 Gyda'r wych yn fawr i gwellio a gweldio i'r 15th ymwneud o ffath, ffasgfaith a chesaf ac ymgyrchol. Fy enw i'md David Torrance MSP ac yn y bryd y bydd y cwrthogau, mae'r cyfnod o gweithio cyfnodd o'r ffasgfaith a'r cyfnodd i'r 1st ymgyrchol. Mae'r bêl iawn i, fel Clare Hockey a'r Tess White yn llwyddiol ar y dyfodig. Paul O'Kane MSP has now left the committee and has been replaced by Kara Mawhong MSP and I would like to welcome Carol to the committee. The first item on our agenda is to choose a new deputy convener. The Parliament has agreed that only members of the Scottish Labour Party are eligible for nomination as deputy convener of the committee. I invite members of the party to nominate one of their number for this post. Can we suspend the meeting while we change places, please? Unfortunately, the convener, Ms Hawke, is not available this morning. She sends her apologies due to illness. I will be chairing today's meeting. Our next item is a decision on taking business in private. The committee is proposed to decide whether to take items 5 and 6 in private. Are we agreed? We now move to the next item, which is engagement with NHS boards. The committee will take evidence from Geoff Ace, chief executive of NHS Dumfries and Galloway. We will take evidence from Professor Grant Archibald, chief executive of NHS Tayside and from Professor Jan Gardner, chief executive of NHS Lanarkshire. I welcome you all and thank you for joining us today. The first area that we want to look at is financial sustainability. Clearly, there are significant budgetary pressures across the public sector. We want to establish some key aspects of that. Audit Scotland's NHS in Scotland 2022 report noted that only three of 14 health boards are predicting to break even this financial year, with extensive waiting lists and increases in emergency care among some of the pressures. Could the panel provide detail on efforts being made by their boards in relation to early intervention to try and prevent the need for emergency care or acute care further down the line, if possible? Perhaps I could start with NHS Lanarkshire, Professor Gardner. At the end of the financial year 2022-23, Lanarkshire is now forecasting to break even, but that has been with significant efforts across the patch. As we go into 2023-24, however, we are in a much more challenging position. Our approach to that is fourfold. We are looking to minimise any waste or non-value added areas within the organisation. We are also looking to optimise performance, looking at upper quartile in other areas, benchmarking to make sure that we are optimising productivity wherever possible. Just those two elements alone, unfortunately, will not bring us to a better sustainable financial position. In addition to that, we are looking at both service change and radical redesign and reform of our service. In that regard, one of the specific areas that we have been focusing in on because of the challenges that NHS Lanarkshire has been facing is in and around our unscheduled care performance. As colleagues will note, it has been a very, very difficult winter. NHS Lanarkshire and Lanarkshire, the people of Lanarkshire were hit most significantly by the direct and indirect impact of Covid. Of course, we have seen, unfortunately, the gap in inequalities for health inequalities widen. We are feeling that very acutely at our front doors. We had a system that was absolutely designed effectively for the healthcare needs in 2019, but we need to acknowledge that those have changed. The healthcare needs in 2020 are quite significantly different in terms of complex care needs. Our population is coming forward with frailty issues and broader chronic condition type issues. We have been doing a piece of work that we term operation flow. It began at the end of January because of the winter. The challenges are for our patients but also for our staff. It was a really, really difficult winter. We are very thoughtful as we have gone into this redesign phase that we do not wish to repeat the winter that has been, and we want to take all of the clear learning from that. The redesign programme of operation flow looked at the different elements, how to keep people well at home, the front door appropriately, how to restructure our front door, et cetera, into our wards optimising how we flow through. We undertook a firebreak of nine days just at the beginning of March, and we saw significant change in our occupancy levels and improvement in our four-hour access. We did that for two reasons, to first of all be comfortable that we were doing the right actions to make that change, and to lift the spirits of staff who have gone through such a challenging period in time that people need confidence and hope that it can look different. We had fantastic impact. Some of our sites dropped from 107 per cent occupancy right down into the 90s, and our four-hour access performance improved under weeks at eight hours and 12 hours reduced significantly. However, the challenge is that that redesign requires resource and further change. As we came out of the firebreak, we moved back into challenging performance, but operation flow has now kicked off, which is looking at this new phase, taking all the learning from that trial period and planning a robust plan for winter 2023-24, and that is where we are at at the moment. However, it is a whole-system effort, and I have to say that launcher works very much as a whole-system across health and social care, and indeed with other partners. Indeed, the work that we did during firebreak and operation flow 2 is working closely with Scottish Ambulance Service as well. That is really encouraging. If there has been a difference in the ability to do three-year financial planning, has that made an impact on your ability to be more sustained in your approach? It certainly will allow us, because we will need to shape change. There is some reform, and it means that we will need to change where we have some of our investment to bolster that front end of the hospital and to get people back in their own homes as quickly and effectively as we possibly can. To do that across one year is incredibly challenging, but across three does give us further flexibility. However, the challenge, and we are working with Scottish Government colleagues in and around our plan at the moment, is whether we will be able to undertake that full redesign and indeed reform and look at how we have sustainable services across our three acute sites within that three-year period. The aspiration that we work towards is to use the flexibility most effectively. What impact has the recent inflationary pressure had on your cost base and, perhaps, on capital investments? We know that there have been particular issues around repair backlogs across several evidence sessions that have had with NHS boards so far. Whilst there is an issue of operational flow, maintaining efficiencies and the three-year financial envelope, what impact does this increase in inflation have on your ability to plan for a break-even point? The impact in 2022-23 was significant around our energy costs. We estimated, based up to the end of the calendar year, that that was up to as much as 59 per cent in terms of some of our additional energy costs, which were very challenging this year. Although we are hoping that that will be significantly lower at the moment, estimating 14.5 per cent for this financial year coming, we still are concerned, obviously, about the impact. We have done a huge amount of work to make our buildings more sustainable. In Lanarkshire, we have three PFI buildings. However, as colleagues may also be aware, the University Hospital of Monkland site has significant repair issues that have also been in media recently. We are continuing to work through those. Those are our most significant pressure areas in terms of our maintenance, because PFI contracts make it a slightly different way of managing some of our capital in terms of maintenance. We still have on-going challenges in the Monkland site apologies. That is an on-going issue that we are also looking at a potential Monkland replacement project at the same time. Is that Monkland replacement project still on track, or are there any challenges around procuring that because of the increase in construction inflation? There have been some increases, as you would expect, but in terms of our case that has gone forward, it also includes all those costs. That decision has gone forward into the executive with the Scottish Government, and we are awaiting a decision on that at the moment. Professor Archibald, I would like to invite you to address us on the points that were made by your colleague from NHS Lanarkshire about the need for flow, financial sustainability and the idea that you have been able to introduce measures to prevent people presenting to acute services where you can address issues further down the chain of the patient journey to avoid costs later on. Thank you very much, chair, and good morning, colleagues. Reflecting on what John said, I think that you referenced the Audit Scotland report, chair. That identifies that this is not an NHS issue, it is not a Scotland issue. There are global challenges emerging from the post-Covid environment, and a lot of those are related to very high inflation rates, ones that we haven't seen in the 70s. Also, increasing energy costs and anyone who has been in any hospital facility will know the high demand on energy that we place. Your reference performance, chair, if I might, our uncheduled care performance in the data that is going to be reported today in Tayside is going to be 94.9%. We have no 12-hour breaches, we have no eight-hour breaches in the last week. Our uncheduled care system is recognised as the best performing in mainland UK, and we are regularly in the high eight-taste and low nine-taste. As John reflected, that is a whole-system approach. You talked about the management of demand and the management of the presentations, and I think that that is a key element. We should reflect that that is a product of GPs, a product of good primary care services, a product of good relationships and a product of good working inside hospitals. We have invested considerably in that over the last decade, and it continues to pay results. In terms of the diversion of activity or managing it in the best place, we would probably be better to reference. We established a flow navigation centre, as was required by government, but we put senior clinicians in the front line in that service, so we put consultants in it. If I might give you just some figures, we routinely see 1,600 ED attenders across NHS Tayside in a week. Our flow navigation centre is now dealing with 700 contacts in a week. A third of those come to hospital immediately. A third of those are identified to come at a convenient time for both the patient and ourselves, so out with a busy time. A third are diverted to other services. That also includes direct contact between our consultants and ambulances on the road to make sure that patients are taken to the right place. That is what we need to remember in all this, I would suggest. This is about people and how they work together. It is about relationships and understanding. I think that that has been key to all of our designs. I am hugely impressed by my clinical team in that they come up with ideas for driving services forward. Not only in unschedule care, but we have continued to outperform the Scottish metrics since the former Cabinet Secretary's announcement last July in terms of our improvement in long waiters on our waiting lists, both for outpatients and inpatients in day cases. We outperform the Scottish average on our cancer services as well. The whole point of that is seeing it as a whole system. That has involved redesign already. We have gone from cataracts doing about 12 to 14 in a day session to our consultants coming forward with ideas about how that might be improved. We now do 50 in a day. That has led to a great improvement in our ophthalmology waiting times, but it also makes us the third most productive unit in the UK. There are examples where clear actions are taken that benefit results straight away for patients but also identify productivity. Given the financial challenges that we face, the least that we should be aiming for is upper quartile, upper quintile performance to be efficient as we can be. However, my final comment would be that I am interested in population health and prevention. I have worked in the NHS in Scotland for 40 years and we are still seeing a 10-year gap between life expectancy amongst those most in need in terms of financial services and those that are most wealthy. Indeed, there are parts of a recent report that say that the healthy life years between those in the lowest economic group in the highest can be 26 healthy years. The challenge for ourselves, and I am doing it with my colleagues in Tayside who are fantastically supportive, in Dundee, in Angus and Perth councils, we are all working together to try to find out ways as the key stakeholders in our Tayside, as the biggest employers in Tayside. What can we be doing to ensure that people don't fall into ill health but we prevent ill health and we promote a health service and not an ill health service? Perhaps through the day we will pick up different examples of that. Before I ask my question, I would like to draw people to my register of interests as an NHS GP who has worked recently within the NHS Dumfries and Gallow in NHS Lanetshire board areas. Professor Archibald, you talked about your figures but you implement a continuous flow model. That means patients moving out of A&E whether a bed is available for them or not. Potentially they would sit in a corridor, sit in a side room or a waiting room or they might sit in a ward environment as an extra. Where would those patients be captured in the data? Patients are captured in the data. If there is anyone who is required to be moved out of A&E, they are still on the clock. We have heard our services audited and we have also had visits from Government to see the systems that we are working. We are very pleased to invite you to come and attend and say that as well because that is a commentary that is often offered about ourselves. My office looks out over A&E and I do not see queues of ambulances and that is a first indicator that a system is under pressure and we do not have that. Perhaps it would be useful for us to share more detail with you but I can assure you that the processes that are reflected in Tayside are a process in working order and I am happy and content to be able to come and see it. I want to turn to Mr Ace, NHS Dumfries and Galloway. Obviously we have mentioned about patient flow and the need for cost avoidance where possible to try to address the financial sustainability of health boards. Can you perhaps introduce some of the things that you are doing in NHS Dumfries and Galloway, mindful of what colleagues have already said? Yes, and I will avoid repetition and share where we are all engaged in the sorts of redesigns that you would expect us to be and we are all engaged in the sort of best value work that you would expect us to be to reduce waste to try and improve efficiency and performance. I think that it is important to note that this is not a usual financial position for the NHS in Scotland. This is not part of our usual times of difficult financial pressures. We will run a deficit for 22, 23 and Dumfries and Galloway for the first time this century, looking ahead at the scale of the gap that you can project using the inflationary pressure. We will use our requirements to achieve activity goals. It is probably beyond our usual levels of efficiency savings. We have set ourselves a target of achieving 3 per cent per year, which is right up there at the historic high levels that the system has ever achieved. That is not enough. It does not bridge the gap. Indeed, the gap continues to grow. While we are probably at the top end of Scotland's financial problems proportionately, I think that all boards are reporting real difficulties with achieving that break-even as you project through that two-three-year forecast. That is not how Scotland has been over the past decade. It has been difficult, but it has not been as it is now. It appears that it is going to be. This is going to require a level of service redesign and real difficult decisions that we have not seen in the period preceding this. For individual boards, particularly relatively small boards like myself, we are going to have to collaborate regionally to a level of engagement that we have not managed before. We are going to have to collaborate nationally so that we have a once-for-scotland programme that brings those plans together. I think that the scale of the gap now, if I was to turn it into workforce, I technically cannot afford one in ten of my workforce. Clearly, I need all of those people and more to deliver the service demands that we are facing. The financial challenge that I would want committee members to be aware of is quite extraordinary at the moment, like Grant. I have worked in the NHS since the 1980s. I am a finance director by background. I have never seen a position as challenging as this. It will require all of us from a national perspective, a regional perspective and local boards to be focused on that redesign to give us a chance of getting through this. Good morning, everybody. I am going to ask Jeff Asa a particular question, but before I ask my question, I need to remind everybody that I am a former NHS and Freeson Galloway employee. I was part of the Covid vaccine team as a nurse during the pandemic, so I just wanted to make sure that I am clear about that. I wanted to ask you, Mr Ace, what particular changes have been made for service delivery? I know that we met last Friday as part of our normal updates. Parts of Dumfries and Galloway are really remote and rural. One of the things that you talked about was the development of home teams. Is that something that will help, I suppose, to manage the service in a better way in order to help look at the services, not necessarily savings, but just efficiency? Yes, I hope for both. I mean hopefully a much better service for the local population and a more efficient one in terms of use of resources as well. I think a number of boards will be able to talk to you about hospital at home type of models. As you said, with our very dispersed population, our rural population, we actually looked at eight local teams across the Dumfries and Galloway. We were trying to base those around GP clusters so that we get our primary care teams right at the core of this, linking them with community nursing, district nursing, trying to avoid hospital admissions and working closely with local care homes in that to allow flexibility in our bed base use. Trying to avoid hospital admissions wherever appropriate, when an individual is admitted to the Galloway community hospital or to DGRI or to Mid Park, we allow as fast as possible repatriation of that individual to a facility close to their home, or indeed we support them back to their home. It's really early days, as you're aware in this project, but initially it seems both popular with patients, it seems to be a good environment for our staff to work in, we're getting very positive reports back, good engagement from primary care and it is delivering that efficiency of model that we need to see. Again, I don't wish to be gloomy in front of the committee, but I would like to say that the efficiencies that we can talk about here are absolutely what the systems constantly need to be aiming at, but they're not of the scale at the moment to address the financial deficit, and that's the one that's probably causing the sleepless nights at the moment, is just that scale of cost reduction that we're faced with. So yes, home teams trust is something that we're throwing an awful lot of management resource and time around to get right, because we think it's the right thing to do and it's the right model for our dispersed community. It will improve efficiency, it will save a little bit of money, but it's not of the scale to address the problem that we see financially. You raised a major point there about one in ten of your payroll, not being affordable, and you mentioned also that the financial efficiencies that you're hoping to achieve will come nowhere near to addressing, even under a three-year planning window, the backlog, so what is it that is needed to make you not have sleepless nights? I think, as I've said, what we need to see is a coordination across Scotland of service plans, workforce plans and financial plans that work at a national and a regional and a local level that deliver that service that's fit for the future. We've all got good examples locally of change that can be made, that can improve service and can reduce cost. We've now got to implement those sort of changes at real scale. I think we've been, during the pandemic years, we've really not had that capacity to look at our models and to say what's going to work for our demographic challenges of the next 20 years. There was a fantastic piece of work that came out a week or so ago by Professor Roy looking at Scotland's demographics over the next generation and beyond, right up into the 2070s, showing that significant increase in the number of older adults in Scotland and a significant reduction in the working age of a population of Scotland. That creates a sort of existential challenge to our current service models and we've got to be similarly radical in our reshaping of those models locally, regionally and nationally to meet those challenges. Otherwise, I fear that the scale of the gap, the financial challenge, will force us into the sort of service cuts and reductions that none of us want to see. It's up to us at this moment to be very bold, I think, in our models for what we see as being the right health and care service for Scotland at that regional, national and local level and to start engaging with our population about those big changes that are needed. Ms Harper, you want to come back in? Thank you, thanks again. Just to come back, Jeff, on what you said about Scotland-wide approach for combined or joined services, do you mean combining human resources as part of joint work and integration or combined financial services? If NHS and Friesen Galloway is a small board, is that something that could work in looking at that or does that need to be a more wider Scotland approach as well? I think both consideration of joint services and that can be clinical and non-clinical and also looking at integrated patient pathways. We've also got huge opportunities with the changes of technology now. As you know, for example, if I look at imaging and I chair the National Diagnostic Board, we can now set up systems where radiologists in one board can report on the scans from another board. We can save huge amounts of resources by pooling demand and addressing that to the right capacity rather than individual boards not being able to report scans and having to go, for example, to private sector to report that overload. There are things that are moving technologically that allow us to work together to collaborate much more effectively than we have in the past. Imaging is a very obvious one. I think laboratory services is another where in Scotland we can be quite bold and look at what is required over the next generation for a population of 5.2 million, 5.3 million. What is the best possible laboratory service that we can provide for that population and how can we configure that in the most effective way? Those are the big questions that we now have to ask and answer in the context of this financial problem. None of that is saying that this will be a worse service at the end of that. I think that we've got huge opportunities to catch up on the change that perhaps we haven't made during the pandemic years and to create a much more modern fit for future service, but it does require us to think on that national and regional scale. Evelyn Tweed, do you want to come in on some areas of performance that leads us neatly into this issue? Thanks, convener. Good morning, panel. My first question is to Professor Archibald. I'm really interested in your A&E figures, 91 per cent, which is fantastic. Can you share with us how that works and whether Sandesh should ask a question earlier? Are you shading your learning with other boards? Thank you very much indeed. This is a product of keeping a system in harmony and being able to ensure that the flows continue to work. Part of the question about flows is about delayed discharges. We've achieved significant improvements in those recently, but having worked on other boards in Scotland, the level of delayed discharges in Tayside is significantly lower. Again, that's good co-operation between ourselves and our IJB colleagues. I believe that the Angus IJB is probably the best-performing one in the whole of Scotland last week. The whole design of that has been formulated by the clinicians themselves. I've run ED departments in Glasgow, Edinburgh, Lanarkshire and Fife, so I have seen other parts of the system. The thing that impresses me most about Tayside is that the clinicians have engaged in a long time with a very clear view about what they're trying to do. We, myself, but indeed previous people have tried to make sure that we support them in their endeavours. The flow navigation centre is a great example of that, because that's creative thinking. If all 700 of those patients were to turn up at the door of my hospitals this week, that would mean that my attendance went from 1,600 to 2,300, and that would be unsustainable in hospital terms. It is about thinking clearly about that. We have an expert frailty model that tries to deal with frail elderly patients that are coming in, so there are all several examples. We have a command centre, Jan, and our colleagues have been to see it from Lanarkshire, with Vadir Sharnaran with us, Grampian have been in contact with us. Two of our colleagues went through to work with colleagues in Glasgow. We're not saying that everything we do is an immediate fit for elsewhere, but, as I said to your colleague, I'm more than happy that people come and see what we're doing, because I'm immensely proud of the efforts that are put in. Given the challenges that have been seen across not only Scotland but England, Northern Ireland and Wales, to be regularly achieving the performance level we have are quite remarkable. In one of the periods, I think that we saw 12-12-hour-reachers in a period from January to April this year, Scotland had 19,000, so we are different, and we are working to continue that. As I say, it's a product of collaborative working, but there are systems as well that colleagues have come to see, and we're very pleased to try and share that learning. I've said in Tayside that we don't need to be the first to do things, but we need to try to be the best, and if that means learning from others, I've reached out to other boards where they are good at things to be supported by them. I think that that's a great offer. It's certainly the one that I would like to take up, and I think that the committee will chat about that after the session. My second question is to Professor Gardner. Can you tell us more about the firebreak? How did that work, and were there any negative impacts from the firebreak? It leads on very nicely from Grant's comment. In terms of the run-up to the firebreak, we took time to design what we were going to do and bring our staff with us on board. Similarly, it's our clinicians who have done the fantastic work. They are the people who drive the service and who have the ideas. However, we wanted to help them to look at the future in terms of how we could do things differently. We did different site visits because we were all very open to learning and Grant and his team were fantastic and supportive at helping us evolve our plans. The first part, prior to firebreak, was designing what we were going to do. The second part then was in the firebreak. We noted a period when we took resource from different parts of our system to effectively create the model of care that we wanted to create and we would like to create going forward. As we enter into yesterday's launched operation flow 2, we will now embed some of that change. It is full system, it is taking all the different learning, and the elements that have been talked about are a decade in the laying down of a structure. The resource piece is really important for us and we recognise that we need to resource it in a different way. We need to redesign some of the distribution of our resources to be able to effectively run a service in the way that Tayside and others have done. We have been to Glasgow and seen some of the flow model that your colleague spoke about in Tayside. However, it is that whole flow. It has to be at the back end of the hospital, so we have to make sure that we are delayed discharges. In partnership working, we work really cohesively with our health and social care partnerships to do a really active view. It starts at the beginning, so it is each different part of the pathway. It starts before somebody comes into hospital. We looked at different ways of supporting. If I give a few examples in care homes where perhaps patients might have been brought to hospital, we similarly augmented our flow navigation to be able to give advice to people who had elderly patients in care homes rather than bringing the patients into the hospital. Through the firebreak, we doubled the number of hospital at home beds, virtual beds that we had and augmented some of the care of the elderly and the advanced nurse practitioner roles in that space. We were looking first of all for opportunities to keep people well. In our flow navigation and taking some of the learning from Tayside in other areas, we then worked with our Scottish Ambulance colleagues to do professional to professional calls. We tried to give advice to a range of professionals in our community and in the ambulance service to give advice at the right place at the right time to avoid again the conveyance of an ambulance. Then, coming into the A&E, for those patients who arrived in the A&E, what we were trying to achieve was a flow in that department. We know, unfortunately, as bedweights become a problem, then the departments become clogged in. The worst challenge that we see and that has a terrible impact on staff morale and patient experience is when, effectively, you have a full A&E and then our staff are trying to manage effectively that flow almost at the same time in parallel. We were working hard in our ward area to make sure that every day, every single person understood their role. That is the big communication piece that we were doing in the run-up to the fabric. That is where people are really keen to get back to. Every single ward had a ward beat, a discharge rate that they were trying to work to. They did board rounds to constantly be focusing on what every patient needed and what was the most efficient pathway for them. Working in partnership, I cannot overstress the fact that this has to be everyone with skin in the game in terms of every part of the system working cohesively. We saw that because everybody was able to free up enough resource. It is not enormous changes, but we look at it like a jigsaw puzzle. We have a lot of the fantastic pieces. We have brilliant people, great clinicians working really, really hard, but we have some of our jigsaw pieces missing. During vibrate, we tried to put those right pieces in place to augment and give a more cohesive picture. It made our ward work more effectively, so we had better flow, reduced length of stay. We started, although not statistically significant because the period was not long enough, we started to see a reduction in length of stay. We started to see a reduction in on-word care needs. Therefore, again, less of an impact on discharge care needs, etc. We started to see a difference in experience for our patients and, indeed, for our clinicians, able to deal with patients. I asked about the adverse impact. I would have to say that the hardest part of it was that we knew that we could not sustain and that people went into knowing that it was to test a new model for us and then to confidently build because it is a significant resource shift that we will need to make. To make sure that we were clear on the returning investment of every single piece of those jigsaw pieces, that is the piece that has come out. It has been hard for staff because their heads were lifted. People started to work in the way that they want to work. Our clinicians felt assured. In terms of all the work that we have all been doing in health and wellbeing for our staff, the best thing that you can do for somebody is to be able to come to work in the right environment in the right way and to provide the care. The distress for everybody of working in the wrong way has been very significant. The hard part is that we have dipped, but the spirits are high and people have the ambition to get back there right now. The commitment has to be that we do that now and we build in time for winter. My last question is to Geoff Aes. I am a former resident of Dumfries and Galloway. I stayed down there for 16 years and one statistic jumped out of your submission that senior managers turnover is 33.3 per cent in 2022-23. Can you talk us through that? We have such a tiny cohort of senior managers that a few retirements really generated that figure. That figure could be nought in some years, but it is purely driven by a small number of retyrals. There are no issues with culture or leadership or any issues of that nature? I would hesitate to say that there are no issues with culture in any organisation, and we should always be looking to challenge ourselves. In these particular cases, I know the reasons for the retyrals of these individuals. That was not a driver. All organisations, particularly coming out of the past three years, need to be very aware of pressure on staff, including managerial staff, and how we regenerate the optimism that Jan was talking about a minute ago. I am trying to get that belief that teams can make things better. That is a challenge for all of us at the moment. You have heard before this sense that staff are tired after the pandemic, that this has felt like a long slog without much light at the end of the tunnel. It is our job as leaders to try and re-inject that optimism and give staff the sort of plan that Jan was talking about. This is how we can make things better, this is how we can make it feel better to work in this environment. This is how we can improve patient outcomes and patient experience. That return of optimism after the past three years is a critical thing that we as leaders need to be focused on. Before we move on, I want to ask a quick question to Professor Nagarn about particular E&E performance in Lanarkshire. It was 60 per cent from the chart that I saw. Can you account for that particularly low-level relative to other areas of Scotland? As colleagues will be aware, in NHS Lanarkshire we have three acute hospitals. That in itself is both an opportunity and a challenge in terms of workforce sustainability and providing those three services. Across our three hospitals we have very different challenges and indeed opportunities and we have seen quite a variation in the performance across three different hospitals. The work that I have been speaking about without going back into all the detail of that is quite targeted on what each of those three sites needs. If I raise particularly the point around, for example, University Hospital Wishaw, which has had particular challenges through the winter, the configuration on that site is slightly different. It also deals as a Lanarkshire trauma centre. It also has our pediatric neonates and obstetrics area coming in through that door. The flow from the population that is served and its location by close to the very centre of Wishaw also means that you have a different flow in. We are looking through the work that we are doing to understand again how we rebalance across our three hospitals and how we raise the challenge. Right now our issues are back to that whole system. I am sorry for coming back to the same point. It is not about our A&E as a challenge. It is about that full system. Our awards, our length of stay has drifted back up. Our delayed discharges were working very well and they are in a positive place although we are working to reduce them further. It is every single part of the system and it is finding that jigsaw puzzle and getting that perfect picture. Why are we in a more challenging position than Scotland? I think that a lot of that is linked to our demographics and the system that we have at the moment, which is not effectively designed to deliver against that demographic. The direct and indirect issues post-pandemic are having a significant issue with frailty, chronic conditions and the throughput of patients with the most complex conditions is a significant issue for us. I am interested in the Covid recovery. The Scottish Government published a Covid recovery document, August 21. I am interested in how that is working out for the different boards. If there is anything in it that you would change after the Covid recovery document, I am interested in how that is working out for the different boards. If there is anything in it that you would change after implementing some of the recommendations as part of Covid recovery, I do not know who wants to go first. I will take that if you do not mind. The video will set your microphones. I do not need to press the button. Do not worry. Thank you very much for the question. Some reflections then from Tayside and then a broader comment. In terms of Tayside ourselves, we have Strachathrow hospital, we have Perth Oil and Firmary and we have Nine Whales, which is our major hospital. Throughout the pandemic period, as compared to other places, we did not ever suspend all elective surgery. We tried to keep some sites running and continue to deliver services. That is evidenced by the Scottish data about the management of waiting lists and the relative growth of our waiting lists compared to the old Scotland position. In terms of the recovery plan, which has been key for us all, we are looking to recover not to 2019 but to what is required in 2023 and beyond. We have targets. I advise that, in the recent Scottish data, Tayside is at 99 per cent of its pre-Covid position in terms of inpatients and day cases, and it is at 96 per cent in terms of its outpatients. At each stage in the recovery plan, we have overperformed against the trajectory that we had agreed with Government. The key challenge is that that is the now, but, as Geoff and others have reflected, the next looks quite different from the pre-Covid period. It is important that we remain versatile and adaptive and understand where our pressures are. I should, as I say, much prefer that we could put more time into prevention rather than ill health services, but there is already a backlog of people who need care, so that is going to be something that Scotland will have to manage over the next few years. In terms of the recovery plan itself, it is very important for us all to give hope not only to the patients who may be waiting for services such as elective surgery, but also to our staff. It is going to be better and different and it is not going to continue to be the same as it is now. That is part of our redesign elements with all our clinical teams in terms of how we build, not back to 2019 now, but to something different and better and more appropriate for the demands that we are seeing. If I may add in terms of the Lanarkshire work, again, planned and unplanned care goes hand in glove and so the challenge for us has been, again, ensuring that we have sufficient beds to be able to bring in elective patients when we have uncedural care pressures. However, Lanarkshire is working very diligently to redesign and to find new ways of working in terms of addressing the plans that we are setting out. We are currently sitting across a variety of specialties from 70 to 90 per cent of pre-pandemic levels. We also have an additional challenge for us in that Lanarkshire uses the Golden Jubilee hospital as part of that elective plan. For the obvious and right needs of Scotland some of those allocations have changed to give to the patients who need it most. That means that we have lost some of our pre-pandemic capacity that we would have had, which again has been a challenge. We are looking at different ways of redesigning how we deliver service. We are also embracing the use of technology with things such as colon capsule and cytospunj offering different ways of being able to give people access to diagnostics in that space as well and continue to redesign, to work differently at the same time. However, it is a whole system. It keeps coming back to the whole system in terms of the balance. We are all absolutely focused in bringing our uncedural care performance up, bringing our planned care back, but I think the point that a number of us have made is the recalibration to what is right in 2023. We are also working with the new national elective co-ordination unit that is a national piece to try to look at the waiting list that we have and to make sure that those who are waiting are still in need of the same thing while they are supported. We are trying different ways to support as we bring our performance back. The recovery plan is a five-year plan, so it is not an overnight fix to come out of Covid. I think that that is something that is going to take time. I know that as a nurse myself. I am interested in the cancer diagnostic centres. One was created in Ysgrinarran, one in Fife and one in Davies and Galloway, and I know part of the prevention and early diagnostics. That is something that I think is happening in NHS to Fife and Galloway, as far as self-sampling for cervical cancer diagnosis. There is a trial going on there. I do not know if that is something that Mr Ace would like to comment on. I think that the early diagnostic centres work in Scotland. As you said, we set up three initial pilots. We are now at five boards that have the early diagnostics route. It is really promising in what it is delivering. As you know, Scotland, like much of the UK, has a relatively poor record compared to international best practice in terms of the early diagnosis and treatment of cancer. What the pilots are showing is that we can identify if we work in partnership with GP colleagues, giving a really rapid access to diagnostic expertise, multi-disciplinary review. We can identify some of those previously difficult cancers that are not presenting with absolutely standard markers that make diagnosis easy. We can get to some of those more difficult cancers earlier. I think that all three of the original pilot sites are reporting very positively in terms of what can be done with fairly small resorts. It is more of an organisational, reorganisational issue. I am pleased with that, both locally and as part of the national working group on that as well. In terms of the broader catch-up with our pre-pandemic performance, I think it is important to stress that, as Grant said, all of our systems are working to get back to their pre-pandemic activity levels. That is a challenge. We found it particularly difficult in terms of major elective surgery, so elective surgery that requires several days post-operative length of stay, because we found it difficult to guarantee those beds because of the pressure on unschedule care. I do not have an elective centre locally, so the DGRI has to operate both as a hot and a cold site. It has been hard to ring fence that cold capacity for major surgical work, so that is a challenge. I would also point out that just getting back to our pre-pandemic levels is not going to fix the backlog. It will simply stop things getting worse. What we need to do then is to overachieve activity for several years, as you have pointed out, in order to catch up with that huge lost work during the pandemic period. Five years is itself ambitious. It will certainly take us a period of time to create that catch-up. If I think back to the early mid-2000s, where we really radically reduced waiting times, we made enormous strides in cutting waits from years to weeks, that came with huge amounts of resources, huge amounts of extra staffing, none of which are likely to be on the table, given the context that we have talked about earlier. That is a massive redesign challenge for Scotland that we will throw ourselves into and we will absolutely continue to make the gains that we are making, but the challenge is very significant over the next few years. It was what Professor Archibald said about prevention and keeping folk out of hospital. I am the cross-party group convener of the lung health cross-party group, and we talk about keeping people with COPD fit and healthy and out of hospital. Is that some of the work that you are undertaking as well? Yes, absolutely. I think that there are two elements of prevention in my mind. The immediate prevention is a good example of managing people with COPD. Some of us are old enough to remember us to come in and be in for four days to get your tonsils out. We now have people at Strachathrow walking out on the same day as they have had their hip or their knee replaced. The world has moved on, yet the demand is still there. My two points would be who can be managed at home through frailty units and support, exactly so. I think that there is a bigger question about how we manage demand, how we get out into communities. We can identify the communities that are going to have particular issues in their health over the next few years. My ambition in Tayside is to engage more and put more of our effort into that to make sure that we are able to deal with the levels of demand that might present in the next three to five years. People think of public health and population health as something that pays back over decades. Sometimes it can pay back quickly if you focus it. The example that I would quote is, in Dundee, we eradicated hep C amongst the drug using population within three years, 13 years ahead of the WHO international standard. I have studied public health and I know that there are issues about eons and taking a long time to deal with things. However, the origin of public health was identifying a dirty standpipe poisoning the population in Victoria and London, and it fixed the standpipe. My last point about that would be the analogy that I have used when I am speaking to my colleagues and I hope that it will be helpful in this meeting. I am young enough to remember that the firemen used to run around and lights were always blazing and were going up and down ladders. Now 80 per cent of firemen's time is in prevention. They put in smoke detectors. What are the smoke detectors in health? We cannot keep developing acute and emergency services, giving the staffing challenges that we will have over the next few years and the financial challenges that we face. I hope that that was a helpful analogy to you. On the recovery plan in particular, are there any particular areas that the witnesses would highlight where good progress has been made and why do you think that that is? I will go to Professor Gardner first. I think that I would want to talk about what good is. I think that that is a challenge for us because we are very often drawn to the numbers. Some of the good, innovative examples of care are also good and it is trying to keep that balance while we also keep the eye on performance. Lancer again is about to have one of the early diagnostic centres for cancer, but we have been doing a lot of really good innovative work in and around cancer as a challenge. One of the elements that we are seeing coming out of Covid is the fact that we are having a higher number of patients presenting with these early symptoms, although the conversion rate to confirm diagnosis is not the same as it would have been pre-COVID. Although the numbers are higher, fortunately, the numbers with positive cancer diagnosis are not in direct correlation. However, we are doing work with using video technology and telehealth to do active referral triage early doors, so that means that people are being seen or indeed their case is being considered early by senior clinicians. It is giving that peace of mind, it is giving the right focused approach and that is really important so that we do not waste resources in this time. We also have the discharge patient and initiator reviews, so rather than giving people lots and lots of repeat appointments and return appointments, when patients themselves are concerned, there are ways of coming back into their service. I have also touched on things such as the colon capsule site sponge, but we are also using things like double q-fit testing to help to look at the patients who are most likely to be in need of our help. Also, what is a really significant part of this next part of health is about pathway redesign, keeping people well, looking at using advanced practice where we can, giving patients access when they know they need the help and that is what we are trying to do. In things such as low risk long pathway that we are looking at as an example in Lanarkshire, again, advanced practice nurses being able to help patients to see somebody when they need it most. It is also really important that we do continue to work with national services such as the national elective coordination unit, where across Scotland we can pull in the resources that are there to again help our patients to be triaged. Those are just examples of where we are beginning to reform. It is not how we used to do things, but it is us trying to look at our workforce, our technology and to try to harness those into our services. Our approach has been twofold. One has been about demand management in its real sense. In that respect, we put in a review of patient-initiated returns, which was rather than having new-to-return ratios dictated by ourselves. How could we get patients to indicate by a call whether they felt they needed to come back or not? That freed up greater than 5,000 appointments. That is a huge achievement. In terms of our active clinical referral programme, we went through that and were able to identify greater than 12,000 appointments that could be used. It is important in all that we do that we engage with our communities. If we can identify the cancer example, that is important. If we get a lot of people worried about being referred in, it will block up diagnostics and slow down the level of capacity that is available for those who are identified with cancer. That is why demand management and our engagement with our population, our GPs, clear referral guidelines and constant dialogue are very important. There is clearly the issue about delivery and productivity. I have already referenced the huge jump in productivity that has achieved clinician-led in our ophthalmology service. We have the best performing single-robot site in Scotland. One of my challenges, which Jan mentioned, is that 53 per cent of my real estate is over 50 years old, and nine wells is 50 years old this year. It is my major hospital. I have been lucky enough to work at Edinburgh Infirmary. I opened Wishaw General and Queen Elizabeth in Glasgow. New hospitals do not guarantee better care, but they give you a better chance of delivering it. I think that there is something about infrastructure that we need to look at as well. Finally, in terms of our key productivity metrics, we are looking at how we become more adaptable to our population needs and providing services at times that are most convenient and going to be used. That is about embracing issues such as DNAs, but also looking at productivity of theatres. Setting ourselves to the most challenging and standard, I said before to the committee, we need to be up for quintile in order to be able to identify ourselves as a high-performing organisation. We then have a debate about the challenges of resourcing going forward, as referenced in the Auditor General's report. I think that in terms of the surgical productivity examples that have been given, we can list our own. We undertook, for example, our first four-joint list. I know that for some of the elective centres, that is a pretty old hat, but for us as a small DGH, that was quite difficult. We just redesigned our own ophthalmic theatres here to allow for more pounds, a was about the same. Maintain a milestone for us to get through—we've redesigned our own ophthalmic theatres here to allow a significant increase in our productivity. I think that, as Grant said, boards will need to be challenged on that level of productivity improvement as we're going forward. I don't think that we have a luxury in Scotland yn�ud bod yn cydant yn prodyctfuzio, gan hy Commissioner nid resultedf yn siŁd. Telleeon I can't be as productive as somewhere else where that then my whole service model needs to be questioned and I need to put into pressure to increase my productivity. We in Scotland need to give that absolute guarantee as individual boards so we explore the real leading-edge efficiency, productivity, flow, redesign, et cetera. Y cyfeiri gwrthwyr cwrwch i gael y cyflawn cyffredig, mae'n gwneud eich gweld cyflym gyntaf, a'i gweinio eich cwrwch, gyda'r cyffredig yn amdu o'r bowd ar gyfer ar y cyflawn. Mae'n cael ei gael ddigon. Cymru wedi gwneud eu cyfreiddio, ac mae'n gwneud eu terfodol ar yr helyg, a poblynu ar y cy Leonard, maid eich cyflawn cyflym yn cael ei gweinio. Mae angen yr hynod, mae'n cael ei gweinio i gweinyddur ar gyfer yr helyg. of our least affluent. That's not some sort of historic accident that they are able to benefit from choices, from their own experiences, their access to leisure, etc. That puts them in a health position that's markedly different from those without those choices. So, as Grant says, we can focus our public health activity and our health improvement activity on those where there is the most massive difference and a rapid difference to take pressure off services, but also to do ethically the right thing. It is completely unacceptable in the 21st century to have the sort of gap between healthy expected life years that we have between our least and our most affluent. So, there's a moral imperative for us to do the right thing here that will also take enormous pressure off our services. And we've seen from work such as the Newcastle Life Curve about how to enable healthy ageing that you can make absolutely dramatic changes to people's frailty and to their absence of dependence on services. That has to be a huge part of how Scotland recovers from Covid and delivers a health and care service that's sustainable, high performing and meets the needs of those that most need it. So, it's one of those beautiful occurrences, I think, where the right thing comes together with what we need to do and sets that agenda for us over the next decade. That's great, thanks. That very neatly leads me on to my second question. I agree with the whole panel that we need to start looking at how we improve population health as a whole in order to not just make the NHS more sustainable but to give people better quality of life as well. Does the panel believe that the NHS recovery plan that we have now can act as a catalyst to change some of the way that we're doing things and move more attention towards that preventative health agenda, or are we just at risk of focusing on the acute pathways and repeating the mistakes of old, of not moving quickly enough? I think that your points are well made and I think that it's a balance that we need to hold. I think that our role as an anchor organisation is incredibly important as we look to the future. In Lanarkshire, like many other boards, we're looking to our youth to understand also in that space. There's the direct public health pieces that we're doing around vaccination and around better health, etc. We've just launched our health together, which is a whole strategy about better care and better value for our population. If I may use the example of our youth, we're looking to work more closely. We've begun the work out in our schools to inspire children, particularly from schools and deprived areas, to help people to understand opportunities of coming into health as an employer, so to look at that opportunity and also to start to develop different ways and different pathways for people for whom on-going university or college opportunities might not be appropriate. How can they come in from schools? We're starting with modern apprenticeships, looking at SQA qualifications that might help children to come in. We're looking to inspire from a young age to help them to understand those opportunities with that double edge of the wonderful pieces if they want to become part of our workforce one day, but if not, then learning through that healthy living and some of the key messages. We then want to help our young people as they come in through academies, so we have a care academy locally and also working with a number of academic institutions in central Scotland and indeed with the NHS Scotland academy again to try to bring in further opportunities for particularly children from deprived backgrounds to come into an opportunity of employment, so it's that health, it's that education employment and the onward benefits that come with all of that. As part of our broader plan, I think that those elements are really important, as health sees itself both as a direct deliverer but also as a critical influencer as an employer. Again, all the pieces that I've touched on for Lanarkshire as an example and the challenge that we have with 52 per cent of our population living in deprived areas, our staff belong to those communities and those are their families. What we see in our population is what we see in our staff group and vice versa, so we hope that through a number of different opportunities, and that's just but one, we can start to influence in our community. I'm going to move on to mental health and escalation framework. I invite Tess White to lead on that theme. I also would appreciate some brevity just because we are against time, if that's all right. I've got two questions for Professor Gardner and two for Professor Archibald. My first question, Professor Gardner, is that 74 per cent of your children and young people are waiting over a year to start treatment in NHS Lanarkshire. Why are the waits so long? We have some significant challenges in our service in terms of the approach to design, however, we have done a really radical review of our camps and psychological services for young people, and I'm delighted to be part of the opening of a new facility from the investment that's been put into our camp services and meet with some service users recently who were talking about the difference that that is making. The impact of that is really significant. We are already reducing almost 50 per cent from August of the year before to August of this year in terms of our camps' waits, and we're looking again to continue through this financial year to bring our waits down really significantly. We also are developing new ways of working in terms of having group opportunities for children to access, and again trying to address some of the needs earlier in the pathway with children in schools and through some of the education in schools. Specifically to our camps and psychological services, we're doing a whole range of improvement work that can be seen directly in our performance as it begins to change. Obviously, we were focused on our longest waits, but in the performance that you'll see now and going into the rest of this year you will be seeing a very significant improvement across both camps and psychological services, and that's through innovation, a refresh of our teams, and a really ambitious and visionary approach from the clinical teams who are driving those services. There's a lot of work that's going on, but has the Scottish Government cut to mental health-affected mental health services in NHS Lanarkshire? Resource is a challenge in all parts of our system, but we have used the resources available and we've worked with the Government, as I said, on the recent example of the £1.5 million investment in refurb of a building to provide an area where children and young adolescents are able to share their stories and talk about their issues. Although it remains a challenge, I think that we've been able to focus, and through that focus we are being able to bring about significant change in performance, which of course every performance number is linked to that child and the difference that that's actually making for people. Professor Archibald, you talk about smoke detectors and use that analogy, which I think is quite a powerful one. The independent report into Tayside's mental health services expressed concern over workforce planning. What steps are Tayside taking to improve strategic planning, staff appraisal and exit interviews? Thank you very much for the question. In terms of mental health services in Tayside, that's one of our key challenge areas and I think that's well known. We had an independent oversight group working with us and they concluded their report. We're actually approaching on a whole system basis, if I might take one minute to explain that, convener, so it's with what's called the Tayside Executive Partners. That's the three council chief executives, myself and the chief inspector of police because we see it as a whole system approach to dealing with the challenges of mental health rather than it just being about acute phases of it, but you're entirely right. We do have challenges in terms of staffing, particularly in consulting staffing at the moment. There is a challenge across the whole of Scotland, but it is most acute in Tayside. We also look to make sure that we can fully staff all our nursing services. We're doing proleptic appointments of nursing graduates and that means that in their last session or their last allocation period to award their department, we're giving them both the offer of a job and the opportunity to spend their last session working in that department and that has involved 70 mental health nurses and a total of 308 nurses in total for the whole of Tayside. That's part of our engagement with the University of Dundee and indeed with the colleges regarding how we can retain a workforce in Tayside and make sure that we can attract people in the future. In terms of our consultant body, we have a high number of long-term locums but that's not an ideal design of the service. That's important because this is about designing for the future and therefore if we know that we're going to have these challenges regarding staffing, we need different models of staffing. 94 per cent of mental health is delivered in community care environments and only 6 per cent in acute services. In Tayside, there was a national report, a national UK report that came out last year in September that said that Tayside had more beds than 95 per cent of the rest of the country and 95 per cent more admissions than the rest of the country. I think that we need to get underneath that and understand why that should be the case. We want to design a preventative system in mental health in a community-based one. Our IJB for Perth and Kinross is taking the lead in terms of the strategic redesign of services and part of that narrative is do we go to single sites for services, much as Jan referenced with her acute care but in terms of our mental health services and therefore we maximise the benefit of those staff that need to be in hospital environments but I think it's really important that we also understand that 94 per cent of service being delivered in the community. If we have more beds than most of the rest of the country, why is that the case and how do we redesign our services differently at the same time as seeking to recruit and making it an attractive place to work? Thank you. Could you talk to us and share with us your thoughts on how you are continuing to derive change in mental health services, particularly in relation to the six areas of strategic focus highlighted by the independent oversight assurance group? Thank you. Okay, thank you. That's quite a big question given the time that we have, so if you wouldn't mind if I could give you the high level version and then we might engage outside the room as a local MSP to have a more detailed discussion but the six were progress towards a single site which I've tried to describe and that's a strategic commissioning engagement that's being led by the IJBs because it is a delegated function, but we contribute to it. In terms of streamlining the priorities and the change programme from a document that was called Living Life Well, which was our strategic document, so we've accepted that we need to streamline that and have far quicker and clearer delivery times for certain parts of that ambitious programme and that again has been worked on through our IJBs and the health board itself. In terms of making integration work and engaging with the workforce that's both elements about how do we redesign the service and make it different and you talked about engagement with our workforce and there's a lot of work going on with that in the moment in terms of exit interviews and understanding why people leave but also trying as I say with the 70 new recruits to make the place more attractive and then there's engaging with patients and families and that's been a huge challenge to us because we have tried but the important thing is do people feel we've tried at the right things and there has been feedback that we haven't so what's being led again through the IJBs is a complete new structure of our engagement programmes with a multiplicity of groups so that we can hear the voices. Our original document was called listen, learn and change and we want to get that listening bit right and hear what the population want and then find you there's a continued focus on patient safety we do have a concern that even with the beds we have being at the very high end of the UK provision there are still times where I have to go into unfunded beds and try to get staff at short notice just because of the sheer levels of demand and that brings me back to my analogy don't try and build more beds try to work out why people need admission and can we intercept that earlier very final example we had a chap who was suffering from depression as a young man he came part of a walking group in the campardown parks which was a I think he's now a park ranger he has friends he is a a poster boy I guess for the success it can be done but it was a non-medicalised intervention it gave the guy a job it gave him hope it gave him friends it gave him social networks and those are things I need help with because they're not things Tayside provides alone and that's why we're trying to do it with all our colleagues in Tayside thank you thank you very much we're now going to move to Dr Gilhane who's going to lead us on staffing issues thank you thank you I'd like to start by asking Professor Archibald about the high staff turnover rate around 13% what do you feel the main challenges are in your area for retaining staff so the the level of 13% in analysing it has a lot to do with people going on to other jobs and and retirel the recent changes in pensions and the ability to bring people back to work that have retired will improve that position we think considerably I'm doing some work with the University of Dundee at the moment the business unit there and what we're trying to do is cut through all the narrative and try to find out by asking people what happens in their jobs what do they feel makes them feel rewarded what would make them stay what would make them consider what else they might do and I'm very struck by the fact having spent 30 years working in the central belt recruitment beyond the central belt is more difficult it just is I return to Tayside because I'm a Dundonian would I have gone there had I not been might be a different question and therefore one of the things we're trying to do with the universities in particularly the medical and nursing schools is say how can we retain the people that train in Dundee because they're our best capture how do we retain our existing workforce by making them feel valued and one of the things and we are proud of one of the things we're very proud of in Tayside is our commitment to partnership working in terms of working with our staff side in our trade unions and they have been so supportive and so helpful through these last four years that I've worked there and they have been a key part of what we're trying to do I have 13,000 people that work for me we all need to work together and we all need to feel valued and that means the essence of coming in and believing you can be successful in your job rewarded and recognised and that's been difficult these last two years particularly with Covid but I remain committed to that absolute statement that we value and we retain our staff and I think as I say the pension rules in particular having spoken to my consultant colleagues and others will do that but we talk a lot about nurses and doctors understandably because they're the big workforce but there are other areas that challenge us at times in terms of allied health professionals radio diagnostics but even beyond that one of the challenges I have at the moment is with my estates department and trying to recruit trained staff to that area so they need to be there to make sure everything works as it should and therefore that's why we've engaged with the University of Dundee we wanted to cut through the narrative and actually be able to determine what is the causation and what can we do about it and we'll develop a plan for that so you certainly have a plan of looking into it to what's happening and I often hear from staff that it's what's always described as little things that makes a huge difference so on my visit to hospital they had a fantastic canteen and they provide hot food at night time yeah is that something your hospital does we've got fantastic canteen there's hot food in the evening but not overnight and I think that's typical for for everywhere I might be wrong but we also created 15 rest recover and recharge rooms for people RRR rooms and the reason for them was to give staff places to go and sit and get a break from the work environment and in there we provide some basic teas and coffees etc during Covid we actually provided food as well but we've just given that a bit of a reflex and the issue with that again is as you say small things the biggest queue I could show you when we talked about ED the biggest queue I could show you is for fishing chips on a friday at the Dundee canteen and it's consultants that say to me this is great and they actually said to me can we get the catering guy to come and talk to us about change because he's turned around the catering department and you're right it's those small things that make people feel valued and make people understand that we are actually listening to them and trying to provide for them and I think our triple R rooms were a good statement of that but as you say the value of a good canteen and I'm sorry a product of those fishing chips it's it makes a difference and it's those sort of things we need to think about it really does and if I can direct my last question to Jeff Ace on video looking through NHS Dumfries in Galloway you've got 12% medical and dental vacancies and consultant roles and 11% in allied healthcare professional roles so being even more rural what challenges do you face and what are you doing to improve them? Yeah it's a staggering challenge and it's on a par with the financial issues that we were discussing earlier I think I think two things we're working very closely with University of West of Scotland University of Glasgow and our Dumfries College that are next door to me here in in Dumfries on the Crichton Park to look at future vacancy projections so what professions will we experience particular problems in and how we can optimise training offers in those in those professions and I think Scottgem is the best example of that that working well when you when you see ourselves and other boards getting together with with the education providers getting together with local GPs and really providing a different routine for professions and we locally have been astonished at the success of Scottgem it's just been fun almost transformational in GP in particular capacity but I think the second thing is to recognise we face a problem that's outside health here in in Dumfries and Galloway and probably in rural Scotland as a whole if we look at future population projections our working age population falls our older age older adult population increases and we become if nothing is done about that we become a less vibrant economy we become a potentially less attractive place for people and their families to relocate to and I think in that sort of future we will be constantly trying to push the rock uphill in terms of professional recruitment to bring people into the area that we want to locate here we want them to see what fantastic opportunities we can provide what fantastic facilities and teams that they can work with so I think there's a real there's a real challenge also as to how we turn around that demographic future and say that the future of rural Scotland is not one of of working age population decline is not one of an increasingly elderly perhaps economically inactive population but is one of vibrancy is one that is attractive to professions to families to move into so I think that's the much larger issue that we're working with our community planning partners particularly the council to try and and change that bigger future because if that isn't fixed I think the challenge for health will always be one of of just how do we bring professionals into this into this community with their families to relocate here and to see exactly how brilliant working in rural Scotland can be two questions in the interest of time I might just ask them both the first thing is in in general we understand we recognize the staffing is a longer term solution but if there were one or two things that we could do by working together that use could do as the boards and the government here in the Scottish Parliament could do what would be those one or two things that might ease pressure in the next year or two and the second question I have is around midwifery in particular a lot of the figures that we see are always nursing in midwifery together I've met with some midwives and there was midwives in the parliament last week and they say that there are particular pressures around recruitment and retention of midwives such an essential part of the healthcare system so how do you find midwifery in your own areas I'd be really interested to know yes so in terms of if I start with the first question in terms of that general element and how the Parliament can support is back to our policies being able to let us bring our systems back into balance I know I made the point earlier but I think speaking to staff the biggest thing that's asked for in terms of retention and retention we often we often go to recruitment but actually retention is almost more important to look after the fantastic people that we have and then also to look to how we bring in more and make it a good place to work there is a really positive piece to help tell our public about that piece I think there's been we've gone through a really challenging space of everybody clapped for the NHS and it was really positive we've then gone into a space where colleagues are concerned about pay and conditions but I think sometimes then there is a skewed view in the public that that it's not a good place to work they hear about the challenges that we're working in so I think it's the opportunities there to help to tell the people of Scotland of all the good work that's being done and the good experience that still can come from working in a healthcare environment which of course we all love but to try to encourage again the public to see some of that positive opportunity the second element is linked to then the working conditions for the staff that we have and that's linked to some of the reform that we've talked about some of the decisions that we'll need to make our brave decisions to change shape to really radically do what's right for our population and make good places to work for our people going forward and also then that also comes on to education the pieces that I touched on earlier make it easier for people to come in make recruitment processes easier we know that how people are recruited now is quite different how people respond to that sometimes these drop-in days where you come in your interview you see you talk those are the types of things that we need to do and also build relationships with communities as early as possible in a child's life and with families so that again we try to bring our families in so that's in terms of the general piece in terms of midwifery in particular I think a lot of those elements actually play out and probably play out stronger because of some of the emotional part that goes round and the importance of those services we know how much we value our maternity and indeed our neonatal and pediatric services and community hold those very dear so the element is around again as being able to create the right conditions offer ways of allowing our staff in post to develop we want to have a more sensitive ladder of development for people so it's easier you don't need to necessarily go out and do postgrad but you can develop easier access you don't need to come in fully qualified these types of things we want different pathways now that will take time to lay down but working in different ways to support people and to give them those opportunities I think are the most significant and also in the environments that people are working in we know often in maternity as an example there is loss and that is really hard what we've seen again through pandemics the same issues our population have complex health needs our women who are coming into our services have more and more complex health needs and actually again locally if I look to just a recent period we've had a number of people coming in and some really acute phases where we've had a number of women much higher than we would have seen before who are unwell in themselves or have complex health needs and they are pregnant and so trying to make the the career supportive and the development opportunities to learn both midwifery and be able to support and indeed develop those multi disciplinary teams and create areas like we're doing in Wisha right now where people can have a birth when perhaps we know it's a stillbirth etc and make the whole experience better for families but also indeed for our staff. Thank you. Microphone, thank you. Just a quick question for GFAs it's regarding the international recruitment so you've been quite successful about recruiting nurses but I'm thinking not just a warm welcome and orientation and training is required but a wider holistic approach like housing is housing a challenge for recruiting folk to rural remote Dumfries and Galloway as well and if so like what can you do about it? Housing was going to be my one ask to the Parliament in terms of what can help us you're right we've enjoyed our experience with international recruitment non-EU recruitment we've been relatively successful we've got a couple of dozen nurses and other staff into the system and we're able to wrap around initial accommodation support and orientate those individuals into the community what we can't do is provide affordable housing and that's a real problem in Dumfries and Galloway and I'm sure throughout the rest of rural Scotland is we are seeing significant difficulties for staff trying to move into the area of accessing that housing that's both convenient and affordable so I think again for healthcare in rural Scotland to thrive over the next generation there are a lot of non-healthcare things that need to be done around the economy and around our ability to house key workers in the right sort of affordable accommodation so if I had that one ask to the Parliament it would be to look at that housing pressure in rural Scotland and what could possibly be done to be done to make it more attractive for companies to build here to provide affordable housing particularly for key workers. Tess White would you like to join us if you have a question? So Professor Archibald one question if I may an area where the smoke alarm definitely is going off is in staff turnover so NHS Tayside has a 13 per cent staff turnover rate and now you're getting information from your exit interviews and what are the main challenges in retaining staff within your health board thank you. Thanks very much as I said the initial analysis of the reasons for leaving have been dominated by people either being promoted or going to other jobs and also by retirel and we I think I'm writing saying that 25 per cent of my mental health nursing workforce can retire in the next three years and therefore we need to find different ways of working with that because life choice is about retirel or clearly for the staff themselves but that's why we need to understand the profile of who's leaving as well as the reasons for because the age of the workforce will be a very telling determinant of where we go next and as I've tried to articulate our emphasis has been on seeking to recruit and coming back to our colleagues previous question in the number of proleptic appointments we've made in Tayside this year from the nursing cohort 40 of those are going into midwifery and that is an area that we have a challenge in so these are very focused actions to try to achieve real results I think the engagement needs to go on with staff we're trying to brand NHS Tayside as an employer of choice we can't make ourselves any closer to the central belt where there's a better concentration of staffing availability so we need to make ourselves remarkable by maybe three things one thing is our performance and our reputation as a high performing board the second is a caring board for its staff that looks after its staff and makes them feel valued and gives them opportunities but the third and most important thing for me is a place where you come and you do your job and you see the benefit reflected by the high appraisal that you get from those using the service their relatives and the communities we serve thank you thank you I'm just going to move quickly to Mr Torrance who's going to talk about the issue of culture thank you convener and good morning everyone in the absence of a national dignity of work survey how do you boards monitor bullying and harassment in the workplace and just for the sake of quickness are boards confident that national christal bullying standards are being followed and that people with concerns are suitably supported I'll come to Mr professor actually first please thank you in order to recognise the time and briefness we have arrangements through our HR function we have the whistleblowing function and we also have our staff governance committee and they analyse any reported cases of bullying and harassment and assure themselves that they were managed appropriately and the issues were resolved I think it's important that in that context there's a high emphasis on early resolution and trying to get people to work together but if that doesn't work then there are further actions that can be taken can I be assured yes I'm assured through my staff governance process and I'm also assured through the area partnership forum which is our meeting with all our staff side colleagues because we have narrative there about confidence in the the conduct and culture of the organisation and it's not always the same in all areas and we need to embrace that and understand why and address that where it's identified but I am assured through those arrangements that we are not only aware of cases of bullying harassment not only that we seek to resolve those but we seek to learn to prevent them in the future so similarly we have a range of approaches that we use and we very much value the relationship with our staff side colleagues where we know that we get direct feedback from staff but we also have through those staff staff side colleagues the assurance that we have a good interaction we also have carried out an internal audit under whistleblowing to make sure that again our framework was in place and that they felt assured that came back in November of 2022 noting substantial assurance and commending the process and the various routes in of course we always remain alive to this I think any any organisation that's peril takes for granted that culture is right it's something that we live in breathe each day but we do feel that we have done significant work and continue through staff wellbeing listening to what the feedback comes through an eye matter surveys and other staff interactions at our staff side and indeed similarly in our area partnership forum and staff governance committees and through the audit thank you mr ace i think that colleagues have said the other thing I would add is what what we're also finding useful locally are specific networks or lgbt networks black minority ethnic staff networks visiting those and and getting first hand those opinions of what it's like to work in NHS Dumfries and Gallows really rich information that may not be captured by some of the bigger survey works so we're finding that quite a useful addition to all that my colleagues have said thanks quick supplementary miss harbour thank you um just a quick question about um what has been learned from the steric review that has been taken forward in other nhs boards mr ace if you'd respond it feels quite a long time ago now the steric review um we had a joint session of our board and our staff side colleagues on all of the recommendations of steric prioritised our local action plan and tried to implement that as best we we could uh as I said I think given what's happened during the pandemic we all we almost need to start again with some of that work because it's been such a an unusual three years in the way that that um we've almost operated under emergency command and control um environment for two of those three years so I think a good reset of where we are with with steric is probably something that we as a board will look at now but as I said at the time we had that full review with us the joint review with our staff side to make sure that we were on top of all of the recommendations that's great well um if there's no further urgent points to make I just want to thank our witnesses for coming professor garner professor archibald mr ace um very helpful um and detailed responses to the questions I think so if there's any further points we want to correspond with you on we will follow up but appreciate your time this morning thank you have a short break now will we change your we'll be a very short one I think less than a minute to the next scheduled panel anything just call the meeting to order thanks very much for your attention and just want to start by welcoming our next panel joining us this morning um and it's comprised of Dr Al Mathers, NHS Greater Glasgow and Clyde, chief of medicine for women and children's services who's joining us online, Dr Will Agour, NHS Asher and Aaron, lead gynaecologist and member of the Scottish Government's mesh complications working group and we have Dr Anna Lamont, NHS NSS medical director, procurement commissioning and facilities, NHS national services Scotland who's joined us in the room and we have Terry O'Kelly, Scottish Government senior medical advisor who's also joining us online so I want to welcome all four of you today um I just want to begin our questions on the complex mesh surgical service with experiences of referral and access to the cmss just to ask the panelists what is the appropriate pathway or pathways into the service how is this communicated to health boards general practice and relevant specialties and do the panel think that more can be done to increase awareness of the service don't if there's anyone in particular who has a burning desire to lead us off if not I'll just direct it to Dr Agour first thank you the the pathway for treatment of mesh complications in women has significantly improved and um there are areas still where it can still be improved the uh that starts from the GP side from the GP practices through secondary care through to the national centre there are also pathways directly from the GP directly into the national centre ideally should go first through the local specialist centre in the local health boards where responsible for for the patients and then to the national centre it's my understanding that there are direct referrals from GPs to them to the national centre streetway um I'm not sure how many of these referrals were there but I think I read this somewhere in one of the documents that was circulated around um one important scope of improvement of the pathway is awareness of the GP of mesh complications and it's my understanding that the Scottish Government has made some significant steps into this um but um we've got to be clear that GPs have all sorts of very wide diverse conditions they're dealing with and I think there needs to be a um some persistent communication on raising awareness of mesh complications because this is an emerging field and also raising awareness that um that these women that these these complications or the symptoms that women present with can mimic a wide variety of conditions and um the there need to be a sort of a lower threshold of attribution of the presenting symptoms to the presence of a mesh device so rather than attributing the presenting symptoms to a common condition like menopause or endometriosis it's important to look back at the history and find out whether there has been a uroganacology procedure for incontos and prolapse whether the mesh device has been implanted and actually listen to the women themselves if they say I think there is something not quite right since the operation I had then I mean our awareness has clinicians in secondary care and also GPs has increased but there's certainly um more more improvement needs to be done and the GPs need to be supported in this and I think this came across in the survey that the committee has done that more awareness of of GPs is is is is required so this is one aspect of the pathway that that could be improved. Dr Lamont thank you so in response to that critical feedback that we've received from women looking for surgery and support for mesh complications I think first of all it's important that I express sincere regret both on a personal level and on behalf of NSS for the difficulties they've experienced. We do appreciate the courage it takes to share such lived experience you know because the challenge it is to actually share such personal information. It is critical I think that we acknowledge the difficulties that they've experienced and that we do look at the pathway variations both in terms of individual boards the lack of cohesion in the referral and that lack of information around GPs and local specialists that we've heard about. I do understand the stress that the women experience actually in terms of trying to access this and that challenge that they describe in that feedback. Back in June 2022 we established a clear collaborative pathway for referrals who are independent providers both in the US and down to Bristol and as a result of that pathway which was shared with the boards and shared with specialists there have been 37 women so far referred for independent provider. That doesn't mean that we're content with that and we are looking to continue to improve and I think reflecting on the responses as has been mentioned there is a clear need to improve that communication that we have with the women all the way through that pathway particularly within primary care and that journey between primary care and the local specialists and I think reflecting on that we should now be looking to communicate more directly with the GPs about the need to raise awareness of measure complications. It's important that this survey work continues and I'm sure that Dr Methys will describe some more recent survey work but we do need to learn from this feedback and to continue to improve and where we can improve we will improve and we will continue to ensure that the services that we can provide are both effective and efficient and I think that that's really we can agree that that's the least we can do for these women. Dr Methys, would you agree with that assessment and what can be done in practical terms to increase awareness of the service? I echo the two previous speakers' comments about just the difficults encountered with patients that have been harmed in this way. Just to correct or just to be clear we do not, the mesh centre does not take referrals from GPs directly now there is a historical element to this and it may be that GPs in the health boards area refer to one of the Eurogynecologists but if the patient has a requirement for a mesh centre MDT then in those circumstances the patient is referred to the mesh MDT by local secondary care using the electronic form that we insist on since October 22. Going back to the mesh centre gets referrals in, how those patients are initially seen and triaged and the awareness out there will be very different in different parts of the country and it's a testament to the fortitude of a lot of the patients who will not take some of the responses that are in their survey for granted and push for referral. I think that more national awareness, better local awareness and local referral patterns will all help because the mesh centre is the top of the pyramid here. The current pathways and increasing awareness. Can I make a comment? Yes, certainly. Yes, so Mr Kerr here, so Terry Kerr here sitting in Aberdeen. So I think we are aware of issues affected that it will be difficulties between patient and clinicians in terms of activity. Or struggling with your sound a little bit. The chief medical officer has already written out to primary care regarding this, testing the importance of the patients to listen to and when they are reporting symptoms. We have also worked with colleagues in the rest of the United Kingdom and Health Education England have prepared and have up and running an education programme for primary care concerning mesh and mesh related complications. The various rights etc have been addressed and this will be available in Scotland in the very near future. We hope that it will be available by now. Unfortunately we do have a different electronic platform for learning education in healthcare given Scotland's tourist system and the programme is being modified for that. In the very near future, we will have an education programme for all in primary care and the chief medical officer will write out to primary care again at that time to advertise this and to promote the programme. I think that with regard to the pathway also, visibility for patients needs to be improved and we would like to work with the service generally around that. Whether this is available on the complex mesh centre website or whether it is through NHS inform is to be decided. We have an upcoming meeting of our accountable officers where this can be discussed in great detail. It is very important that the initial interface between patients and physicians is favourable and that patients feel that their issues are being taken seriously and that their care is being taken forward in a recent fashion. It is important to say that I am a practicing GP. You spoke about the pressures on GPs with the number of things that we need to be aware of. I can give you examples in your CKD brain tumour. They have come to Parliament and they are pressing for GPs to be more aware of these as well. I am sure that you are aware that we do not always know patients have had mesh when we get our letters. We do not know what the surgical procedure that actually happened was. All we know is that someone went into urology and has come out. Is it not better to also have a central access point for the women to be able to call directly if they know they have had surgery and had problems since surgery? That is an easy one. If someone tells me that I have had problems since surgery, my first thought is that it is surgery. Common things are common and that is not always our first thought. I totally agree. Not only that some GP will not be able to know whether a mesh device has been inserted, some women themselves do not know that some devices have been inserted. Some women present with a common complaint, for example, like bleeding after the menopause. We get investigated for postmenopause bleeding. We are just found by incidentally that there is a mesh exposure that is causing the bleeding rather than what the most common cause for postmenopause bleeding. There used to be a central helpline. The Scottish Government has put in a central helpline, a national helpline, for women to contact. I think that that was at the height of the crisis a few years ago, but Terry could correct me on that. I think that when the crisis became more awareness UK-wide, the national helpline moved to become a UK national helpline. I am not sure whether it is still going on, but it is my understanding that the national helpline was more of a supportive service and more of a signposting service to the women. It is my understanding also that the women who engage with the national helpline has found it incredibly helpful. What I am not sure about just now is whether it is on-going, whether it is still active, whether it is still someone at the end of the line answering patient questions. It used to be a specialist nurse who was mis-aware. I think that there was one of the nurses here in Glasgow and then the service moved to England. What is important is if no one is sure if a message has been implanted, if a woman calls that helpline, they need to be able to find out. A national helpline to be able to find out will need to go into the patient record. Those who have access to the hospital record will be clinicians like myself. I need to know whether the patient is presenting with problems in relation to mesh, whether they have a mesh device or not. Clinicians in local hospital and local earthworld are best set to find out this piece of information to support the women and her GP and receive the referral when it happens. I am not sure how the central helpline that is already existing would support that. A central helpline is very useful when there is public awareness. I should emphasise that I am also a practising GP. There is a challenge for all clinicians to be aware of all complexities and all details. It is one of the reasons why there is a pathway to referral from specialists. However, we can do more to improve awareness. I think that we also have to consider that if a specialist helpline is made available or is available, the women first of all need to know that they need to access it. That first step is a critical step. A central helpline would also not have access to the records. While it can be reassuring, supportive and helpful and guide, it cannot provide that critical information that is required. I think that it has already been spoken about resources such as NHS Inform. Having those accessible resources in places where people would expect to find them is where to put information like that. There is a challenge in Scotland in having information and guidance for GPs, and as we have spoken before in the introductory statements about that educational platform for doctors and how they access that information. However, having a helpline is only useful if people have already realised that they need to phone it. You need to be able to have that information, providing a different form that is accessible. We also need to understand from the women themselves. We have seen today that we have looked at the evidence and that it is about the feedback about how people's journey and their experience of that journey. Before we would put into place any kind of education or support from women, we would need to hear from them about how they look for information and how they would then first come to understand what they needed. For GPs, we also need to recognise that they cannot be specialists in every area, but it is about having that awareness that somebody is presenting with a concern that then needs to be referred on to that specialist who can then take that more critical view. We did at the height of the concerns around mesh and, I suppose, the maximum activity in publicity, et cetera, back in 2015-2019—I suppose 2018—we did have a helpline, established and staffed, but the number of calls fell off quite dramatically and remained at a very low level. It was then unreasonably in you. That was withdrawn. There are now information pages and entries before. We are all picking it up, as far as our practices are concerned, but we are sitting here in secondary care as a practising surgeon. I think that NHS patient care works best when it is integrated across primary and secondary care. I am a great believer that the patient's best advocate is their GP. The first contact should be with primary care through clinicians, whether that is medical or non-medical, to explain problems and those for them to go forward. Then there is that important interaction with secondary care. If we dismantle that, we are seeing that sadly now in medicine and NHS here because of the issues post Covid, but when that integration breaks down, we end up with problems of communication, problems of ensuring that patients who might have many intercurrent issues—where those are overlooked and on-take count for—we end up with practising poor medicine. We need to try to avoid that, if at all possible. Going back to what Dr Agar was saying about the patient presenting, let's say that the post-menopause is bleeding. That is the reason why a patient should be assessed and referred. It will become apparent that mesh is the underlying cause. One would like to think that standard practising should persist, but it is important that general practitioners' primary care is tied into the on-going management of patients, otherwise we will end up with poor medicine, and patients who will suffer as a consequence. Evelyn, do you want to recommend on waiting times and referrals? I would like to ask Mr O'Kelly some more about its comments about educating GPs. Your comments are really difficult to hear. I think that the sound has been amended now, so you are sounding much better. I will go back to what you were saying. I think that there is obviously an issue with referrals. GPs don't always know how to deal with these. I think that that is obviously having a knock-on effect on when people are being seen. Did you say earlier that the Scottish Government has an education problem to programme to help GPs? What are you doing immediately to help them? The kick-back officer has already written out to primary care, drawing their attention to issues with regard to mesh and alerting them that patients may present that they listen to, and issues are axed upon. We have also worked with colleagues across the United Kingdom, and Health Education England have developed an education and training package for primary care. Unfortunately, the electronic platform for education here in Scotland is different from that in England, and at the moment the programme is being modified, I said that I had hoped that this would already be in the primary care for the education training, and we expect it to be available very soon, so I apologise that there has been a delay in this coming. Once it is available, the chief medical officer will write again to young practitioners advertising and drawing their attention to this, and hopefully that will, in addition to what has come before, will help to address issues that have been described. All that we can do is to promote the education to canvas opinion from primary care, their thoughts, but also from patients who have their initial experience with colleagues in primary care. They still have the same issues, and if they do, we need to make further modifications. Thank you. Can the committee be told why are there such long waits between appointments and to anyone who would like to come in here? I would ask a bit of clarity on the question, because we do need to recognise the difference between different stages of the appointment. There is a referral from a specialist to the complex mesh service, and there have been delays in that, and the capacity of the complex mesh service has recently increased. A number of people per clinic have improved, and that waiting time is coming down. I will let Dr Smith speak more about that. There is then the waiting time from a decision to have surgery to have that surgery undertaken. That waiting time has been reducing, and, after this month, they are offering surgery within 12 weeks of a decision being taken. I want to point out that a large part of what the complex mesh surgery service is about is not doing surgery. We talk about it being a complex mesh surgery service, but more women, after speaking to an understanding of the complexities and the challenges that they may gain or may not gain or may have issues with the surgery, opt not to have surgery or opt to have some other form of treatment. It is important to understand that the complex mesh surgical service is more than surgery. It is also about deciding positively not to have surgery or perhaps to delay having surgery. It is that surgery is not a procedure without cost to these women. We talk about the financial cost, but it is important to understand the time and the recovery period and the complications that may happen after that surgery itself. To come back to your issue about waiting times, there is then also the time that, if a decision is made for referral to an independent provider—to Dr Veronica, to Dr Ashim. At the moment, an MDT will make that decision. The decision will then be referred back to the local consultant specialist, who will then come to NSD with a request to refer out the area into the US or Bristol. That decision is taken typically within 48 hours and would then make a referral. Dr Veronica has been very good about booking appointments, working with the women to find a date that works for them. We will organise travel. That time is typically less than six weeks, typically a lot less than six weeks. The waiting time, which I think that people tend to focus on, quite rightly so, is the time from being referred into the complex mess service to being seen. We acknowledge the challenges in that. Some of that is reflected in the survey's responses. It is improving. Certainly, the time from a decision for surgery to having that surgery is now a lot better than it was. Dr Mathers, would you like to come on this point? I think that, from the papers that we have demonstrated that we are reducing the waiting times for first assessment, one of the things that came out from our own feedback was that women were finding it quite overwhelmed the way the initial referrals were made. The patients were seen by a large number of clinicians at one time. We got feedback to say that that was quite overwhelming for some individuals, so we have adjusted the process to facilitate that. Just like every other specialty, we are trying to manage quite considerable waiting pressures. We have a good news story in the sense that, while I would still be very uncomfortable with the length that people have to wait, it is something that has been steadily going down, as you will see from the data that we presented. We expect to be reduced by another further eight weeks by the summer. What treatment is being offered to patients that are on those long waiting lists? What happens to those women while they are waiting? Is that to me? Yes, please. They have been referred by a GP in primary care, or the secondary care, rather. They are referred by the GP to secondary care and then through that to the mesh centre. In that time, some of the problems will be pain management, psychological physiotherapy. They do not have to wait until they are seen at the mesh centre to have those aspects managed locally, but every part of the health system has differential waiting times with regard to the more holistic aspects of things, as opposed to just the functional bit of identifying with the individual patient. Whether she feels that surgical treatment of some form is what she would have preference for. Thank you very much for the information. It is much appreciated. I wondered whether Dr Lamann or Dr Matters might be able to just for the record be clear. I am interested to know you have provided some information, but it would be useful to know exactly what the average waiting time is and the longest waiting time. How long has the longest woman had to wait to be seen within the service? There are patients who have waited, and you will see that from their survey, ostensibly for years. One of the problems is to know exactly what that route for an individual into the service would be. We have quoted an average waiting time here, but there is a huge range simply because there will be some people with problems that have been identified that require more urgent treatment, and there will be other patients who will have other needs arise and will defer their appointment. As far as the longest goes, we have to take the evidence from the women's survey to say that some of them have waited years. What we are trying to do is, from the reset of establishing the mesh centre, to consistently bring that down and to identify why there would be long-waiters in that. We do that for all the other gynaecological services, or I am sure for all the board services. There are women who are referred to the service, but we cannot be clear why they have not been seen yet. It is just a long process sometimes for people. If you are electronically referred to the service through the process that was introduced in October 2022, you will be put into that process. The average wait for that service in 2122 was 72 weeks. We have moved it down to 55 weeks, and we expect it to be 47 weeks by June 2023. That is, in part, a reflection on increased capacity and the acknowledgement that we were overwhelming women by seeing an awful lot of individuals when they attended. No one in any way is doubting that being to be seen in that kind of service with the long history of problems that they have had is something that can be dealt with in a short appointment. I do not know if Dr Lamont has anything further. I always say that, as the commissioner of the complex mesh service, we have exact details of medium waiting times, longest waiting times, shortest waiting times on a quarterly basis, and certainly that very detailed data can be provided on request, if that is what it is being looked for. I do think, though, that when we are looking at this, we need to acknowledge that we have had the Covid and winter pressures, and that has impacted on the Glasgow service. That is not to excuse, but it is to explain why there has been perhaps a pause and delay in terms of catch-up, but I also want to acknowledge the efforts that GG&C and the complex mesh service have made this year in terms of catching up and improving that access time. The outpatient clinic has doubled its capacity and is now seeing double the number of women that was being seen last year on a week-to-week basis. That is the number that is critical, less than the surgery-wise, which has also improved and is now going to be under 12 weeks. That number of women, essentially, means that waiting lists will be coming down. The longest waiting time is not always the best measure. It is a measure that I can understand as of interest, but sometimes people will choose not to delay appointments that do not work for some of the women, and they need to be changed. We tend to work by the medium waiting time, and we can provide that on a very detailed quarterly basis. I have that available here. I would really appreciate the data. Obviously, people come to us as individuals, and it is important for us to be able to feed back. Those long, long waits for women have been going on for years, and it is our job to scrutinise and make sure that everything has been done. The next question that I am interested in is whether women have chosen the other option to go down south or to go across to Dr Veronica's. Is there anybody currently waiting on a referral loan in the system, or does everyone who has requested that today have a referral loan or has had their referral loan? The pathway that I spoke about is a referral that MDT will work with the women to understand what their preference is. We have a preference service, which is unique in MDT about whether they wish to be referred to an independent provider or not. They also have a choice on which independent provider. 37 women have chosen so far, and those people have been referred. Of those 37, 29 have been referred now on. The difference between that number is because those are the numbers that are with local health boards awaiting referral to NSD for approval for financial and for arranging the transport and the surgery. It takes 48 hours typically, and we are not aware of that before the site had asked the team if they were aware of any that had taken more than 48 hours, and they were not. Within 48 hours, we would approve that, and we would then get in touch with Dr Veronica's. There is a clear pathway that has been worked with the boards, and we have a mechanism by which the information is shared with Dr Veronica's, and he will then contact the women. So far, Dr Sheen has taken only one surgery so far, but that is again relating to the patient preference for the date of surgery. I am confident that there is no significant delay between the decision being taken for referral to an independent provider, and that is being arranged. The figures have quoted that. Does that mean that there are eight women just waiting now to be referred to or that have chosen a different pathway that they are waiting to get their final referral on? The multidisciplinary team, the MDT—I apologise for using acronyms, we are used to that in the NHS—will work with the women to decide that that is the route that they wish to go down. That referral is then passed back to the local specialist service, because a complex mesh surgical team themselves are not able to make that referral. That referral has to come from their own health board. Once that referral is made, it then comes to the NHS ourselves, and we will then authorise that and make arrangements. So, there is a short delay, usually in a matter of days or a week or so, in between the referral being going back from the MDT and being returned to us at NSD. Emma Harper, you might have a supplementary and also some questions on communication. I will go direct to the communication parts of it. I am just looking at the NSS website and the Greater Glasgow website. The Greater Glasgow website is a bit clunky for finding the information that people need. That is not something that you can control, probably, Dr Lamont, but the NSS pathway is quite clear in what the process would be. I am just interested in how people are communicated with, how the women are communicated with from the start and then the referral and as it goes on. Is there open dialogue? Is it by contact with a direct clinical nurse specialist, for instance? What is the process for communicating to keep people feeling like they are well informed? Responsibility for communication and care rests with their own health boards. That initial decision around referral is with the MDT from Greater Glasgow and Clyde, so they will be aware that that referral decision is being made. Their own specialist will then communicate with them about that referral being made. As soon as we receive that referral, we will contact the women directly. Once we have received a referral at NSS, we then establish a direct line of communication, and Dr Veronica and Dr Sheeham also directly contact the women and arrange a suitable day based upon their preference. We will then continue that contact around arranging transport, travel, expenses, and we will then contact them again when they return to ensure that surgery is taken place. There is then also information that is then passed back from Dr Veronica and Dr Sheeham back to the local health board to their specialist about their in-patient stay. However, we both from the feedback that was received from the critical survey feedback and the continuing feedback, we are not resting on our laurels here. We do need to look at where we can improve this. I think that some of those areas of communication around websites, we can continue to improve that, and I think particularly it is about improving that handover of those care between the return back from the US or back from Bristol, back to their GPs and back to their specialists. It is not an area that we can directly influence, but I think that we can share the feedback and we can then look at how we can make that pathway better. As I said in my opening statement, where we can improve, we will improve, and we have responsibility to do that. How are women then advised about waiting times, for instance, or what do they expect, or feedback around the processes? Is the communication done electronically by email, is it done by letter, or is it done by telephone call? How do we make sure that everybody feels as if their preferred way of communicating is the way that is done for each individual person? Regarding communication around waiting times and the pathway before it reaches NSSI, I will refer you both on to Dr O'Kelly or to Dr May, because there is responsibility primarily around that part of the pathway. For ourselves, we will contact women directly by telephone and also sometimes we have some communication by email, but generally we try to avoid communication by email because in terms of that personal information sharing, we are very sensitive to the challenge that these women have in terms of sharing information. We want to make sure that it is consistent. Dr Ronacus arranges team's video calls to arrange those consultations, and also checks in with the women once they have come back by video consultation. Primarily our part of that communication is by telephone, but I will defer to my colleagues in terms of the communication about waiting times. Dr O'Kelly, do you want to come in? I apologise, but I am sorry that I am joining you remotely, but there is a reason for that. Anna-Ann I think has concentrated on the pathway in communication between patients, service, NSS and Dr Ronacus. Of course, a lot of patients, the majority of patients, are coming from secondary care from local clinicians to the complex mesh sedger in Glasgow following an NHS route. I would like to draw the committee's attention to the work of the patient engagement and public involvement team in Glasgow, who have looked at communication specifically as one of the domains in their surveys. I hope that we have seen that. Clearly what they have shown is that they have asked questions, they have listened to what patients have said, and colleagues have made changes in Glasgow. It would appear from the results of that survey—there is another iteration due soon—that the performance of the outcomes is now at a very high level with very significant results with regard to patient satisfaction. I do not know whether Anna-Ann wants to say more about that. Dr Mayers, would you care to come in on that point as well? Confirm that when the patients are seen at the mesh centre and elect to have their treatment, we send back a standard letter to the referring consultant to ask for referral to the relevant party, or we obviously list them for care at GGC if they wish to surgery in the mesh centre. Because we insist on an electronic referral pattern, we are able to put those answers back faster. Following on from that, I will go back to Dr Mayers earlier. It was yourself that referenced the amount of information that women receive as a result of going down this pathway. How is that information followed up for women? Is there a standard way of communicating that in writing, or is there another way to ensure that, after an initial appointment, women can go and digest that information in a way that is accessible for them? The short answer is that we are always trying to improve the communication, but I do not have specific data to tell you the degree of that. We have had feedback to suggest that we are doing well. We have now had two cycles of feedback and we will have another two cycles by June 2023. I would be grateful if I could take that question away and just find out more. That would be really useful. I wonder whether that might be the needing the same treatment for this question. How do you communicate how women can keep themselves well and receive alternative support while they are on waiting lists? Many of them will be experiencing pain in a variety of other symptoms, and long waits will exacerbate or continue those presentations. Is there a current standard way that women receive information of where to seek additional support or how to keep themselves well while waiting for appointments or for surgery? Individual women will see a range of specialists, including psychologists and doctors, depending on their particular needs. We will deal with some people more urgently than others because they have a septic issue or are clearly triaged into a more urgent phase. The other aspect of all of that is that one has to be careful when women have comorbidities, so it is not just mesh. It will come with rheumatic problems, diabetes, etc. It will have a whole stack of potentially different medicines, etc. One has to be very careful that you do not... That is where a general practitioner who has got a very much better handle of drug interactions, etc. ensures that we have no risk of causing medical problems by interfering in areas that we should not be primarily responsible for. The centre does attempt to deliver a holistic approach to a wide-ranging problem, and surgery is not always the offered or preferred solution to that. Does that answer your question? Yes, it does. Thank you. Thank you, convener, and good morning to witnesses. Dr Mayvers, I think that this is for you. How many women were seen by a service where surgery was not advised and where other management or treatments were advised instead? I do know the committee asked for this information before today's meeting. I will have to... I have data on the patients that elective surgery and had surgery. I do not have the answer to the precise question that you have posed at my fingertips. I am sure that we can look into that. The other thing that is probably worth emphasising is that some women are given an offer and they think about it sometimes for as long as a year. Though we will only... If someone is waiting and not determined whether they want surgery, then we do have a system of follow-up contact, and then, after a year, seek them to be re-referred simply to ensure that they are not lost. Thank you. I do have the data. Referring to the financial years 2021-22 and so far 2022-23 as well, out of 165 first assessments seen by the complex mesh service, 59 patients have opted either for conservative treatment or to defer the decision on surgery. 56 surgeries have been carried out and this is as of 31 March. 13 were on the waiting list for surgery in GGNC, sorry, later Glasgow and Clyde, and we have had 37 independent provider referrals. Thank you for that. The complex mesh surgical service submission states that the service is primarily a surgical service. To what extent are witnesses confident that women engaging with the service are given a clear understanding about what it can and can't do in providing terms of treatment? I will pass this in a moment on to my colleague Dr May who is speaking specifically from the GGNC. You are absolutely right that this is commissioned as a surgical service, and I think that when we speak about the complex mesh surgical service, we tend to think about the surgical service. However, a significant part of this is about assessment, about the experience and assessing how much mesh may be still there after partial removals. The contribution of mesh and other complexities. We have heard people talk about co-morbidities, what we mean by that is about other concerns and the problems. It is also recognising that mesh will have been inserted for a concern in the first place. A significant part of that service is about the expertise in assessing these women who have got really complicated and complex concerns and around understanding what can be done to help them. The mesh service provides not just the assessment, but scanning, psychological support, pharmacological support as well, and what medicines can help with pain and other complications. Obviously, it provides that centre of expertise for surgery. I made the point earlier, and I will reiterate it, that although we talk about it being the complex mesh surgical service, it really is the complex mesh service. It is really to acknowledge that the women who have been harmed by mesh is a whole system, a whole complex form of complaint. It is not just about doing surgery. If surgery was what we could do for all these women to solve all their problems, this would be quite a simple service, but it is far more complex than that. The complexity of the service reflects that. I think that Mr Kelly wanted to come in on this point. I suppose that there is support out of there. When we understood the work back in 2019-20 regarding the need for a centre for management of mesh complications, it was thought that at that time surgery would be the answer for most women. Over time, it has been absolutely clear that a number of women's mesh removal is not necessarily the best way forward. Clearly, decisions are made with sharing information and meaningful conversations between clinicians and patients, patients with power to make decisions about themselves and their health. I think that the service was developed with a holistic foundation. That is going to be really important as we go forward. I suspect that more women coming to the service may not go down the path of surgery. That is certainly the experience in the other centres across the United Kingdom. It is very interesting that we had a summit of mesh centres in London in December, and that was one of the key messages that came forward. Surgery might be an answer for some, but not for all. Even if surgery does go forward before mesh removal, patients will need non-surgical care and other interventions in the future. It is important that we have that expertise. I understand that. Do you have any wishes to respond on that point? To emphasise that the patients who elect not to have surgery are not left bereft of care. A GCC patient might see a urogynecologist in the mesh centre, but if they elect not to have surgery, they can still be referred to a urogynecologist subspecialist in the service. As they could if they came from Lothian, they would go back to a specialist in that area. As Dr Lamont said, it is not just about pain. There are some women who will have continence issues, recurnt urogynecologist, and things that will require on-going specialist care in that particular area. Do you wish to respond to that? Yes. It is just to confirm that the survey conducted by the committee did one of the respondents mention the identity of the service. I think that everyone agrees that it is not just a surgical service, it is a holistic service, as we are saying. So, whether this holistic service is delivered in the mesh centre or in the local health board, I think that needs to be communicated very clearly to the women, so they do not feed back in the subsequent survey that there are still concerns about the identity. That could come in the mesh, in the centre information leaflet, or the information leaflet that perhaps we provide locally in the hospital, is that this is a holistic service and surgery is just part of it. I think that we really need to consider perhaps whether we need to keep the name surgical in the title. You have both said, Dr Lamont and Dr Argyll, that it is about a holistic approach, and that is something that just in reading the notes, there seems to be information about continuation of feelings of being let down, prolonged and continued anxiety, already disappointment because the expectations were already low and therefore expectations were not met. It seems that they are in the conveyance of lack of empathy for the experience. It is almost like there needs to be a mesh centre equivalent for the people who have had mesh injuries. It is quite difficult to read some of what has been presented. How would you describe or talk about the holistic approach? I know that psychologists are involved and clinical nurse specialists in that. How would you see the progress being taken forward based on feedback from the surveys about people's experiences? I am in response to the survey that I said earlier that I personally and on behalf of NSS always sincerely regret that that has been the experience. You talked about how do we progress, and I believe that we have progressed, but that is not to be complacent. The surveys that have been published just in the last week and the surveys that will be published by Greater Glasgow and Clyde, I believe, do show that we have progressed. I can certainly point to the information that we have and the feedback about providing an independent provider pathway. It is my thanks to the Scottish Government and my colleagues here for highlighting the issue and making it possible to have this independent provider pathway, which is one option. We also have the specialist service, which continues to be responsive. I believe that the continued survey response will show how we are responding. Dr Mavis can speak about how specific pieces of feedback have been acted on to change how the way that care is being delivered in the service. I have said where we can improve, we will improve and we are improving. Thank you. I am not sure if Dr Lamont or Dr Agar would be the best person to answer, but Dr Mavis referenced the specialist urogynological specialist. As of July 2022, there is a vacancy and there is no consultant in post. My question is, how does this impact the service? I would probably refer back to Dr Mavis, but I would also say that there is an active recruitment for that position. We are also looking at how the service can be supported by other areas in Scotland to fill that position. The numbers at the moment of women that are being seen surgically through the clinic are below the capacity that could be seen if we were functioning under recovered entirely from Covid pressures. At the moment, I do not believe that that vacancy has significantly affected the waiting list and that has reflected in the improvement in waiting times. However, as I have said, it is not to be complacent that we are actively recruiting and we are also looking at how that support can be provided from elsewhere. I do agree with that. There are urogynacologists already in the service and there are two colorectal surgeons, which is absolutely wonderful. However, the absence of a urologist is a concern. I am not part of the service, but I refer to the service. The absence of a urologist is a concern. The vast majority of these mesh devices are implanted close to the bladder, and this is where the urology specialist comes in. Clearly, there has been engagement with urology before. There was a urology member in the service before, and I think it is quite important that the service ensures that a urology joins the team because that will improve the confidence in the care from both clinicians and patients. Do you wish to commend Dr Mithers, if you would like to refer your microphone? Just to be very clear, we have urogynacologists who come from gynaecology and urologists. Both of those are present in the UK. Services that are having a great deal of difficulty recruiting to and appointing to. However, as Dr Agour mentioned, we did have an arrangement with Lothian and we have developed a specialist in Lothian who we will be hoping that they will be able to come to Glasgow to work from their contract in NHS Lothian. We continue to sculpt and try to attract a urologist to the current post, but we are in no way complacent about the need to have urologists in the service. Dr Lamont, I do not want to get into a comparison. What I am looking for is reasoning. NHS England has established a number of specialist services for women with medical complications. How many of those services have been rolled out? What differences do they have? If not, why? My understanding is that there are nine specialist services that have been developed in NHS England. That reflects the difference in population sizes between England and Scotland. The specialist service in Glasgow and the specialist service in England have the option for a referral between them. There is certainly the option there for NHS England if the women chose that they did not wish to have surgery, similar to the independent provider pathway that Cambridge referred up to. I am not aware of any women who have taken that option yet. That reflects the evolution of services. The service in Greater Glasgow and Clyde is a very advanced service. The expertise is recognised nationally in that. UK nationally, not just Scotland nationally. I am confident that the service that we have in Scotland is UK-leading. As Dr O'Kerry speaks about, there have been recent conferences and shared experiences. There is a move to credentialing, which has not been spoken about so far, but it is really just to acknowledge that it is work that continues to be developed. There is an expectation that, once that is up and running, all the services within DGNC will meet the requirements for that and will be effectively credentialed as well. On one final, hopefully quick question, Dr O'Kerry, if I could ask you, whenever we talk about mesh specifically in this environment with all the concerns we have, the specialist mesh service that we have, people are concerned about implantation of mesh in other ways and other devices, other types of mesh, with other types of surgery. I suppose my question is, do you feel that those patients having mesh in different scenarios is safe and something that they should not be overly worried about? Sorry, could you repeat the question again? It is really looking at the difference between the specialist service we have here and the complications women suffered with mesh. When people hear the word mesh, they think it applies to absolutely all mesh and they think it applies to all different types of surgery, so I am looking for your opinion as to whether we can reassure women that mesh in other circumstances is very different and safe. I can only comment on mesh used for gynaecological procedures because as a gynaecologist I am unable to comment on the use of mesh for hernia surgery, for example. I am aware that there is a petition in front of the petition committee with regards to mesh devices in other areas. I am unable to reassure or not reassure women about these issues, but since September 2018, since the health minister at the time confidentially suspended the mesh procedures, no mesh procedures have been implanted vaginally. However, there are abdominal mesh procedures being performed for gynaecological surgery and the risks are different. The risks are perceived as to be less, however, we have gone so far in providing the information and offering the alternatives to abdominal mesh surgery for prolapse. While I have my own views on this, the standard in Scotland now is that mesh for gynaecology can only be implanted abdominally after full informed consent and after the patient has fully understood the alternative. This is a significant improvement since the height of the crisis about nine years ago. Mr O'Kaley, want to come in? To the mesh sensors in England, we have worked closely with the development of the sensors in England. It should be recognised that the centre in Scotland was established almost a year prior to publication of the Cumberlatch report. We recognise the need for this, so we work for all runners. Colleagues in Glasgow asked me to congratulate them for the work that they have done and now for the evidence that they have from patient engagements, public involvement and the improvement in performance that they are registering. Anna, the comments that she makes about the Glasgow sense of being a leader are right. In a number of fields, we call mesh removal surgery in taking forward a credential etc. Colleagues are to be congratulated for that. It should also be pointed out that they have achieved all this at a time of intense scrutiny both in the media and in the Parliament. I think that that has been very difficult for them, so I think that we should recognise that. With regard to mesh and other sites, I think that your colleague on the committee spoke at the and I may correct him if I wrong, there was a debate in Parliament about mesh used in other sites, particularly in hernia repair. I think that this is an issue that has been considered at length. The Scottish Health Technologies Group undertook two reviews, one into ingol hernia repair, predominantly in men because men are affected, but subsequently in herniocytes elsewhere and involving more women. I think that the conclusion is that in hernia repair mesh should be used although alternative should be available and the use in mesh in other sites is supported. We know from the longevity that mesh has been inserted for hernia repair that there are not the same volume of issues that are being dealt with with women. Back to Dr Agur's comment about transvaginal mesh. Yes, there is a halt and there is no prospect that that will be removed from the Cabinet Secretary for Rural Affairs. With regard to the use in gynaecology of mesh through the pervicore abdominal routes, those are the subjects of a high vigilance protocol. The Accountable Officers and Aluminades is one of those responsible for ensuring that there is attention to detail with dotting of eyes, crossing of teeth to make sure that patients understand etc. This can only be used where there really aren't reasonable alternatives to recognise that, but also where there is a high degree of scrutiny to ensure that patients completely understand what is going to happen, why it is happening and that they have had the information that is empowered to make decisions for themselves. My question is to Terry O'Neill. Mr O'Neill, there should be scrutiny and it is more than just dotting eyes and crossing teeth. What I read in the papers for this meeting was harrowing. What has happened to many of those women is harrowing. Has the service for women in Scotland been set up in line with the NHS England service specification? If not, why not? It is just Terry O'Kelly rather than Terry O'Neill. The commissioning of services in England, as you know, is different. Certainly in England, there have been a number of commissioned specialist services for women who suffer from stress union incontinence and pervigal control apps. I think that the number is 40. Within that, there are nine centres that have applied for and have been designated as mesh removal. It could manage mesh removal surgery should that be required. The commissioning is different and the payments are different. As you know, it is commissioned through health boards here in Scotland. Each health board in Scotland has a council officer. We have been meeting with council officers since 2018-19. They are responsible, they are either medical directors or senior medical managers such as Alan Mathers, who are responsible for ensuring that the care for women goes forward in a way that they need and is commensurate with their problems. I am absolutely not complacent about the management of these women. In fact, I am probably at the end of the spectrum of engagement and demand. The stories that women tell are absolutely harrowing. I have great sympathy with what has happened to them, but we need to move forward. We need to ensure that the services that we provide for women and the way that we communicate with them are at a level where not only do they feel supported but that they are empowered to make decisions. When that treatment goes forward, it is provided at the highest possible level. We have worked very hard with boards and clinicians to ensure that that is the case. I am sorry, but I was very concerned to read the SPICE report and was very troubled by it. It is not clear whether all the comments that have been made are contemporary and it would be helpful to spend some time with and just look at that. I would draw your attention to the work that has been done, and it is on-going in Glasgow with the patient engagement and public involvement team. They are addressing those issues and it does appear, given the satisfaction that patients are reporting, that a lot of what has gone on for has been addressed and has been corrected. I hope that that answers your question. I would like to come back in, Tess. Not really, Mr O'Kelly. If you could actually say what has been set up in line with NHS England, if not why not, if you could answer that question. Are you talking about people and mesh complications or the treatment of patients, the care for patients, presented with stress union incontinence and public warm products? The latter, thank you. We have worked with the health boards and the council officers that we have looked at provision of services for those patients. I think that the work that is on-going, but I have no reason to suspect that what we are asking of boards and what they are delivering is really any less than what is being delivered in NHS England. The IPP, in part, is looking at a pelvic floor oversight group. I will move to Carol Mocken to lead us on options for non-surgical treatment. Thank you. I think that today has really raised for me the importance of this non-surgical side, and I am sure for other members as well. I really appreciate you speaking about that. A lot of the issues have been covered as you have gone through the session. Is there anything in terms of communication with the boards that we need to do around that? Specifically, whether you think that there should be an expansion around the multidisciplinary team and any pain management, because there is a lot of working pain management out in the community and with other services that provide that, and whether that would be helpful for women who cannot or choose not to go down the surgical route? Thank you. I hope that you recognise what I have been saying that we really value that non-surgical approach with the elements of that, the pain management, the psychological support, but also the explanation and understanding about what has happened to them. Sometimes the survey reflects the difficulty with communication and understanding what has actually happened, and we see women that have had multiple surgeries, multiple partial removals, and the question is asked about what has happened to them, what is left. A significant part of this is about re-establishing trust, and I think that is reflected by the fact that we are having these committees and these meetings. A lot of this is about establishing that trust relationship with women again and demonstrating really what the measure was in there for the first place. Why was it put in? What were we trying to do? No one put this measure in with the intent to harm. No doctor would have done that. Everything that was done was with the true belief that this was going to help the women, and it is a sad reflection, and it was in the Cumbledge report about the harm that has happened from that. We cannot undo those harms, but what we can do is try and do the best that we can for these women. The GCNC centre has some state-of-the-art scanners that it can actually see in a different way from the scanners that perhaps other specialist services have exactly what is there and what can be done there. There is also that skill of interpreting that information and being able to convey that information. A lot of the feedback that the GCNC service has had is around the number of multidisperate team members. In fact, one of the responses to the survey work that they have done is to make it so that not everybody in that multidisperate team is there in every room, because I think that it could be a bit overwhelming in that. One of the big changes that they have made is about how that information is delivered in a steady way, and that may need to come back and have that information repeated. Pain control, psychological support—we have spoken about that as well, and certainly there is dedicated pharmacy support within the GCNC team as well around that. I just want to add a point to this. The issues of improving confidence in the women in the service—obviously, there are historic issues with this, and we fully understand why many of these women describe communication issues and describe empathy issues and lack of trust, et cetera. One way of improving this is by reassuring them that we are communicating within ourselves, within the multidisperate team well. We know everything about them, and we are communicating this from the local hospital to the national centre well. That is easy when we talk about surgical issues. It is very easy to communicate that this surgery has been done locally and the patient wants to have this surgery done nationally or outside Scotland. What is difficult is the non-surgical treatment. When the patient is referred from locally to nationally, the national centre does not know exactly what sort of non-surgical treatment happened locally. One of the reasons behind this is that we don't communicate to the national centre. We could say, yes, the patient has been referred to the psychologist, but what has actually happened? What was the response to the patient to that? The patient has been referred to the physiotherapist, has actually improved or probably she didn't, because she requires the referral to the national centre in the first place. What I am proposing here is that we have a multidisciplinary team discussion, the local clinician and the team nationally, and we talk about those patients, what did we do exactly? There are things that I can communicate to a clinician colleague that the electronic form will not communicate. We used to have that, and that is in the paper that I circulated to the committee a few days ago. It is a historic paper, it describes practice that is probably a decade ago, but it does show that when we talk to each other, when we are present in the same room, either virtually or whatever, and most of these meetings were done virtually, by the way, before COVID. We were able to communicate well, and we did have the trust of the women, because the women, oh, you have spoken to this person that I am going to see in Glasgow. Yes, I did, and I think that is a good point, and it will also reduce the waiting time, because I can see in the patient leaflet provided by National Service Scotland that there are two steps in the pathway here that could be replaced by an in-person meeting, a virtual meeting, or simply you would invite the local clinician who referred from the local hospital to the national centre to attend this particular part of the mesh MDT nationally that discusses their own patients, so they go there and I would be able to present my own patient to the team, tell the team exactly what sort of treatment she had locally and what her wishes are, and I think that that would, this interface between the secondary care and the national centre would boost the patient confidence, and hopefully that would be reflected in the next survey. I'm interested in just going right back to the beginning, knowing what we know now about mesh complications implanted for stress urinary incontinence, right? So as a nurse who worked in the operating theatre, I participated in anterior and posterior pelvic floor repair operations, but before we even go there, is there work being done to encourage whether it's continuous nurses, physios, midwives to talk about things like pelvic floor exercise as a, okay, that's like it's free, it's free advice? Is that something where we're measuring whether that work is going ahead which actually might mitigate the need for any surgical intervention in the first place? Yes, so that engagement with non-surgical treatment for conditions that are induced by child birth injuries in terms of incontinence and prolapse, the first non-surgical options are the physiotherapy and the continence advice. Physiotherapists and continence nurses are integral part of MDTs in I think almost every health port and the intervention they form has prevented many women from having surgery. So it is those women where these interventions don't work, then they would get discussed by the MDT, which include myself and other surgeons and gynaecologists to discuss the surgical option. But yes, it is there. I'm not sure whether anything at a government level, maybe Terry would be able to help with that, whether this is being done on a larger scale, for example to schools if we talk about pelvic floor education for girls at school even before the reproductive period, that would certainly, if we start this seed at the very beginning, that would be important. At schools, for instance, one of my former colleagues teaches Pilates, but she also does pelvic floor exercises as part of that, to kind of de-stigmatise it as well. But she's even seen young women in schools breaking down these barriers of conversation, so is that work that you would support is to take it right out to the schools, take it to the level before young women start having, well, I suppose, experiences that might lead to urinary incontinence? Yes, absolutely. Yes, there's no doubt about that. Many women who, after childbirth and they come with already damage that has caused incontinence and prolapse, these are the problems that we're talking about and the reason why the mesh was introduced in the first place, when they come in, many of them don't even know what the pelvic floor is and how to contract the pelvic floor, how to engage the pelvic floor, and that's why the physiotherapists spend quite a lot of time with them, educating them. But if this happens from school at the very beginning, then during the reproductive career, at the end of this, if they were unlikely to develop these conditions, then at least they will be able to know what's going on and perhaps to engage better with the physiotherapy service. The other point of improvement would also be postpartum physiotherapy, which would immediately after delivery. The programme at the moment, it's my understanding that it is relatively short period of time and there is a possibility of improving the programme to extend it at a lengthy or a more regular supervised sessions by the physiotherapist for prevention in the future. We're talking about just in the first few weeks after delivery. Mr Torrance, do you want to cover some points on local and national services? Thank you very much, convener. What are the benefits of a national service over a local one in support of women affected by transvaginal mesh? National and commission services are highly specialist services. They are services that it would not be possible to provide in 14 different territorial health boards. That's reflected in that there are nine specialist centres being provided across the entirety of England and one for Scotland. NSD is part of NSS commission's approximately 150 highly specialist services for Scotland. Those are services that are funded through the individual boards, but they all contribute to that national service. They all reflect whereby there needs to be highly specialized service that then can provide competence and confidence in a national service. We would not be able to be having these conversations about the confidence and trust if these services were being tried to be provided from multiple centres that would then only be seeing a few small numbers of cases. Primarily national services are about whereby you would need to concentrate that expertise and attract people into those services to be able to provide that as a national service, but also to convey confidence to those people who are then utilising those services. In the current financial circumstances, is it feasible for bespoke services to be established in every health board or region? I refer back to my previous answer. It would not be possible, nor would it be desirable to try and establish a bespoke service in every single centre. You would not be able to provide that level of number of cases and experience and expertise and confidence if every single centre was trying to provide the same sort of service. We also have to recognise value to the NHS here and value to the women that are undertaking these services. We need to provide highly effective and efficient services, that is part of our responsibility as the NHS, and providing the services that are highly specialised, highly competent in individual centres is a mechanism to achieve that. We would love to be able to provide highly specialised services that are accessible, short distances from home for everybody, but when we are dealing with specialised services, the demographics and geography of Scotland does not provide for us to be able to provide highly specialised services in every centre of Scotland. That is the reality that we all face when we are looking at trying to arrange services. I will make a point on that. In the Petitions Committee, which I was formed by a member of, we did hear evidence from Dr Neto from the shoulders hospital in Ontario in Canada. He made a similar point about the need for centralised services to provide that sufficient scale of experience, a critical mass of expertise. Have you undertaken any international benchmarking about service design and considering how to develop this in Scotland? The service agreement that we have as the national services are under continual review, and we have a regular cycle of review. As has already been mentioned by Dr Kelly, this service in Glasgow was actually the first service in the UK to be set up. Reflecting on what we are talking about, are we following England? In fact, in many respects, what has been done in England is following what has happened in Scotland. We are at a very early stage in terms of that idea of benchmarking. There are the national committees, which have already been mentioned. I think that primarily the mechanism towards that is around credentialing. That is the route that we are all going down. It is going to take time because it is not something that has been done specifically within Scotland. However, there is a commitment from the team within GGNC to that. They have already progressed and applied for that. There is no expectation that all those within GGNC will then qualify for that. Mr Kelly, do you want to make a point? It is just to say that I recognise the point about shoulderies. When the centre was established, the recommendations for establishing the centre were the work or the outcome of short life working groups. They were engaged with all the necessary stakeholders, health boards, patient groups and other clinical groups. The decision was to continue development of the specialist service in Glasgow. As has been noted, a year before the conclusions of the IWMDS report. Anna has mentioned credentialing. It is going to be really important to benchmark clinicians in Scotland against a curriculum and framework that has been published by the College of Obstetricians and Gynaecologists working with the College of Surgeons in England with the specialist associations. Also, with the patient reference group, the documents have been out for a wide consultation including public reviews. I encourage people to look at that. The other thing that we will be introducing to you is a registry, not only to look at patients who are having mesh removal surgery but also primary surgery for stress union incompetence and pelvic organ prolapse. All procedures will be captured and that is a UK wide registry. They will allow us to look at our activity and our outcome outcomes that will include patient reports outcomes for all those procedures and will allow benchmarking, comparison, etc. We will hopefully help to further build confidence in the centre of Glasgow but also in the care for patients across Scotland. Dr Ogerda, do you want to make a point? No, thank you. Dr O'Kelly has just made it. Ms Harper, do you want to make a supplementary point? Yes, just a quick point. The convener mentioned the shoulderised approach but the strict criteria for a shoulderised repair like weight loss, no alcohol, ability to exercise. It might be difficult to apply that in the sense of Scotland, for instance, when there might be additional comorbidities that people have that do present, that might need a inguinal hernia repair using mesh. Is that something that we can compare apples with oranges? Again, that is outside my expertise because I am not a general surgeon. I have done only two hernia repairs in my whole life and that was before I specialised as a gynaecologist but I am not qualified enough to give you a full answer to that. However, in general, the shoulderised repair is a non-mesh repair that in shoulderised hospital has a wonderful outcome and they managed to save the vast majority of their patients having to have a permanent mesh device implanted forever that can cause problems in the future. Clearly, the mesh related complication induced by hernia mesh appears to be less than that for gynaecological reasons. There are so many reasons for this. However, the presence of comorbidity or for comparing populations in Scotland to Canada, I do not believe that the presence or any perception of difference in comorbidities should stop a shoulderised-like approach here in Scotland. At least, you start building the native tissue approach and at least you try to allow the surgical technique to evolve our surgeons to improve their skills and be more confident in offering the native tissue non-mesh surgery. There needs to be clinically based criteria, selection criteria, of which patients would benefit best from the shoulderised repair. This evolution, in my view, needs to start as soon as possible. These are clinical decisions on individual clinical patients given consideration to the comorbidity, definitely. I do believe that that needs to be supported by local government and nationally, too. That is my view, but again, I am not an expert in this area, but this is how I see things. I had a hernia repair myself and it was a shoulderised repair, and the two hernia repairs that I have done were also shoulderised repairs. Are there any final burning points that any of the panellists would wish to make before we conclude matters? Mr O'Kelly? I am not sure that this is the environment for discussions about shoulderised repair, but we have had that being well rehearsed previously. One thing that we have not mentioned is the patient's waiting. The patient's waiting in Scotland, the United Kingdom, is a major issue. One of the things that we have not touched on is the possibility of waiting well. The fragrance of waiting well will also fit for surgery. We are also part of waiting for this team here in the Scottish Government. I would advertise and promote these initiatives. There are opportunities for patients to make lifestyle changes in the time that they are coming to surgery to get fit. I think that the long-term health benefits can be very substantial and there is certainly evidence from around the country that would suggest that. Colleagues in Glasgow will know about those programmes, but it probably is something that we should consider and promote. Thank you very much. I would like to thank all of our panellists for your attention and your expertise and your contributions today. We hear your value as parliamentarians, so just to show our appreciation. Thank you very much and good afternoon. We are now going to move into private sessions to take the next items of business.