationship between volume and outcome. Rural surgeons can often feel particularly highly scrutinised for continuing to offer a wide surgical service in their own environment, but where that's done in a sensible way with clear links with bigger centres and a sense of support from them, then care should be delivered locally wherever possible. Gillian Theingill? I think I wanted to come back in on that business about the training numbers and for us it would be, there's only so many mid-wise nurses that you can send to a particular area because under the NMC guidance they will require to be supervised and they're required to have what they call a sign-off mentor and also the other big angle is the exposure of the women for us to too many trainees, so that's an important aspect of it. I think for Midwifery I think the centralisation has had a huge impact for us and we see different things being done now by mid-wise that were not previously done. If we look at Orkney Shetland, the Western Isles to a certain extent but lesser because they have some consultants there, is that we're now seeing mid-wise doing vongtooth practitioner roles, which is assisting the baby with a vongtooth cap that they didn't do before. There's lots of other things that they'll be doing, general surgeons will carry out some of those C sections when we look at Shetland, so it's kind of like looking at all of our professions and somebody mentioned it earlier on and looking to see who the actual person is you need to carry out the role and I think the multidisciplinary team working. The other thing I just wanted to say before I moved on that there are huge culture issues as well about when you have to transfer women for us, patients in from remote and rural areas into the central areas of expertise and how not only the patient but how the practitioner that's doing the transfer in is received and I think often that that's something that we need to to deal with, is behaviours and attitudes. Yeah, I really just wanted to pick up on the wider aspects of recruitment and retention in rural areas. I chaired the being here steering group, which is an action research programme looking at sustainability in remote and rural areas. We've been working with all sorts of people, we've been interviewing them around why they didn't come, why they maybe came and left and we've called it being here because that's what it's about, it's being here generally, it's not just about the job as David has said. What we discovered was that housing is a huge issue, even initially, where especially in remote and rural areas the available housing is so expensive. The holiday lets, as Gillian has already alluded to, these are big issues for them. Partner employment, if you're moving to a remote and rural area, what is there for partners? So we need to be working with all of our other public sector partners around that. Education for children, transport links, these are all really very important. One thing that I want to really impress upon committee is the goldfish bowl effect of living and working in a remote and rural area. Work-life balance is extremely important. If people have come for the environment, for the outdoor pursuits, for the really nice opportunity to live and work in those areas, they need to have the time to do that. What people have told us time and time again is that they can never be off duty. Even when they're not on duty, they are stopped in the supermarket, they're stopped in the post office, and people want to talk to them about their issues, even challenging them what they're buying around the alcohol or whatever. That is quite amusing. You're all laughing, but that is a huge issue for people, not only the individual but their families if they are constantly being challenged in that way. We need to find some way of addressing the public expectation. Dr Finlay is not around any more in those communities, and we need to be helping people to understand that our professionals need to be able to have a work-life balance. It is really, really important. I think that there's a number of us around the table that empathise with that point. Donald? A couple of things. It comes back to a point that Gillian made earlier. We need to look at what do we mean by rural and remote. Our data suggests that, amongst the top four most difficult locations in Scotland to recruit and nurse in a social care setting, we're talking about the borders, and we're talking South Lanarkshire. Not two areas which might be traditionally perceived as remote or rural, but they are nevertheless areas with their own particular challenge. The second point that I wanted to make, and it cuts across the professions, is that, whilst we might be able to recruit nurses at the entry level, what we're beginning to face is that, as organisations are seeking to reduce costs, not least because of agency costs, and are flattening their structures, the opportunities to recruit to management and to supervision and to mentoring roles are diminished. That might be a quick way of making a resource saving, but in the medium to long-term it's extremely damaging because if we lose that skill base of middle management in all professions, but particularly in nursing and social care, then we're facing real difficulty of getting the skillset necessary for all the advanced nursing that we're wanting to see in the next and in the medium term. Well, we all apologise, I should have brought you in earlier. That's okay. There's a few points that I would quite like to pick up. One is that David's great success in Arran, I think, is largely down to David's very, very effective marketing strategy that he has done. So there's something to be learned from that. David has evangelised about the joys of working in Arran, and that's infectious. We could evangelise about all sorts of areas in the highlands and islands for that matter and make it appear more attractive to our young doctors and young nurses and young midwives. Ron's point, I think, was also very pertinent that rural is not just one place. So if we wanted to attract rural surgeons, we perhaps should consider recruitment with a basis that your end point will be where you want to be. There's no point in recruiting somebody to remote and rural, training them in surgery in general, and with our ambition being to work in Oban if the only vacancy arises in Shetland or Wick. So we've got to think our way through that training pathway, too. The other point that I just wanted to pick up was Stuart's about the recruitment of young surgeons, I think, has got to happen early. We've been somewhat thwarted by the college's view and the surgical hierarchy's view that training in remote and rural should take place late. I think the trouble with that is that people have generally, speaking, established their relationships and their home base in the central belt where they've been trained. If you catch them relatively early at core training level, they are more likely to remain, and we've evidence of that from Wales, where it's proven a successful strategy. I just wanted to pick up on the issue of centralisation there. I've often wondered and I mulled over how much of the issue of centralisation, how much does it come from the professions themselves. You've alluded to it, too, that there's perhaps a disconnect within the professions that some of the professional leaders are very urban based and are proposing solutions that don't fit the whole of the country, given that a third of the country is rural. Even that decision a very long time ago, it seems now to go from dual qualification to single qualifications. There were fantastic reasons behind it, but it did have a really challenging effect on midwifery in the highlands and islands. What are people's thoughts about how we can influence the professions? My feeling, as a health professional myself, is that much of the drive towards centralisation is coming from the professions. David, do you want to add on that specific point? Yes, absolutely. I think that centralisation tends to be a bigger organisation, a sense of mean bigger organisations. With that comes security. When we are looking at interventions, we can't mince words, but we are in a crisis. We have passed that point. Cut is being made to services. I have seen that in the letters that I went through last night, that outpatient departments are being extended. When people work in centralised systems, there is a security there. It is just to make the point that rural practices are very fragile. I would say that most GP practices are very fragile, but rural practices feel very fragile. Behind every good GP is an amazing practice team. For example, in Arran we have between 8 to 10 GP's working different kind of whole-time equivalents. We employ about 32 staff on the island. We have a very fragile model that doesn't take much to sway that. That understanding of that fragility is really important, particularly if we are in this crisis that attracts a top-down approach, crumbs, let's get everything in control. We need to be very careful and realise that a lot of answers are in individual practices. There is a view supported by Wonka, the world organisation of GPs, that once you have seen one rural GP practice, you have seen one rural GP practice. It is not that you have seen one, you have seen them all. It is to reiterate the point that centralisation sometimes brings a feeling of security that those of us out in rural areas are not feeling at all, and we need to be mindful of that. I absolutely agree with Marie there that there is no doubt that there is an impression from the Royal Colleges, if you like. I don't mean to castigate them specifically, but it emanates from the top within the professions that being a rural practitioner, be it in general practice, or in any of the other surgical or medical disciplines and aesthetics that you are a second class citizen. We need to again evangelise about the fact that rural practice is not just about the doctoring, it's a much, much wider thing. It's about community resilience, it's about community support, it's about provision of much more than just the day-to-day prescriptions or surgery that we offer. That's what we need to get over to our young colleagues, and we won't do it if they've already entrenched their career aspirations within the teaching hospital in which they have learned their craft. We need to pick them up earlier and enthuse them about that. Thank you. I'd just like to thank everyone for their input. I think we're learning a lot about the impact of centralisation today, not just of services, but I think that David Hogg's point about what was happening on Arran by looking at the BBC website, so there's clearly a need to improve dialogue markedly. I'd perhaps like to address this question to Stuart Ferguson if I may. You touched on the subject of volume to outcome, and Kate Forbes hosted an event which I was only able to attend at the very end, unfortunately, but I kind of appreciated it. I think there was a bit of myth-busting going on there because I think we are told, yes, if you want to have security and surgery, then you should go somewhere where one person is carrying out that particular procedure time after time after time, so perhaps like a bit more information on that, but also if you could let us know what development opportunities are there for those seeking further specialisation who need to maintain that generalist skillset in a rural area. There is definitely a clear relationship between volume and outcome in very risky cancer surgery, such as cancer surgery in your gullet. It's clear that you want to be somewhere where someone is doing a lot of those procedures, but the majority of general surgery is not really that important of volume outcome relationship. I've personally researched into emergency abdominal surgery and compared rural centres and urban centres, and if anything, the rural hospitals have better performance. I think that's partly because the most risky cases get transferred out, but nonetheless, the evidence is that they actually do a good job, so there's not a big volume outcome concern from my point of view. In terms of how you maintain skills and how you train for this environment, there is a rural surgical fellowship and that is offered to people around the end of their surgical training. That's in fact been advertised less than once a year over the past while, and at points there's been capacity really to be training two surgeons as generalists, and so that rural surgical fellowship perhaps needs to be better utilised. In terms of maintaining skill, one of the models that is developing is that surgeons from rural hospitals might go and do some operating for a week every so often in a bigger centre, and that works mutually very well. It sounds to me as if, with the rural surgical fellowship, we need to be better advocates for what can be achieved in the rural setting. The rural surgical fellowship is definitely important, and I think that we need to finance more posts for early career surgeons in rural hospitals as well. I think that that point you've made on how people are keeping their skills up, and that whole argument about whether you need people doing their repeat operations. For me, you've made a very significant contribution this morning, and we might need to come back to that, because that flies in the face of many of the arguments that have been made for the centralisation of services across Scotland, so I think that we might come back to that. Ron, you've been waiting something. Yes, thank you, and actually I wanted to take us back to Jill's commentary from 10 minutes ago, which I would wholeheartedly endorse, and I think that's really getting to the crux of the issue in terms of recruitment and retention in rural areas. I think that the question then that is raised is, well, what do we do about it, and what are our strategies moving forward? Now, there are a few things that I think that I would want to mention. It's important that we are able to address recruitment and retention if you like, by growing our own. Using the latent workforce within our rural communities, and that can happen in a number of different ways. For example, some of the initiatives that we are moving forward with, we are looking at vocational qualifications for school leavers in respect of a career in social care. I mean, we've talked a lot about medicine today and that's important, but these other professions are hugely important as well, and we have just as a bigger challenge in recruitment and retention in some of these areas as we do in others. But if you look at something like medicine, we've also been working with the universities to change the direction or interpretation of something like the REACH programme. I'm a huge fan of the widening participation agenda and it's work that I've done in a previous life as well, but I've been working along with our medical director with Glasgow University to begin to think about the REACH programme, which, if you like, provides additional opportunities for pupils looking to enter into a career in medicine to go through a programme run by Glasgow University to more readily access medical school. We've focused that now on remote and rural schools and I think more of that would be good and the more that this committee could do to support that, the better. But in addition to growing our own, we also need to think about the labour market within health and social care and how we engage with that. I mentioned earlier on the competitive element and that's something that we just have to connect with. I mean that there is a reality there. I heard, for example, earlier on, the committee talking about Brexit and the international element and I think that that is something that we need to be quite honest about and open about and thinking about how we tackle that. We have 13 consultants working in the Western Isles hospital. Of those, there is one person who is Scottish. The reality is that we have an international workforce and that will continue to be the case and we will continue to need to draw down on that. We are actively recruiting from Spain just now, so there are questions about whether that can continue. Again, the more that the committee can do to raise that in a political sense, the better. There is also the labour market in terms of how economic incentives play out and what we can do around that. There has been an opportunity, for example, to allow health boards to pay an additional amount of money to consultants, up to 20 per cent, I believe. The problem is that no health board wants to do that because as soon as one does it, then everyone will follow and you'll just raise the total cost. However, maybe there's an opportunity to think about this specifically for rural areas and whether we can perhaps connect with that more generally. Finally, and it just goes back to the point that the committee was engaged with earlier on around pathways through graduate training, I think that there is a conversation that could usefully be had about the degree to which we allow a free market versus a planned economy, if you like, and specifically that issue of if we invest in a person's education, does that person then have an obligation to pay back to the society that has funded that education? I think that is a conversation that we have to have. We need to open that up, particularly around about bonding and whether that is a viable opportunity, because I think that that's something that we need to look at. The reality is that for professions like medicine, there is huge demand out there within the schools and huge appetite among school people to become physicians, so let's at least have a debate about whether that would be something that we should take on just now. A list of people still want and we're running short of time. I'm going to bring Richard Dorn, because I know it's in that particular point. Yeah, I've gone to Cullid, said it, and basically it's the higher cost of living. In London they have the London waiting allowance. I noticed that we have the distant island allowance of £947. That's only less than £20 a week. My son stays in a boin and basically the high cost of housing, and the point David Hogg said earlier, should we have policemen, we used to have houses for policemen to put them in. You're bringing your family. Moving is sometimes a horrible experience, trying to get vans and different things, but short on this question, should boards look at getting a package together to bring people into the rural area and should we look at a rural waiting allowance? I would say yes to that question, but my points were really going back to the centralisation, but I would also say it's not only centralisation but super specialism in all careers, the fact that we've moved away to be specialists. I would encourage us to be celebrating the rural generalists as experts, so they are specialists in remote and rural care, whatever the background is. In order to support that, someone talked about rotational and it was stirred. It's important that we encourage people to rotate to the busier areas so that they're feeling better connected. Professional isolation is a huge issue in remote and rural areas. We're also going to have to be offering more and more flexible career choices, portfolio careers and people who have part-time in practice and perhaps in education and research. We've got to be open to that. We've recently appointed people almost on an oil rig model, whose family don't want to move but they want to be in remote and rural practice, so we are facilitating that. They're coming in, working for two out of four weeks. We just have to be as open to these kinds of opportunities as we possibly can. The other thing that I wanted to come back to is David's point around people wanting to come and train. Perhaps one of the challenges around those 82, David, is the capacity to train. The fact that we can't just put them into a practice, they need to be trained and that takes a significant amount of time. Sometimes in these practices and indeed for wider professional groups, that can be a bit of a challenge and we've got to recognise that as well. That might be one of the reasons that we're not able to find 82 placements. About 15 minutes left. Maybe when people are contributing there's a couple of things that we'd wanted to cover and some bits of that have been mentioned. So, if people couldn't have a wee think about the financial incentives that might be put in packages, as Richard was saying, do we need to package that up? Also about examples of good practice that are on going at the moment as well. If you've got the opportunity to just throw them in just very briefly as we can because we've got a short period of time left. Could I ask Colin? One of the issues that I think Jill touched on briefly is a massive issue in the south of Scotland. I'm just interested to know how widespread it is. It doesn't matter how many packages you put in place for the individual that you're trying to target for the consultant vacancy or whatever that vacancy is, but if there are no opportunities for their family in that area, their partners, then there's no way they're going to move to that particular area. The wide issue of job opportunities around whether it's a public sector or the private sector for partners is one of the biggest barriers that I find in the south of Scotland to people actually moving to the area. I just wonder how widespread that is in other rural areas and if that's an experience that the professionals have. William, do you want to come in? Yes, sir. Just to respond to that point, this is one of the things that we've been talking about. Jill, who's a fantastic advocate for new things, has been pivotal in the idea that we should have a relocation officer that looks after that sort of finding employment and employment opportunities for others who are maybe considering moving to a rural area. I just wanted to pick up Stuart's point about the rural surgical fellowships and the fact that we have tried this on a number of times, but we've only succeeded in training one individual who's ended up working in a rural general hospital, and that's in Fort William. We've trained others who've then elected to go to bigger hospitals, Ray Moore, Elgin, and so it is an initiative that we've had, we've tried but has been difficult. I'm not saying it shouldn't be part of the blend, but it's been an issue. The people who've tended to apply for these posts have sometimes been overseas doctors who have been highly specialised in their field overseas, vascular surgery, cardio, thoracic surgery, so they're not really fitted for training, for working in a rural area where they have to do orthopedics, they have to manage sick children, they have to do a bit of ENT, a bit of ophthalmology, and a bit of gynaecology as well, perhaps in the emergency situation. So there are real challenges in using that model and I would just like to float for the sake of having it on the table, is that perhaps we do need to look at a different model of staffing these smaller hospitals, such as the one that's been implemented by NHS Highland for Caithness, where now it's largely the elective surgical service is provided by specialists from Ray Moore, and the elective medical services for that matter, and the emergency services are provided by well-trained rural practitioners who've got the basic skills to resuscitate and manage acute situations, anything from a road traffic accident to a mental health emergency, anything from gynaecology to an abdominal surgical catastrophe, they can stabilise that individual and arrange for them to be transferred. That model works well in Broadford hospital as well, small population, it's an expensive model, but recruitment retention to that area has not been a problem because people get good training, they get an interesting and varied job, and they get plenty of time off to enjoy the pleasures of being in the sky. So just something to have on the table. Claire. I just want to pick up on an issue, I'd ask the other panel about, and I guess we have touched on it a little bit here, and that's about the recruitment overseas staff, and you've alluded to that in terms of the consultants that you have in the Western Isles Run. Have you seen an impact of the changes in work visas? I'm thinking particularly for health and social care staff coming from India, Pakistan, because it's been an issue raised with me by constituents, or an impact from the post study work visa in terms of you being able to recruit staff. I mean, my view on that is not yet, but it doesn't mean it won't happen, and that's why I think we need to be particularly vigilant as we move into political discussions over the next few years, and that we are mindful of the fact that there are communities in Scotland that rely very heavily on professionals from across Europe and indeed across the world. So it's important that we're alive to that and we're making decisions based on the needs of the whole population of Scotland and not just the central belt. I also wanted to pick up briefly on the issue of partners and spouses, because I think that's very important. Now, I was fortunate enough to be able to move up to the Western Isles into a relatively well-paid position. Not everybody has that opportunity. Nonetheless, my wife works as a clinical psychologist, and it was important for us that she have an opportunity to continue to work within her profession. Now, we've managed to do that, but again, I think that we are one of the fortunate couples, both in terms of remuneration and in terms of the opportunity that was available. I think that if we can become more structured in supporting and facilitating this type of issue, the better. Particularly for those professions that can't rely on that level of salary. I mean, if you look at the home care workforce or wherever, we have to be much more strategic and collaborative about how we bring people in, including looking at supporting partners and spouses into employment. It's a very opportune moment to bring yourself in. To reiterate what Ron has just said there, it strikes me that as we're talking about health and social care integration, we have focused quite a lot today on the health workforce, but there's a real potential for us to try to break down our siloed ways of thinking, and at times our siloed ways of working. That gets to the heart of the myths around rurality, the myths around professional status and value, not least the distinction between nursing in the NHS and nursing in a care home environment. I think that when we're talking about workforce planning, we have got to recognise the fiscal realities, the resource realities. Attracting an individual to work as a social carer in rural Scotland is increasingly challenging, especially if they have a spouse who is going to have difficulty getting a job. In terms of Brexit, I've already said before to the committee, we have profound concerns, particularly in rural parts of Scotland, where a significant number of staff come from outwith Scotland that Brexit in the medium to long term, I think to answer Claire's question it's too early to say, but in the medium to long term we will have profound difficulties. I spoke to a major national organisation last week and they said that they were having to close their recruiting office in uncontinental Europe because people were stopping to come. That's the beginning of a sign that we are having difficulty and we'll have difficulty to attract people, particularly to lower paid roles. A few people to bring in in the past five minutes so we really need to be brief on this. Sure. Just to respond to a few things, one thing I should have said earlier in response to the feeling that sometimes it's the profession itself that can make it difficult for rural practitioners. I think that I should highlight that the Edinburgh College of Surgeons produced this year a document that endorses the value of rural surgery and that was circulated to the group. I think that Bill made a very fair critique of the rural surgical fellowship and I do agree that we should be training our own surgeons and that absolutely is the best model and we need to make that attractive. I would say that different service models are going to be appropriate for different rural hospitals and certainly the model that we see in WIC in my view will not work in an island in the long term. Those are the additional points that I wanted to make. In response to your question about financial incentives, if we are going to make those early-stage trainees attracted to come, we need to give them a supplement. They may well be maintaining mortgages in the central belt. They certainly have significantly increased travel costs. They may be needing to meet accommodation costs where they are working, so that has got to be part of the response. David, just before I bring you in, last week we spoke to senior service servants and the cabinet secretary about NHS. The chief finance officer would not be drawn on the issue of there being cuts in the NHS and said that there were only efficiencies. Earlier, you said that there were—is that an example of the disparity between strategy and rhetoric and reality on the ground? Or what I am actually asking you to do is justify your statement? Yes, absolutely. I have some figures here and I realise times of the essence. I have two very quick points to make afterwards. As an example, we know that in terms of the waiting list, six of my letters last night that I looked at were advising patients that they would have to wait another six months for a routine cardiology review in Ayrshire, and that is affecting, apparently, 320 patients in Ayrshire now and that, that their appointment times have been extended. It varies depending on the actual review period set, so I would not be able to go into that much detail. However, we are seeing this. We know that urgent gynaecology referrals in Ayrshire up to six weeks. In Greater Glasgow and Clyde gastroenterology referrals 40 weeks. The one that really stands out for me is NHS Highland and Neurology referrals. I have unreliable information that the waiting time for a routine neurological appointment is 72 weeks in Highland. Those are not individual things going on. We used to see this in pain clinics, CBT, and they had extended waiting times. We are feeling this. Something else that you said made me think of something that if I am in the co-op and the patient has a cardiac arrest or there is a road accident outside, I want to be there. I am part of that community. However, increasingly, as a face of the NHS, we are having to answer for these cuts. My experience in the co-op is sometimes more, oh, I have not had my referral through yet. Can you see what is happening? It is that kind of thing that gives you the Goldfish bowl effect. If I was a six-year-old having a seizure down the road, I want to be there. I wanted to make two very quick points. Originally, just to highlight that, I have confrears who have trained overseas and contributed a lot to the NHS. They are feeling very vulnerable just now as a result of post-Brexit. They are feeling very vulnerable and some are choosing to leave already. That is going to compound the problem. Just to finish off, I want to highlight the need for rural proofing. This is not all about money. If we rural-proofed our policies, rural-proofed our management, saw things like the stack agreement, which can have the effect of a 75 per cent pay cut on on-call staff, non-medical on-call staff in rural areas, those things are not being rural-proofed. We need to value people on the ground, particularly for our care workers who we see as patients. We need to see them valued, and that does not cost that much money. We just need to have people who are more sensible and holistic and valuing it in that approach. William, then Gillian and then we will have to call it a day. I think that David has made most of my points, but just to respond to Claire, that we do see people from the Indian subcontinent coming in to largely locum posts on a tier 2 visa, so that system still is extant and seems to work okay for that. There are quite a lot of them because there are quite a lot of vacancies. I was just going to say around the whole Brexit issue that we have done some work on that, and it is done for across the UK, so you will excuse me if I cannot tell you the exact figures for Scotland, although it would be much less, but we reckon that when this goes ahead, if there is not any commitment to the workforce, we will lose something like 1,500 midwives, and if some of you know that England is three and a half thousand short at the present moment. Now we are in the next month, assuming next month to six weeks, going to have the maternity and neonatal review come out in Scotland, and I cannot pre-empt that, but one of the drivers down south in their maternity review was around continuity of carer, and there is no way that we can say that continuity of carer does not give better outcomes, but if we don't have the people on the ground to be able to deliver on that, it ain't going to happen. Okay, thanks very much. It's a big meeting today, it's a big panel. It's not the easiest to manage, but I think that everybody's hopefully had a fair kick at it, and if there is further information that anyone wants to provide, then please provide that to the committee clerks in writing. Okay, thank you very much, and as agreed earlier, we'll move into private session.