 and they run in that snaps inside children and young people who are most at least advantaged. We are already supporting a range of activities including raising attainment for all, which worked, as I said earlier, with over 150 schools across Scotland to drive forward sustainable and consistent improvements. As to our school improvement partnershiprogram, our access to education fund and as to announcement programme for government, attainment advisers to be based in the local authority across Scotland as well as a very clear focus for improving literacy and numeracy i'r P1 to P3 pupils thru'r Read, Write and Account programme. Michael McMahon I thank the cabinet secretary for a response, but with recent reports indicating that students from more affluent backgrounds are 50 times more likely than students from more deprived areas to obtain five higher grades A. Another statistic showing huge gulfs between academic achievement from affluent areas to deprived areas. Will the cabinet secretary give us a clear indication today what practical measures are being taken to reduce those gulfs because we cannot allow our education system to maintain such differentials between students with strong academic potential, not achieving their aims and ambitions because of the geographical area in which they happen to grow up? I think that Mr McMahon and I are in agreement that inequity anywhere in our education system is not acceptable. This Government will do everything within our existing powers to tackle poverty and inequality. I have already said to members previously today that my top priority is the Cabinet Secretary for Education and Lifelong Learning, which is attainment for all to raise that and to do everything that we can to close the equity and attainment gap. I regret that we do not have more welfare powers to tackle poverty, but nonetheless we will, with the powers that we have, focus on pragmatic measures on the front line within schools that will make a practical difference to the lives of our children on a day-to-day basis and ensuring that more of our children reach their full potential. To ask the Scottish Government how the expansion of funded early learning and childcare will benefit the most disadvantaged. Through the Children and Young People Act, we are investing £329 million in this financial year and next to expand annual funded early learning and childcare for three and four-year-olds to 600 hours. That represents an increase that will save families up to £707 per year per child. We have extended this entitlement to our most disadvantaged two-year-olds with around 15 per cent becoming eligible in the current school year, rising to 27 per cent next year. That is more than any of our predecessors have done and more hours of childcare than in any other part of the UK. I thank the minister for that answer. Could the minister outline what the Scottish Government is doing to raise awareness of funded childcare to parents and carers? Launched the second phase of our marketing campaign to raise awareness amongst parents and carers of the expanded childcare entitlement that follows an initial phase of public information that happened in the summer. The new launch of the campaign coincided with the cabinet secretary's visit to Melville Street, Nursery and Edinburgh, which I hope will address some of the concerns that the member raises. Many thanks. That concludes questions. I will now move to the next item of business. I will ask members to change places as quickly as possible. The next item of business is a statement by Shona Robison on NHS Grampian, health and improvement Scotland reports that the cabinet secretary will take questions at the end of her statement, and there should therefore be no interventions or interruptions. Presiding Officer, in March this year, the then Cabinet Secretary for Health and Well-being, Alex Neil, was made aware of concerns about quality of care and patient safety by a number of senior consultants from Aberdeen royal infirmary. The Scottish Government acted swiftly in response to that contact and within a week, Health Care Improvement Scotland had arranged to begin the first stage of the work that has culminated in the reports published on his website yesterday morning. The short-life review of quality and safety in Aberdeen royal infirmary and the report on care for older people in the ARI and Wood End hospital. A third report on NHS Grampian has also been produced by the Royal College of Surgeons of England. The board has published the terms of reference and the recommendations arising from its review on its website, but it has not yet published a full report due to legal action initiated by individuals named in the report. However, Health Care Improvement Scotland has seen that report and has made its own recommendations to address many of the issues raised by the college. Those reports highlight significant failings in the management of NHS Grampian, which, as the leader of his review team has said, makes sobering reading and which we take very seriously indeed. It also highlights the important role of the inspection regime that the Government has put in place to scrutinise safety and quality in the NHS in Scotland. That statement sets out the Scottish Government's response to the findings of those reports and the action that we expect NHS Grampian to take immediately and in the longer term. It is important to make clear up front that the work done by his did not identify consistent or widespread concerns about patient safety. Without minimising the importance of some of the concerns raised by his report, the review highlighted that Aberdeen royal infirmary is not significantly different from the Scottish average for a range of indicators of quality and safety of patient care, including the hospital's standardised mortality rate and infection rates. Patients and carers also provided very positive feedback on their experiences during the inspection of care for older people, with 89 per cent stating that the care that they received was good and staff being described as compassionate and considerate. However, the report highlights a number of issues relating to leadership, management and staffing, which, if not addressed immediately and decisively, pose a clear risk to the quality of patient care. That they have not impacted adversely on the care of patients, the report makes quite clear, is due to the hard work of dedicated and highly committed front-line staff who have gone above and beyond to compensate for weaknesses in the structures and processes of NHS Grampian. I want to put on record my sincere thanks to every member of staff in Grampian for their work in ensuring that the patients continue to get the best possible care, and I want to give them my assurance that we will do everything possible to support them in making things better. This review was a complex and thorough piece of work. His review team, headed up by Angus Cameron, currently medical director in NHS Dumfries and Galloway, agreed with NHS Grampian that they would examine too many areas. Firstly, the culture, leadership, values and behaviours in operation in the board, those things can be difficult to pin down but they shape the day-to-day interactions in any organisation and are essential to support the on-going delivery of a safe and high-quality system of healthcare. Secondly, the review team looked in detail at the actual quality and safety of care in a focused number of specialities and services, including the emergency department, general surgery and care of the elderly, with a clear focus on outcomes and the experiences of patients using those services. The review team worked with NHS Grampian for over five months and gathered information from a wide range of sources. In addition to analysing nationally available data, the team spoke to around 530 members of staff, received feedback from 362 patients and carers, reviewed 49 case files, looked at 32 complaints and analysed 13 adverse events. Their work has created a rich picture of healthcare provision in Grampian. The picture that Dr Cameron's team has painted is a worrying one. It describes a climate of mistrust between clinicians and senior managers in several specialities, unprofessional behaviour by a number of consultants that impacted on morale and on the effectiveness of the service and which went largely unchallenged, and a failure to respond effectively to concerns about staffing pressures and vacancies. There is also evidence that managers were distant, trainees were inadequately supported, complaints were poorly handled and that systems of governance and performance management were weak, muddled or indeed absent. Make no mistake, those things are unacceptable in the NHS in Scotland and they will be resolved and let me also send a clear message that no matter who you are or at what level you work in the NHS, those behaviours highlighted in his review will not be tolerated in our national health service. The key issue must now be how those findings are responded to. The report on quality and safety contains 13 recommendations grouped under the headings of patient outcomes, leadership in culture, governance and accountability, staff governance and complaints management. Those are accompanied by 22 more detailed areas for improvement in the report of care for older people. I visited Aberdeen royal infirmary yesterday and spoke to staff and to the board to emphasise how much importance we attach to seeing real improvements being made. I was given assurances that NHS Grampian accepts every single one of those recommendations and, under the leadership of Malcolm Wright, in its new interim chief executive, has already begun work to address many of those areas. The board has apologised for those instances where its patient care did not meet the required standard and has committed to improving leadership, management and engagement at the ARI and across NHS Grampian. The report highlights some particular concerns around nursing staffing levels and vacancy rates. The board is continuing to experience challenges around recruitment with factors like the high cost of living and competitive job market contributing to that challenge. The board invested in the creation of 100 additional nursing posts in the year to March 2014 in priority areas like theatre, the emergency care centre and mental health services. A further almost 100 posts have been added to the nursing establishment since March and funding has been allocated for up to 40 posts in 2015-16. NHS Grampian is also actively recruiting to vacant medical and nursing posts using every means at their disposal, including social media and executive search, as well as more traditional means such as medical careers, events and graduate nurse recruitment, which saw 88 graduate nurses from Robert Gordon University placed in 2014. His reports on NHS Grampian, while challenging to read, must be seen as a vindication of our unflinching resolve to shine a light on poor practice through the systematic use of independent inspection processes and to hold to account those healthcare providers who fail to provide the quality of care that the people of Scotland deserve and the support that those working in the NHS in Scotland have the right to expect. We also recognise that we have a role to play in supporting the board to improve and we recognise that improvement will not happen overnight. Scottish Government is providing record levels of funding to NHS Grampian to support its recruitment efforts. In 2015-16, NHS Grampian's resource budget is planned to increase by 4.4 per cent to £812.6 million, above inflation and the largest increase of any board, having previously increased by 4.6 per cent in 2014-15. Those increases include sums of £15.5 million this year and £17.5 million next year to move the board closer to its target share under the NRAC funding formula. The intention is that by 2016-17 NHS Grampian, along with all other territorial boards, will be no more than 1 per cent away from NRAC parity. In addition to the financial support that we are continuing to provide, we have put in place a comprehensive support team to advise and work alongside the new interim chief executive and his executive team in implementing the improvements that are needed to strengthen key systems, structures and processes. That vital organisation development will be supported by an additional allocation of £100,000 to help to develop and strengthen leadership at all levels within Grampian. We are also fast tracking the identification of a new chair for the board with interviews that are taking place today and with an expectation that the new chair will take up posts very early in the new year. The report of the quality and safety review makes it clear that the board is expected to develop a detailed and considered improvement plan that sets out exactly how it intends to implement the recommendations in the report, along with timescales for action and clear accountability. The plan will also be expected to clearly set out what success will look like. However, those are serious issues, and while we expect immediate action to be taken in relation to several of the key findings, we cannot expect changes to culture and leadership to happen overnight. Those changes must be taken forward in partnership with clinical and staff side representatives from the very beginning if they are to be woven through the fabric of the organisation as we expect them to be. We must accept that that will take some time. The Scottish Government will be monitoring the implementation of the plan very closely in the coming months, and I will receive regular updates on the progress as work goes forward. That has, and will continue to be, a difficult and challenging time for NHS Grampian. However, by putting patient outcomes and patient experiences at the heart of their services and with the involvement of the committed and dedicated staff that we know are working in NHS Grampian, I am confident that NHS Grampian can turn around a situation and begin to live up to its ambition of providing top-class healthcare services for all the people of the north-east of Scotland. Thank you, cabinet secretary. The cabinet secretary will now take questions on the issues raised in her statement and then tell me around 20 minutes for questions after which we move on to the next item of business. It would be helpful if members who wish to ask a question were to press the request to speak back now. This week's three reports on NHS Grampian and Aberdeen-Ryland-Firmraith paint a grim picture of the NHS in the north-east. The weaknesses at board level, poor management, low morale, bullying, a lack of accountability, concerns ignored by managers, a staffing crisis, a system of cover that staff felt was unsafe, a surgical unit described as dysfunctional, patient flow and capacity at the ARI and Wyden hospital, not fit for purpose, putting patient safety at risk, inappropriate boarding and effective discharge systems, and wards continually short staffed, just some of the problems being experienced here. Many of those issues are common across the Scottish NHS and are not unique to Grampian, but what is evident is that there appears to be a small group of consultants at this hospital who appear to think that they are above the rules that apply to everyone else. What will the cabinet secretary do to ensure that we have a culture where systematic failings are evident early, where a nurse, a support worker or a cleaner can have their concerns raised without fear for their job and action taken to address those concerns? It does not rely on a powerful group of consultants with a hotline to a friendly minister to expose failings that have an impact on the wellbeing of staff and patients. How does the cabinet secretary intend to keep this Parliament, but more importantly, the patients and taxpayers of Grampian informed of progress? I start by reiterating the point that is made in the report very clearly, and that is that, although patient safety was not adversely affected by the circumstances at Grampian, it is important to reiterate that, because we do not want patients to be afraid of the services in NHS Grampian. The services provided and the results and the outcomes for patients are as good as other parts of the health system here in Scotland. It is important to reiterate that. However, clearly, those behaviours did not help in improving patient care, and because of the efforts of front-line staff, in going the extra mile, they managed to overcome some of the management clinician challenges that could have adversely affected patient safety. The small group of clinicians who Neil Findlay described as thinking there above the rules—I think that I said very clearly in my statement—no one working in the NHS, no matter who they are, is above the rules. That type of behaviour would not be accepted in any other workplace, nor should it be accepted in the NHS, and we will absolutely make sure that those issues are addressed. I am sure that Neil Findlay will understand that there are a number of processes emerging from the report, whether that is the general medical council looking at those issues, or indeed the internal processes of NHS Grampian will have to take their course in addressing the behaviours of those individuals as those investigations go forward, but I can assure the member that that is exactly what will happen. In terms of whistleblowing, we already have processes in the NHS that encourage anyone who has concerns, no matter who they are, working in the NHS to be able to raise those concerns, and that is exactly what people should do. In terms of keeping Parliament and, importantly, the patients and public informed, I would certainly expect, first of all, NHS Grampian as they take forward their implementation plan for change to be very good with communication to staff, patients and the public about those changes that they are taking forward. I am very happy to keep Parliament informed whether that is through the Health and Sport Committee or an update to Parliament here in terms of the progress that is being made within NHS Grampian. Thank you, cabinet secretary, for an advance copy of her statement. For those of us who represent the north-east, the on-going problems facing NHS Grampian are both concerning and upsetting. The reports clearly point to a number of areas for improvements to be made. Like health boards across Scotland, NHS Grampian is facing significant pressure from the increase in demand on health services and the difficulty of recruiting and retaining key specialist and nursing staff, especially given the added pressures of the oil and gas industry. Patients want to be reassured when they go into hospital that they will receive both first-class care and a well-managed service. It is reassuring that the reports about NHS Grampian are clear that, to date, patient safety has not been compromised, and that is due to the hard work of its loyal staff. However, a number of failures in strategic leadership have been clearly articulated, and that is something that I know is being urgently addressed. Indeed, I am pleased that NHS Grampian has already undertaken to act on all the recommendations that are made to it. SNP ministers are ultimately responsible for the NHS in Scotland, and they must work to address the increasing problems that we are facing within our health service. I therefore ask the cabinet secretary whether the Scottish Government will undertake a review of all current vacancies within the NHS Grampian area and look to publish an action plan to address staffing problems with the minimum delay. I say to the member that absolutely it is important that the NHS Grampian were clear that it is going to act on all the recommendations and accept all the recommendations without reservation. I think that that is very, very important. She highlights the increased demand for NHS services, which is absolutely a pressure on NHS Grampian in the same way as it is a pressure on other parts of the health service. Recruitment challenges, though, are a particular issue for NHS Grampian because of the issues that she cited in her question. They are looking at the use of the medical workforce bank in the way that the nurse bank has operated in other parts of the country very successfully. The medical bank has worked very well in Lothian, so I know that Grampian is looking at that as well. On the management of vacancies, there are some specialities that, for a variety of reasons, are much harder to fill because of the challenging nature, the 24-7 availability and the pressures therefore within those posts. Again, we are looking at how we make those posts more attractive, how we make them more flexible potentially. We are working very closely not just with NHS Grampian but with other boards to look at how we address those difficult posts to fill. The member can be absolutely assured that we are not just sending the new interim chief executive who started in his job this Monday to sort of these problems out himself. He has got a team behind him and he has a lot of support from the Scottish Government in taking forward all of those issues. I appreciate the interim chief executive of NHS Grampian meeting with MSPs on Monday and for the comprehensive briefing that we received there. I recognise that resources are in place to recruit for clinical and nursing vacancies and that there are funded plans to expand the nursing workforce even further, but key workers often have difficulties in getting affordable housing in the area. Can the cabinet secretary give me an indication of how many houses will be allocated to health service staff on the Craig Inches site and what further plans the Government has to increase the number of affordable homes available for NHS staff in Aberdeen? The cabinet secretary raises an important issue here because we have to look at how we tackle some of the underlying recruitment problems, not just an issue for the health board but for the local authority as well. Without a doubt, the cost of living in Aberdeen is a critical issue. I can reassure the member that I have asked for an update on the plans and the discussions that are going forward between the NHS and the council around the affordable housing solution. I am very happy to share that with the member once I get an up-to-date briefing myself, and I would be happy to keep any other members up-to-date with how that progresses. It is absolutely the type of innovative solution that we need to be able to overcome some of the recruitment challenges within the public sector, not just Aberdeen, but Aberdeenshire as well. Lewis Macdonald, followed by Alex Summond. Thank you very much. The cabinet secretary will be aware of the statutory duty of candor, which applies in the NHS elsewhere in the UK and which would require publication of a report such as that from the Royal College of Surgeons, which she has mentioned today. While that duty does not exist in the same form here, in the spirit of candor, will she urge NHS Grampian to publish the conclusions as well as the recommendations of that report as soon as possible? Will she tell us how she intends to reassure individual patients that they will be told whether their care has been affected by the unacceptable behaviour of a small number of consultants that was identified by Health Improvement Scotland at the earliest possible date? Can I start with the issue of individual patients? His team and their inspection looked at that issue very carefully to make sure that there were not any individual patients who had been adversely affected. I know that there was a degree of follow-up to those patients, so I hope that I can reassure him on that. I am happy to provide him with additional information about that if he finds that helpful. In terms of the conclusions of the report, he will understand that there is now a legal process around that. Certain individuals who were named in that report have taken legal action to stop the report being published. NHS Grampian, therefore, is in the position at the moment of having to work through those legal issues to get to position at some point that the report can be published. I am sure that he will understand that point. However, the main findings of the dysfunctional nature of the relationship between those clinicians and other clinicians and those clinicians and management are pretty much laid bare in his report, because his team saw the report and had a copy of that report, and therefore reflected that in the findings of his report. I do not think that there is anything stopping us now or NHS Grampian getting on and resolving those details. They certainly do not have to wait for the publication of that report to do that, and they are not. In terms of duty of candor, the member will be aware that that is something that is being looked at in terms of the public health bill. I think that it is certainly a measure that we should be taking. I think that the whistleblowing procedures that we have are good, but there is something about that explicit duty of candor that sends a very clear message to the NHS, and that is something that we will take forward through the public health bill. Alex Salmond, followed by Alex McInnes. I am thinking about the serious problems in NHS Grampian and comparing them with the tragedy in the Vale of Even. Was not the essential lesson of the Vale of Even is that the health service had to develop systems that allowed the identification of problems before they impacted on patient care and safety? Surely that has happened in this case through Health Improvement Scotland. For example, the emergency rates are vastly better than NHS Grampian today than they were in 2006. The cabinet secretary put that down to the excellence and hard work of the staff of NHS Grampian. I think that she is right to do so. Therefore, is it not incumbent on every single member of the chamber to rally behind these staff and the new leadership of NHS Grampian and take matters forward? Absolutely. I agree with the member on that point. The systems that we have in place, and although it can be uncomfortable reading, I as the health secretary would rather know what is in all where there are problems within our health service, because only by knowing that can we actually take the steps to address it. Previously, before those systems were set up of independent inspection, we had no ability to look in detail at some of the problems that were in the health system. I think that the huge lessons that have been learned from the Vale of Leven is a case in point there. On the rallying behind the staff, I got the sense yesterday when I was meeting staff in the Aberdeen Royal infirmary that we have a group of very dedicated staff that were under a lot of pressure in terms of the report. It makes difficult reading, but they had a resolve to go forward and to make sure that Grampian can become one of the top-performing boards in Scotland. When I met the board, many of the non-executives in the board were very keen to step up to the leadership plate and to help NHS Grampian to become that top-performing health board. I think that we all know that it can become. The cabinet secretary mentioned in her statement 100 additional nursing posts, but this report is not the first one to warn that wards must have not only sufficient numbers of nurses but also the right skills mix. What planning is the Scottish Government doing with the NHS boards to ensure that the right people are in the right place at the right time to maintain quality of care? Does the cabinet secretary believe that, in those circumstances, NHS Grampian has the capacity to move at the pace that is required to effectively achieve the integration of health and social care? The nurse number is an additional investment in nurses. I laid out in my statement that it is a significant investment, but it is absolutely the member's right in terms of the skill mix. One of the features that I found yesterday that was very heartening was that, on one of the care of the elderly wards that I visited, they had absolutely looked at the skill mix. It was not just nurses, it was the allied health professionals, it was the healthcare assistants who were helping with some of the food and fluid issues that have been highlighted in the report in terms of making sure that those personal care tasks are there. I am sure that I am not the only person in this chamber who will regularly see that coming through as an issue within their mailbag, so it is really important that we get the right skill mix. Of course, we are helping boards to do that. On the health and social care, it is really important for NHS Grampian and the same with all the rest of the boards to absolutely make progress on that, because only by integrating health and social care and by stopping people turning up at the front door of the hospital who do not need to be there, making sure that we get people discharged from hospital who do not need to be there in a timely fashion, that we can actually reduce some of the pressures on our acute sector, but also give patients a better experience. For a vulnerable elderly person, often, as we know, an acute hospital ward is the last place that they should be. What I saw yesterday is that, on delayed discharge and dealing with discharge, NHS Grampian is doing a lot of work in that respect, so I have every confidence that they will be able to take forward integration plans. I say to members that I am extremely short for time this afternoon. I am not wanting to get in everybody who wants, so can I urge short questions and answers? Mark McDonald, Folff, I would like to make a message received and understood, Presiding Officer. Part of the responsibility for leadership at a local level rests with the board. Does the cabinet secretary share my concern that the board appears to have not had a grip or sufficient proactive oversight of many of the aspects of performance of the NHS in Grampian and has contributed to some of the leadership vacuum that existed? Can she say how she will be making clear to the new board, chairman or chairwoman, the expectations of the board itself to provide effective scrutiny of those issues and challenge the executive of NHS Grampian? I think that Mark McDonald must have been a fly on the wall when I met the board yesterday, because one of the things that I was asked by one of the non-executive members was, what more can we do as non-executives around the board table? The answer that I gave was to ask questions, to scrutinise and to absolutely make sure that anything that comes in front of them is questioning and questioning. That is, as far as I am concerned, a key role of the non-executive members around the board table. Obviously, as I laid out in my statement, there is a fast track to get a new chair in place. That chair is going to have a key leadership role in making sure that the board goes forward with renewed vigour, along with supporting the interim chief executive. What I can say to reassure members is that absolutely the view that I got from the board every single person around that table was that they wanted to take this as an opportunity to reset relationships in NHS Grampian, to reset the way that they go about their business, and to take this opportunity to get Grampian back on track to where it should be. Richard Baker, and then very briefly, Christian Allan. Thank you. The cabinet secretary's predecessor said that NHS Grampian would be brought more quickly towards parity of funding under the NRAC formula if more funds are made available for the NHS by the UK Government. Can the cabinet secretary confirm if this is still the Government's policy? As I laid out in my statement, with the significant additional investment that was not seen previously, I have to remind the member of that that we will, by 2016-17, move to within 1 per cent of NRAC parity. I think that that is a great deal of progress that has been made in previous years, and I would have hoped that that is something that the member would welcome. The feedback is very important. I would like the cabinet secretary to understand that many comments on the patient opinion website tell us about the good experiences of patients in Grampian. However, the healthcare improvement Scotland report highlighted a very poor response rate to complaints made to NHS Grampian. Can she outline how the Scottish Government will expect the board to respond to complaints and to positive patient feedback, such as through patient opinion? The Scottish Government has provided updated guidance and changed all boards on responding to feedback and complaints. I made it very clear yesterday that this was an area that needed to be addressed. I can reassure the member of that there has already been support from the Scottish Government working with NHS Grampian to make sure that it responds not just timuously to complaints, but that it addresses the complaints in a full fashion as they should be. That is a key priority moving forward, and I can keep the member updated about that progress. Thank you. That ends the statement by Shona Robison on NHS Grampian healthcare improvements Scotland reports. The next site of business is a debate on motion number 11763, in the name of Mary Fee, on private sector