 Good morning, and welcome to the 28th meeting of the health and sport committee in 2017 agenda item one as on NHS governance. Could everyone in the room to ensure their mobile phones are so in silent, of course, except who to use their social media mobiles but please do not photograph or record precedence. The first item on our agenda is the Declaration of interest in accordance with sections 3 of the Code of Conduct can invite Sandra White to declare any interest relevant to the remit of the committee. Thank you very much Sandra, and you are very welcome to the committee. NHS governance is the second item that is around table evidence session on clinical governance. We have received apologies from Dr Brian Robson, medical director of health improving Scotland, who was due to give evidence this morning. I will introduce myself then if we can have people around the table and introduce themselves. Neil Findlay MSP for a load ends in our chair of the health and support committee. Ash Denham MSP, and I'm the deputy convener of the health and support committee. Nick Fluck, I'm medical director for NHS Grampian. I'm Miles Briggs, I'm conservative MSP for Lothian, and conservative spokesman for health and support. I'm Tracy Gilliff, I'm the medical director for NHS Lothian. I'm Alex Cole-Hamilton, I lived MSP for Edinburgh Western, and I'm also the lived health spokesperson. Chris McIntosh, medical director for south line health and social care partnership. Jenny Gurruth MSP for the Midfife and Glenrothes constituency. Good morning, I'm Jason Leitch, I'm the national clinical director. Hi, I'm Emma Harper, I'm MSP for south Scotland region. Robbie Pearson, chief executive at healthcare improvement Scotland. Alison Johnston MSP for Lothian. Ivan McKee MSP for Glasgow Proven. Rosemary Agnew Scottish Public Services on Bidsman. Brian Whittle, conservative MSP south of Scotland, and sportsman health education lifestyle and sport. Sandra White MSP for Glasgow Kelvin. I'm Sheena Morrison, head of public protection and quality assurance for the Glasgow City health and social care partnership. I'm Colin Smyth, MSP for south of Scotland, and Labour spokesperson on public health and social care. Okay, thank you very much. We have got a lot of people around this table this morning, so brief contributions would be really helpful. We'll try and cover as much as possible when the time has got allocated. If you want to contribute, if you just indicate to me and some of us here will hopefully catch your eye, okay? Emma, would you like to begin? Thank you, good morning, again everybody. Last week I was my first week attending, but the evidence that we took was that there are standards and guidelines that do exist, and that the patient groups generally think that they're good. So, I'm curious about how do we implement the guidelines, how do we feed it down to the shock floor level, how do we make sure that the patient delivering the care actually deliver the guidelines that are recommended? We would like to begin. Robbie. I may, convener, just put on a bit of context render. So, health improvement Scotland has a pivotal role in terms of supporting the production of those guidelines and standards. So, the Scottish Intercollegiate Guidelines Network has around 50 guidelines currently out there. In terms of standards, there are around 15 as well. So, what is healthcare improvement Scotland seeking to do? What it's trying to do is to put a framework, the tools, the means for good practice, the best evidence to be shared. And one of the key roles for healthcare improvement Scotland is the dissemination of those guidelines and standards. So, one of the things that is important is to think about how best we implement them. And there's not a single answer to that. That requires use of digital technology, for instance, in terms of dissemination of those guidelines and standards. But it's also important that we provide the environment for staff working in the health service to use those guidelines on a day-to-day basis. Now, one of the key challenges, I guess, in a world of more complex care and more patients presenting with comorbidities is how do we make sure those guidelines are tailored to individual needs? And I think that that's an important part of the discussion, perhaps this morning, about how we make sure those guidelines are relevant and can be implemented in day-to-day practice. I just want to follow on from that. As ombudsman, we have a very specific focus on this. And that is we handle complaints. Very often, this involves where guidelines are not adhered to or not met. And one of the things that strikes me about this is it's not just about implementing, there are two other very crucial things. And one is when they are in place, it's about ensuring that if they're not adhered to, there is effective learning from them. But the other, and I feel very strongly about this actually, is that staff are actually given the support. If something goes wrong, they're given the support to understand why, that the organisation embeds that learning culture and that the soft skills, as well as the clinical skills, are also there for both clinicians and non-clinicians. So, for example, we see quite frequently the issue is record keeping or communication. And it's not that people go into work to do these badly, but there just aren't always the facilities or the support there. And for me, the governance mechanisms have to actually embrace this and embed it to understand why if standards aren't met, was that the case? What was the root cause? Because it isn't necessarily human error. It might be the systems that surround them actually enable something to happen that shouldn't have happened. So I think in terms of the standards, getting them in place is important, disseminating them is important, but once they're there, we have to continually monitor and learn if they don't deliver the outcomes that we expect. It's a crucial question about how you implement best practice guidelines around the world in health and social care. And Scotland has 55 guidelines just in sign. Each of their all colleges have guidelines. NICE has 297 guidelines. It's almost impossible to keep up with the guidelines in your own specialty. Never mind the guidelines that are generic and everywhere else. So therefore, relying on sending guidelines to clinicians is clearly not going to be the final answer. It's part of the answer, but it can't be the final answer. So you have to inside the system make it easy for the guideline to be followed, whatever that guideline might be. It might be hand washing. It might be putting a cannula in the back of the hand in a certain way, five steps, whatever it is. And Scotland has an enviable reputation for applying improvement science techniques inside the delivery of those guidelines. It's not perfect, but people come from all over the world to see how we have implemented elements of those guidelines. So now, when I trained, 100 per cent of people got a needle put in the back of their hand when they arrived in hospital. Now, about 60 per cent get a needle put in the back of their hand because we know 40 per cent of our healthcare acquired infections are from that needle. So we now don't do it in people who don't need it. We've implemented that by applying methods inside the system, not by sending everybody a letter to tell them how to do it. We require the evidence, which Robbie's organisation finds, writes up publishers, but then inside the boards and inside the wards and the GP practices, they then implement it inside that system. And the Scottish patient safety programme is our neatest, you would expect me to say that, our neatest example of how we implement those guidelines. Okay, Tracy. So I was going to give an organisational view about how, when signed published guidelines, we take those in, so we have a process for all newly published guidelines to look at them. The guidelines come with recommendations which are graded by their quality of evidence. And so we make an assessment of our own system involving the local clinicians about are we delivering care that's to that standard or not, and where we're not, then we put in place an action plan to say how will we address that. But I think there's an important point that's been raised about how do we contextualise that for the patient who's in front of us as a clinician, and how do we discuss with them what options there may be, the evidence may say one thing, but their particular context, circumstances, preferences and beliefs may wish them to have a different care provided in a different way. And so I think that's an end part of the process that we need to remember is very important. And the part that I think Rosemary's picked up that we need to get better at is if we don't provide care according to some of those standards, we need to remember to explain in the notes why that is so somebody else can come and see afterwards why that was. The guidelines are to be followed for implementing best practice for patient care. Last week Dr Benny talked about some of the guidelines being single specific condition only, so but we've got patients coming in now, we multiple diseases and processes. So should the guidelines take cognises of that, should we be rewriting guidelines and looking at co-morbidities in the guidelines, which might be complicated? It's a very good question. I come from a general practice background and the majority of patients that we see within general practice have more than one long-term condition. And at times the guidelines for one are to a certain extent fighting against guidelines for another. And one could give examples. And some of that comes from the fact that the evidence behind it comes from good quality evidence and sign and his and so on are very good at rating evidence, but really good quality evidence tends to come from single disease processes for all kinds of research reasons. The other bit about guidelines is there are not, this separation between a protocol and a guideline I think is important. A protocol is something which has to happen and the guideline should cover 90, 95 per cent. And I think what one is using clinicians for is to actually use their experience and learning to make best use of the guideline, but not to be an automaton. I think just to build on that, I mean it's clear a very complex landscape and I think there's a risk of us actually multiplying ever more increasingly guidelines to try to address that issue about individual circumstances. And I think actually the argument is counterintuitive and we should be heading back more into a direction of simplification. Because as I mentioned, we've talked about organisations implementing guidelines on their responsibility and much as Tracy says, our organisation takes that approach, but we've also got to consider the professionals in the system. So the professionals are really have the accountability to sit down with patients and plan what the right treatment is for the individual. And that combination of high-level guideline plus individual clinching discussion is what generates good care. And I think we need to caution against generating guidelines which are hugely detailed, ever expanding and working tandem together with our professional bodies. Sandra is on guidelines and standards yesterday. Thank you very much, convener. I was just going to ask a question in which Mr Flick had already mentioned about how complex it was because of different ideas coming forward. And what I wanted to ask the question was how do you monitor, how do you monitor the guidelines that are being used properly so that there's less complaints going to the ombudsman if they're being used properly? And who is responsible for this? Is it multiple agencies or is there one responsibility there? Or would it be better if there was? I'll just open up to that. Jason, yeah. So it's not a neat single answer, I'm afraid. Nick is right that at an individual level it's up to the clinical team and the patient to decide on the treatment with all of the knowledge that they can possibly gather about what that might be. So you might have a gentleman who's diabetic, who's got depression and has a very complex family history and kids to look after. There isn't a guideline for that. There are elements of guidelines that will tell you how to look after his diabetes, how to look after his depression. There won't be a guideline about how he looks after his children. But to try and make that intellectual decision with, usually, with a general practitioner, actually, initially, it is quite complex. Now, if something is obvious, let's say you have an operation, everybody knows now that you should have the surgical checklist completed prior to the operation. You should know who the patient is, which part of the body we're operating on, the X-rays up the right way around and everybody's had their drugs correctly. That's a guideline from all kinds of authorities implemented by the boards. So Tracy Gillis, as the medical director, has responsibility for implementing that inside NHS Lothian. The surgical teams have responsibility for that. So if somebody doesn't have that done and then has an error, that would be a board challenge. So the board would then look into why that hadn't happened. More nationally, Robbie's organisation would go in and check the numbers of people who are having surgical checklists, the number of people who are following the diabetes drug protocol. So Robbie's organisation, in its scrutiny arm, would then inspect, at a more national level, implementation of guidelines that are appropriate to implement nationally. So three levels, individual clinicians, boards, and healthcare improvements going on. I just wanted to add a point to your comment about simplification. By the time complaints reach me, my organisation, the guidelines become standards against which you're assessing and we assess on the grounds of reasonableness. I think there is a strong argument to simplify and also make clear that the conversation that goes with the guideline is as important as the guideline, because as soon as something says 90 to 95%, if it's not 100%, then often patients can feel that they've not been given the treatment they should have had, their expectations are very high. So I think I just wanted to add that point about simplification, I think is a good idea, but also we do need to really emphasise the importance of the conversation at the individual, and the board, and the patient level. Sandra, do you want to back in? Obviously, just a small coming back in that particular one. Simplification, yes, absolutely, I think we need to look at that, but from what everyone's saying, it would seem a long way off to get simplification on guidelines so that people do adhere to it, because everyone's different, as you said, there's guidelines for x, y and z, and you can't put x, y and z together. So are you really saying that it would be impossible to get to that stage? I'm saying you should standardise what you can standardise and individualise everything else. So there are some things we have decided, as a health and social care system, that are no longer acceptable. It's no longer acceptable not to wash your hands before you do an operation. It used to be that you didn't do that decades ago. In more modern times, we've decided that it's unacceptable to put lines into people's necks intensive care without full barrier protection. That's a guideline. That's a standard. That's now not done anywhere in Scotland. It's now almost impossible to find anybody who has an infection from a line in their neck. That wasn't true 10 years ago. So there are some things we have standardised. And that will continue to be true. It may be there's new evidence which comes out next year that says, this is what you should do about people with kidney injury. This is what you should do with people with dementia. However, underneath that, there are people. Individuals, families, carers, complexity, houses, all the other public health elements which make up somebody's health and wellbeing. That's almost impossible to standardise, and you shouldn't. Which is why general practitioners, healthcare professionals, physios and houses have conversations every day about what would be best for you, what is it we can do for you. And that may be, in some cases, off guideline. It may be that in a conversation with an elderly lady in our house who, if strictly speaking in the guideline says she should do this, she says, you know what? I don't want to do that because I'm 85, I've lived in this house all my life and that's an individual healthcare team conversation with a patient or a carer. And that's individualisation around the standardisation which we've made across most things. Christopher? Well, Jason, but that wasn't what I was going to say if he'd done the general practice line superbly. I wanted just to bring attention to West Scotland Cancer Network reports because I think they illustrate very well how a guideline gets translated into some real work which is then looked at and checked on an annual basis. So West of Scotland Regional Network for Cancer, a specific cancers, here are the things that we should be measuring. The measurement changes, it is a professional-led group, you see improvements year on year and you see improvements on outcome year on year. So that is taking standards but it is this quite specific area of single-disease work but it's very impressive and it's worthwhile picking up one of them and having a look through and seeing how standards get converted in evidence and professional regulation into good outcomes. Just to add a bit about what Jason referred to in terms of context, so if there are 17 million GP consultations a year in Scotland then each one has to have a context and be individualised for the patient in front of that particularly general practitioner. But it's important also to separate out guidelines and standards so healthcare improvement Scotland has inspected and produced reports for the care of older people over the past five years. We've produced 64 reports telling the story in terms of improvements in standards of care but also where there is an need for further improvement and similarly in respect of the healthcare environment inspectorate where we've produced around 270 reports and the number of requirements and recommendations has fallen consistently year on year along with the reduction in infections so MRAC rates, for instance, have fallen by 90 per cent. So it's important to put in context about what we should do and must do in terms of standards but also contextualise it for the individual patient. So far it was specifically on that point that Jason made a want to follow up on things that clearly you must do wash your hands and things like you might consider guidelines which are here some background and how you might want to approach this particular. Is it clear in the ways that are documented what the difference is? Or is everything called guidelines and it's got all that stuff kind of thrown in the one? It's a good question. We're dealing with a human system. There's 160,000 staff just with NHS payslips. If you add social care into there we're well over 200,000 people who are interacting today while we're in here with families and carers around the country. So to naively, as some countries would suggest you do, send everybody a list of must do's or send it, it just doesn't work. So what we do is inside a framework of improvement for the health and social care system we say inside the Scottish patient safety programme these are the things which we say now need to be done. We call them the 10 essentials. So the central line infection bundle, the surgical checklist every time you have an operation. So we make those decisions after a period of time where it's embedded, where we know people are doing it, where it's working, where we have evidence. And then we have other things which are still slightly more innovative. So the acute kidney injury bundle just now about people who are in hospital who have kidney injury who are not in renal units who might be in surgical units. So we're implementing that more gradually over the whole country eventually if that works and outcomes improve we will make that one of our essentials. So there's a kind of scale of evidence and implementation according to where we are on that journey. It would be lovely if it were neat and healthcare work you could just take off the wall the evidence of how to treat dementia or the evidence of how to look after a guy with diabetes and whatever. It's not quite as neat as that and that becomes most apparent if you spend a day in a general practice where the undifferentiated unwell arrive in those rooms with all kinds of diseases where there isn't a guideline for the undifferentiated unwell on the wall. Just to build on that I mean I think at the extremes it's pretty clear to most people about the absolute must do's and some of the things that are guidelines. I think it's the territory in the middle that's a bit more confusing. And it's interesting picking up on Rosemary's points because I think for some professional groups and clinicians there is sometimes an anxiety around the generation of guidelines that something does move into the territory of you must do this because guidelines says it. And definitely we've got quite a lot of material sitting in that hinterland which is really genuinely a guideline to help guide clinical management and conversations but the individual interpretation of that may be that this is something I have to do and if I don't do it I will be found that I've done something wrong. So I think it's absolutely the case we should recognise there is that anxiety for professionals in the middle ground. At the extremes that Jason describes absolutely clear and that's a good example of simplification of the system saying look these top 10 things are things that we absolutely have to do. That works well at the bottom end where you get into specialties which produce great volumes of information about their area it's quite clear that's guideline material. Okay, I know. Yeah, just very briefly so I hear exactly what you're saying and it makes a lot of sense so is there a requirement for something more clarity round about that then to say these are the things that you have to do and these are the things that are if there is that gray in the middle? You know why are some things monitored very closely in other things left apparently? Well, I mean, I think there are two separate questions actually. The clarity question is an interesting one and I guess if you look at if you go to one of the regulators to the GMC you'll see they're very careful about the way they use words and they're absolutely clear about musts and shoulds and I guess in legislation we have that around mandatory and statutory so I guess some careful use of language and a lot of education around that might help in some of those extremes but I think it is tricky in that middle ground where you've got so many different sort of bodies generating information and guidelines to get that degree of consistency where if we say should that's actually something that must never not happen if you see what I mean. Some of the standard procedures and guidelines can be translated down into learn pro modules or e-learning modules. Some of them can take five minutes to do and some of them can take an hour or even longer so I'm aware that some of the education is even delivered in one minute outside the dining room on a high travelled pathway for staff so you can do essential information like one minute scrub for the central line or whatever you need to do so are we able to make the guidelines and what's required must do nice to know need to know in a way that is more accessible for the front line staff. I was a GP until recently and just speaking about the accessibility sign guideline comes as a big book and a smaller book and a leaflet. So there is a real effort made to ensure that as far as possible the main points and the main structure get dealt with in a way that is accessible to staff. So absolute credit to sign in terms of being able to do what you describe. Having said that some of those very small bits still become quite large because something like management of type 2 diabetes requires a lot of thinking and a lot of business going in behind it. In the other bit I think which again from a general practice point of view we've talked about the morass of guidelines that are available. If you look at the kind of diseases that come through you know there's a big bunch of circulatory disease there's a big bunch of respiratory disease there's a big bunch of cancers but it still leaves a big bunch of very rare diseases and whilst one might have a command across most of the first collection very rare diseases even recognising that a disease is in existence and requires to move on to a secondary or tertiary centre can be difficult and I picked up a patient opinion last week which said you know there's a guideline about this rare disease why doesn't my GP know it's a good question but it's illustrated by the fact that you're one of a huge range of rare diseases. Okay Jason So the basic answer is yes of course if it can be summarised into something neat and tidy then NHS education for Scotland or the organisation which will translate that into an educational product and we do that around cleanliness champions we do it around dementia champions if it is standardisable in that form we have an organisation who will do that and then inside the boards and the institutions the practices the hospitals then they would then do that so we run to pharmacy awareness days or hand washing days or whatever whatever the implementation might be and then at some level that's supervised and monitored by those by those individual boards so if it can be summarised and not everything can of course you can do it in that educational environment the other point is the individual clinical teams responsibility for doing their best for every individual that they meet and that might mean in the case where this is a rare disease I've never seen before I'm absolutely certain somebody will have said something about this somewhere and telling the patient this is a very rare disease I'm going to go find out I'm going to and that's okay to say I don't fully understand this process but we're going to come back It's just ready to build on that thing about rare diseases because I think that's a really important point rare diseases are actually quite common so rare diseases are classified as a frequency lower than 1 in 5,000 and we've got a great big manual full of them but about 8% of the population have got a rare disease so whilst individually they are very uncommon and that signposting is critical they actually represent quite a bit of stuff that comes in front of general practitioners or other clinicians On the rare diseases as the chair of the rare diseases implementation strategy oversight group which is a bit of a mouthful but it really is thinking about how in Scotland how are we implementing the strategy that's out at a UK wide level around caring for people with rare diseases and there are a huge number and it's a very very fast changing field so actually the way for patient families to receive the best information and signposting to the right type of care would not be for individual professionals to try and carry that information in their heads it would be to have a level of awareness and access to good resources to know where to go to get the most updated information and how to be able to get professional to professional support about the best diagnostic path or the best support mechanism to then be able to discuss that with the patient and their family So have we got the right systems in place to do all of that? So we do have access to good systems yes and we have a lot of collaboration going on and participation in the right professional networks Alex Thank you convener Good morning panel thanks very much for coming to see us today I'd like to move the discussion on if I may to a discussion about service redesign quality and the tension that that creates for patient groups and in particular communities in geographically remote locations I'd like to start by specifically addressing the issue and I think that Jason Leitch if I could ask you first and foremost there is I know a formula around a certain number of surgical procedures that people need to undertake in order to retain their ticket as it were and that obviously then leads to service redesign if a surgeon is just not getting that daily exposure to perform those surgical interventions then they're relocated to somewhere where the demand is greater and that they can meet that Who calibrates that first and foremost and how is that done? How do you come up with that number and who determines when somebody falls below that that they're going to lose well they're going to lose their edge as it were So for clarity I no longer meet the number of surgical procedures required so that's why I no longer operate The the royal colleges of surgery so there are three four if you include Dublin so Glasgow, Edinburgh, London and Dublin they are the hosts for that surgical standard if we're talking about surgery but it also applies in medicine it applies across other specialties in general practice in other places but it's neatest in surgery as you as you illustrate it's unusual further to be an actual number but it's true in some places so for instance knee revisions if you have a second artificial knee place that's quite a difficult procedure very complex and there is a number it says I can't remember what the number is Tracy might remember I think it's 15 a year or something you have to do of knee revisions because that's hugely complex you're only going to need a knee revision once probably in your life maybe twice but it'd be unusual to have three knees in your life I don't mean three knees I mean three consecutive knees on the one knee so you make a decision as a health system whether you're Danish or Scottish or Swedish that knee revisions will be done in the knee revision expert centre another knee revision expert centre is in the Golden Jubilee and in Lothian you're going to have to travel for your knee revision so at that end it's probably reasonable when you go and ask the public what happens about knee revisions or cleft lip and palate maybe we don't want to talk about cleft lip and palate too much but again 100 babies a year along with a cleft lip and palate it's pretty clear we're not going to do that in five centres it's pretty clear we're going to do that in a very small set of units diabetes hugely common hundreds of thousands of people we're going to have to do that everywhere so there isn't any choice GPs are going to have to see diabetics we're not going to suddenly say you can't go to your general practitioner if you're diabetic you have to go to the Golden Jubilee so the two extremes are okay every healthcare system in the world is struggling with where the line is in that continuum particularly those with rural challenges like Scotland so if you're in Inverness at some level we're going to have to continue to provide most surgical specialties inside that centre but there are decisions to be made around trauma around cardiothoracic surgery around neurosurgery where the numbers are not tiny but they're not big enough to manage huge centres because you just wouldn't get enough care you wouldn't get enough cases if you stay and rake more for the major trauma that you would require to have the skills and there are both numbers and competencies about how you might do that so the fundamental answer to your question is the royal colleges decide and can inspect and can look at what our surgical levels are we then give advice to the ministers about how we should then distribute that care around the nation taking in the views of the public the views of the clinical teams the views of the local elected officials at every level inside those environments but at some level somebody has to make a decision about what's going to be provided in NHS Grampian NHS Pylent and that won't always be everything okay if I may convene it you touched on two particular issues there the cleft palate surgery obviously close to the heart of everyone who represents constituencies in the Lothians because we've now lost our unit there because of the service redesign and also rurality and I think we'd all accept you know that that's one of the negative consequences of that system is I mean how is this reviewed and does it take account of you know the the views of patients in these areas the the fact that we may have an absolutely white-hot physician who is practicing but maybe just doesn't get the you know a few shy of the 50 or whatever they need to perform how much flexibility is there in that so nobody's making a decision on somebody who's just shy of the 50 that it's much much more complex than that I promise you and it's the support teams it's the staffing around them it's the other services that we which we can provide around neonatal intensive care or whatever the system might be it's also where that expertise might live so we moved cardio extensive departments of cardiothoracic surgery into a single unit in the golden jubilee because combining that expertise makes the on-call much more efficient it makes the research base better it's just better for everybody the decisions are made fundamentally on it the advice is given let me correct the advice is given based on the quality of the service provided that even at an official level even when I give advice about what we have to do with a service is based not only on the quality of the clinical care but also on the patients and the families and the carers who are in that environment and we do our best both at local board level and nationally to listen to that conversation and then there is advice given to the ministers of the day about what we believe should happen inside that service most of those decisions are made without any controversy at all most of those decisions are non-controversial the public are engaged everybody agrees and we move on to that service redesign the ones that reach the level where you get them or you make a case for them they're the edge they're often at that edge and then we have to make a country decision about how we're going to deal with that it doesn't always come from the basis of you can't provide that because it's rural Dumfries and Galloway has doctors who are employed by Greta Glasgow and Clyde so they might be getting the core of their work in the Queen Elizabeth and travelling to Dumfries and Galloway, Ostra and Rar to do outreach clinics to do other work Lothian has examples where they have surgeons who go to Grapean where they have surgeons who go to Fife who are maintaining their clinical expertise and their senior group of clinicians together in Lothian or Glasgow where the bulk of the work is and then they go on the road I used to do the clinic in Oban when I was a head and neck surgeon I would do my main work in the west of Scotland and then some young guy had to always go to Oban once a month so I got it so I loved it I went on a Thursday and a Friday once a month and I did surgery in a clinic in Oban they couldn't have a head and neck surgeon an oral surgeon in Oban they didn't have enough work but I would go from my clinical base in the west to Oban to do the work By all means let me open this up to the wider room but maybe you want to come in first Jason on this is that the changing landscape of the NHS will that necessitate a review of how we do this because I'll give you an example of that I was visited by a constituent who is happy for me to name and Dr Patrick Statham who is a neurosurgeon at the western general who was very concerned about the fact that he and his colleagues were persistently having to cancel elective neurosurgical operations because of bed blocking in the wider hospital they had no inpatient beds to receive them and that as we know is an escalating point I think you have the point way off what we're supposed to be on here so you might be able to speak to Jason at the end Right, I will do, no no, that's fair because we want to get on to your accountability so I shall bring you in now Thank you, convener We've had a number of previous evidence sessions no doubt our witnesses will be aware of that and some concerns were raised with the committee around about the idea of accountability of NHS boards so I'll just run through a couple of them so one of them was variations of treatment and care between the boards another one was that complaints that are dealt with by the boards themselves and the other one was about serious adverse effects also being dealt with with the boards and with witnesses saying that they weren't reported either to HIS or to the Scottish Government at that point so my question to the panel and I'll be interested in your views on this do you think that NHS boards are sufficiently held to account for what they deliver? It would be remiss of me not to say something about complaints really, wouldn't it? I think it's worth recognising that in the past few years has been a significant change in the approach to complaint handling and part of my role is the Complaint Standards Authority so from 1 April 2017 NHS boards were part of the sector that had a model complaints handling process that saw significant changes so there is now two stages you try and resolve it you look at it in more detail and if the person who complained remains unhappy they come to the ombudsman now what's significant about that is for some NHS boards this changed their approach from being up to seven stages into something that was much more simplified the systems in place what we now have I think as a challenge is to make it work as well as it possibly can work and that's why I think the role of my office is so important because what we will pick up is where there is inconsistency in complaint handling and it's part of our strategy part of our aim that there has to be learning from complaints complaints have to be valued and we monitor how this happens now I don't think we've reached a perfect place I think we're on a journey collectively in Scotland but to change something now I think would undo a lot of good work that has been done what I would like to see is more education for complainers to get better consistency of how boards actually carry out their complaints handling we do this through a variety of ways for example my staff attend a network meeting of complaint handlers but there is still for me a gap in this and that is at the corporate governance level it's very difficult I think to separate out clinical and corporate governance here because what we don't always see and I have to say this is my observations based on seven and a bit months is I still don't see the right level of connect between clinical and corporate functions if you like so we see it in responses to us where there is clearly a corporate explanation for a response to a complaint but I'm not always convinced that there has been the right level of clinical input into that and if it's true for us then I suspect it is also true when boards and organisations are responding to complaints so what I would like to see and which my organisation will continue working away at is to try and shift the culture so that it's more about learning and valuing as part of that wider framework not just of itself but also to embed it into governance system so that rather than simply monitoring numbers and how many we upheld how many we didn't boards particularly in governance terms play a much more active role in the more qualitative things about views about the quality of care the standard of care how both parties felt about it so that what we have is a better understanding of why we're getting the outcomes we want to need or why we're not getting those outcomes and yes it can link to standards as we discussed before but ultimately I think this is about a different approach to how we use the information through organisations like his as well so yep we're on a journey we've got I think a good system in place but we need really still to embed it more at a governance and a cultural level OK, Tracy So really just to build on that point I think it's helpful to think of a complaint as a patient experience adverse event because that's really what it is so if we take adverse events I think it's something very important that as a system we need to own and understand them there when we look at adverse events now then they're not about as Rosemary said earlier they're not about pointing the finger or blaming an individual they're about understanding what's happened and what do we need to put in place to make sure that doesn't happen again and that needs to be done by people who are working within that system I think the risk if it's done entirely from outside then there's not an ownership to actually change that system and embed that into everyday practice and I understand the point about the interwovenness of corporate and clinical accountability and I think that's about how open you are as a whole system to trying to learn when things aren't going according to plan so we meet every fortnight as a group of executives not just the clinical members of the team but the non-clinical ones as well to talk about significant adverse events and what we've learnt from those to talk about serious complaints or difficult cases we have in our system and that's led to a much greater focus around the board table in what's happening in our system and what do we need to change I think that's something that you said there telling that you want to call it a patient experience adverse event but I bet you most people just want to call it a complaint so you know this to me is that's I have to say I think that's an indication of where there's a gulf between the people who are making the complaint i.e. the patient and the board and others who want to call it something else who want to pretend it's something else I'm sorry maybe I should have been clearer I'm not trying to pretend anything really I'm trying to say that when a complaint happens for that individual and their family things have not gone according to plan and that's why we would think that when we're not trying to call them anything other than complaints that's what we call them it's it's maybe I didn't explain it clearly okay I she not and then I'll come back now just I suppose wanted to reinforce some of the points that rosemary was making and the importance of that expectation within an organisational culture of openness valuing learning and in and basically that continuous improvement loop that reinforces the need for for that learning and to recognise and I think the discussion already this this morning has emphasised the complexity of the health and social care world and the interplay of of of so many different elements that come to come to fruition to some extent when somebody either makes a complaint or there is indeed a significant adverse event and and I suppose from an IJB health and social care partnership point of view the point I want to sort of reinforce again is the need to recognise that that we are talking about individuals who have not just got complex medical circumstances in terms of co-morbidity of a whole range of medical requirements but their social circumstances obviously play a major part in that and in their health and wellbeing and the interplay of health and social care services in the resolution of a number of both those health and wellbeing issues as well as the resolution of a complaint or a significant adverse event being considered. I think that the importance of learning and valuing that learning and that openness is one that certainly within the IJB that I report to is one that we've been really reinforcing because it's the only way it seems to me that you actually reaffirm that need for accountability whatever the processes are whatever the governance arrangements are the actual ability of the organisation to recognise when something has gone wrong and to then admit that, accept that and move on is I think the the value of the inherent culture in that organisation. Brian, is it on accountability? Yeah. Yeah. Thanks Brian. Thank you, good morning panel. I think I'm interested in adverse events and what constitutes an adverse event and has that consistently applied across all health boards and whose responsibility is it then to review the levels of adverse events and what happens if there's major changes in numbers of adverse events within a health board? Thank you, convener. In terms of healthcare improvements Scotland we've created a national framework in terms of what an adverse event looks like what the processes are and the categorisation of adverse events from permanent harm through to potential to cause harm and near miss for instance. And what we've done in that framework is seek to put in place the building blocks to allow local NHS boards to move to a system of openness, of learning as opposed to a system which frankly can look like defensiveness and evasion. So that is an important part of putting in place the building blocks. So going back to the point about accountability there is a very clear line of accountability from NHS board chief executives to the director general of the health service, the chief exec of the NHS ultimately to the cabinet secretary and into this parliament. So the accountability system in some ways in Scotland is simpler than south of the border but we in healthcare improvement Scotland have got a role in terms of the improvement support, the tools, the helping to build that open culture and also in terms of subsequent external assurance and scrutiny. So one of the key points for healthcare improvement Scotland is about our powers or our independence. I think those are pretty clear. What is important for us is we have that system of follow-up and ensuring that progress is being made. Christopher. Thank you. Following on at a board level the NHS board through our healthcare quality and improvement committee monitors the numbers of significant adverse events and there is a timeline for responding and getting investigation and where we are in the investigation of each of those gets monitored and then the board is interested in the outcome of each one and what action we have taken and following through. So there is a clear line of accountability. I think the issue of accountability is pretty laid out and very straightforward. I think the question went back to this idea about the degree to which boards should internally handle things versus how they should involve people outside. And again, I think there's a, you know, a lot lot that can be done around that but again, I think we sometimes fall into the trap of sort of language. You describe it yourself is that we talk about, you know, different processes we go through and regulatory organisations will also describe them in different ways. The third party that's critical and I think is where we're trying to move forward on is how we involve the people who are actually involved in the complaint or the issue itself. And I think that's when you really sort of make some difference in terms of giving accountability some tangible benefit to people. So you're quite right, people for people, it's a complaint but there's nothing better than having that direct dialogue with someone to say what is it for you rather than saying that we're trying to categorise this as, you know, our complaints system still has sort of language such as whether a complaint is upheld or not. Well, the business isn't trying to decide whether someone's complaining or not. They've written a letter they're complaining. So it's about understanding. So I think some of the stuff around duty of candor will probably help. I think increasingly involving patients right at an early phase in resolution or involvement in investigation will also help. And I think there is a balance between internal and external investigation as well. Tracy. So I was just going to add into one of the things that we've started trying to incorporate into our adverse events processes to actually ask the family or the individual what questions would they like to see answered as part of that investigation and it makes for far more powerful investigation. Okay, I'm still on accountability. Brian, you got a follow-up in this? Please. I could. And what I'm hearing there is that accountability stops at board level. I asked a specific question is who is counting the number of adverse events happening with an individual boards and what happens if that number changes which we know is a huge disparity across health boards at the moment. And I didn't get an answer from that, Mr Pearson. Oh, yeah. Yeah. Can I pick up that point? So I think there is an issue about consistency of reporting, also the quality of the reporting and also the quality of the investigations. The thing that I would caution against is creating a counting system alone. The important point is about the learning. So the experience in England when they created a national reporting system was it created a very large database. That database in itself does not lead to learning. So how do we actually create a system picking out the points for instance by the the ombudsman about there's a genuine system of openness and learning. Duty of Canada will be part of that but it's also a cultural shift that is required. I'm still not getting my question answered here. If there's a huge change within adverse event review reporting within a health board who's counting that and what then happens after that? Who's watching that? Cos all I'm hearing just now is that a board is responsible for their own adverse events and I completely understand that what we're trying to do here is create an environment where of openness and learning. But if you're leaving it to the board himself and nobody like it and we know HIS is gone they're not responsible for counting adverse events or monitoring adverse events numbers within a health board if there's a huge change in that surely that must instigate some kind of reaction. So what we see in terms of system the system is in terms of the numbers is only part of it. So if we see changes in patterns of incidents or concerns then there's an issue there for the individual board also there's in the context of their clinical governance but we have a broader role in healthcare improvement Scotland in terms of that external assurance of the systems and external assurance in terms of the quality of care. So that's all part of the role but what I would really caution the committee against is a system which we're counting something on an indicator what we want to be doing is actually trying to create a culture of openness and transparency which is frankly some of the issues that we've discovered in our recent reviews. So in terms of Ayrsharnarn it was about fairers to follow protocols in fetal monitoring there was a lack of involvement of the families and the quality of the adverse event review itself was put up. So what we're trying to do is to build a system which takes us away from defensiveness to openness and I think that that will be all part of the the approach which healthcare improvements Scotland is seeking to embed but this is a cultural shift. I think we're trying to find as to who knows the numbers though and that's a critical thing maybe Jason can help us on that. You're not you're not I'm not going to give you a neat answer which isn't I presume you can predict that. There are some reportable events that the government get knowledge of so we know how many infections there are we know how many stillbirths there are we know how many very very unusually but how many people have an instrument left in after surgery so there are very very unusual and rare events that we know a number for and if that number changes dramatically infection is the neatest example even now because infection is so unusual even a very small number of infection gets activity so we would contact the board we would ask them what they were doing about that ward with Cdiff or E. Coli or whatever and we would react and that reaction would be principally to check their monitoring was adequate if they needed external help for that we would we would do that if we felt that system of older people's care was failing in some other way we would contact healthcare improvement Scotland and we would ask them to scrutinise that service. The addition of adverse events into a table is not going to help us because the definitions are so broad and so varied that individual clinicians are making those judgments we have to rely on the boards to have processes in place around clinical quality committees morbidity and mortality meetings that happen regularly so the clinicians will talk about the adverse events that happened talk about the failures talk about the good cases that happened in there we seek knowledge from the complaints and adverse events are unusual let's keep it in context millions and millions of transactions every week and it's still unusual to have a complaint or an adverse event we have systems in place for learning from both of those elements a few years ago we decided we didn't know enough about feedback we didn't we knew the complaints and we knew the adverse events but we didn't know what the vast majority of people were experiencing so we decided to use care opinion so care opinion now has 9,500 stories where it's positive negative mixed who come back with stories that the system then learn the MSPs in this room get reports from care opinion if you've signed up for it if you haven't you should and you get an understanding of what's happening inside the system the boards and even below the boards inside the local systems so if you're a GP practice if you're a surgical environment focus on yep adverse events and the consistency and inconsist itself reporting on that I think that's what we're trying to get to the bottom of here so if you seek a national reporting system for adverse events I think it's the wrong answer most countries who have it have abandoned it and most countries who still have it just have a big database of counting yeah it's actually not what I'm asking here what I'm getting to here is that if there's a huge change in the number of adverse events reported in the health board that to me indicates that there's or could indicate that the bar is being set at a different level for whatever reason who monitors that I'm not saying I'm not saying the Scottish Government monitors that through performance management frameworks where we would monitor their board papers we would monitor their governance committee papers we would know if that happened well in that case what what then protocols are put in place to change that because that is not my experience at all and when I asked that specific question in an HIS review I was told nobody monitors the numbers of adverse events within any health board well you asked a broader question on that you didn't ask just who monitors the individual numbers we we monitor the government we have a performance management infrastructure that meets with boards on a regular basis that monitors the board papers that sees the minutes that sees the data along with healthcare improvement Scotland who are involved in improvement science improvement organisations inside those boards and the scrutiny so between us if such a thing happened that you'd describe we would know be helpful here in bearing in mind time I think the committee is probably right to you to clarify the situation and maybe get some more information on you on that is that helpful okay thank you yeah I've got Jenny Jenny and then Alison thank you convener and good morning to to everybody who's here today just a specific point Dr Macintosh with regard to your submission you mentioned that evidence about safety and effectiveness come through the DATICS incident management system and last week at our evidence session we heard from the Royal College of Emergency Medicine who flagged problems with the DATICS system they said that it hindered rather than helped and that it was a barrier to changing a culture of resistance to learning from mistakes on the NHS would you agree with that I think that thank you I mean I think there are questions about how it is used in different boards and the the there is there is something about culture it I think it probably accurate to say that it has been at times a barrier and some of that will have been in terms of just how easy is it to use it so there's kind of IT solutions IT access but and some of it then is what is the response again it picks up on this idea about are we using complaints as a measure and a monitor which does something about saying you haven't performed well a bad person or are you actually using it as a learning experience which is what we are tended to do within Lanarkshire increasingly and that gets a better response there are a lot of things that go into datex which actually never really see the light of day and they're not of of huge benefit but there are huge numbers of things which come in tend to show us patterns tend to allow us to make changes before they actually reach the level of requiring significant complaints adverse event reviews and so on and that huge area where we haven't actually got to a significant event we may not even have got to a near miss but things could have been done better as it can be improved and we're tending that gets picked up in datex so it's not perfect yeah I think there's something about expectation here it's a relational database it's better to have something where we record what happens than not to have something where we record what happens the question is how you make it improve its utility for individuals and how you make it bespoke for different purposes so I think that just requires an ongoing bit of work within each of the boards so we've done lots in terms of customising it for different settings making it easier for people to put stuff in so you can just go into a front page on the intranet and within one screen enter something that's happened in your area and assign it to one of your line managers to have that looked at so I think there's a huge amount we can do to improve it I've heard over the years lots said against all sorts of IT systems I haven't met anyone who's loved an IT system when it's first arrived and I think we should just accept that recording stuff is a really good thing to do and then we have to do a pile of work around the culture and the processes and the behaviours about how we use that information to learn from it OK, Jason I watched the evidence last week and I was this was the bit that surprised me I was quite surprised by Dr Chung's evidence and I intend to make contact with Dr Chung and see how we can help I also asked some other boards about Datix Datix is just a company Datix just happens to be the one we use mostly in the country and most of the feedback I got was not the same as Dr Chung's it was a much more nuanced approach that Nick describes frontline teams adapting it for their own use front pages where they could enter it very quickly morbidity and mortality meetings where they were using the data and the knowledge very well Grampian was a particularly good example that Nick describes Lothian had some particularly good examples for me this week about how they have adapted it for use there's a Datix users group so there is a national thing that comes together to share best practice amongst Datix users so we get better at it as a whole country and I'll make sure Ayrsian Arran are involved in that and see if we can particularly the ED which she described we can see if we can make that better Conversations with staff it comes up very very regularly certainly in the it does with me too yes not in a positive way I have to say that from my experience people come to surgeries or people I know Robbie Yeah just to echo the points that Datix is a system that allows information to be imported what's really important is we take the learning from that system and how do we ensure that it's embedded in day to day practice and that's the key thing so there must be a feedback loop so there was an incident then the feedback and then the learning now I think that's the key bit in terms of what we're trying to introduce in Scotland in an adverse event framework and that is not just important for staff it's important to give meaning to patients who wish to share in that learning as well and I think that's a crucial part of what we're seeking to do here and when we're trying to bring together adverse events, complaints management will be touched on that and duty of candor so together we need to see them in the round Still on accountability Alison Yeah well on these issues witnesses last week spoke of the lack of that feedback loop and I think Dr Benny said reported that there's a culture of learned helplessness in the NHS because staff see no point in passing on bad news as they don't think anything will happen I think the SPSO in the written submission really highlights the importance of learning from these events but also I think has concerns that that doesn't always happen and if we're looking at learning we keep hearing about a need to change the culture but I think the witnesses last week maybe suggested that it's difficult to change a culture where resources and capacity are really really stretched and David Chung last week in his evidence you know he said he you know he felt really uncomfortable that a doctor as a doctor he had protected CPD but the nurses for example who are responsible for delivering so much healthcare in Scotland don't have that same automatic entitlement to that time that they're having to come in on their days off and I'd just like to ask why aren't the bodies here insisting that all medical that all professionals who are working in healthcare have access to CPD because if we're expecting people working in this environment to take on all of these guidelines and standards and deliver them I think it's really difficult the RCN employment survey found that 37% of members in Scotland reported not receiving any CPD in the last 12 months you know if they have to keep up to date with you know how to insert various you know how to carry out various practices how how can this be sufficient Mary you want to do them thinking about this word accountability we're taking quite a sort of process governance approach to it but actually we're accountable collectively to many people in many different ways and the issue about datex and you know staff are saying we put lots of things in I hear lots of talk about learning I hear lots of talk about improvement but actually what we also have to see and this is important to users of our services is something has to change as a result of it if we constantly ask for information constantly ask for feedback constantly say we're learning from complaints and nothing actually happens all that will happen is it will undermine credibility and trust so I think coming back to points that you've made here about it's also about how we have that feedback in a different way at front line level at the conversation about how the care is delivered and it's the danger is we become too focused on the numbers and the reports and the governance and we lose sight of actually accountability is also about experience and how people feel about their healthcare and their health provision and that's where we have to make better use of all the information we gather the other point I would just add is in relation to his as well the we're one of a number of organisations who provide information to his intelligence group and one of the things that I see as an obstacle for my organisation is our ability to be able to share the information that we have we have very rich information but under no illusions it's in a very small if you like sphere because it is specifically about those complaints that reach the ombudsman and what we find a challenge very often is that we can't share some of the information that we think would help and help develop services so that's an area that I'd really strongly urged to be looked at is how we can share information so it is not just within boards but it is across boards and across Scotland too A quick point on datex just again in the context of integrated governance arrangements datex within the Glasgow Health and Social Care Partnership provides a huge amount of information and rich data the accessibility of that information and the ability of other social care staff for example to input to the system is more limited and as we begin to progress and obviously hope to improve a range of governance and accountability processes that's one aspect the other quick point was really again on the feedback loop and recognising that the importance of having the structures in place that allow for reflection on a whole range of activity but particularly at adverse events or significant clinical incidents significant case reviews and having that built in a dissemination process built in is really important and again ensures that staff feel more involved in the developments that come from the learning from such events Nobody's answered Alison's question about CPD and people's learning and their opportunities for that we'll make sure that is answered before we leave Alison okay but I want to keep on this accountability thing first okay dash you want to come back in Yeah I just wanted to follow up on the accountability more in terms I suppose of this idea of high level oversight you know maybe above the boards we had some evidence last week that seemed to be suggesting and I'll be happy for this to be contradicted if that's the case that there wasn't an awful law or there wasn't a process necessarily for sharing good practice between boards so I suppose I would ask you know if there's a board you know over here and it's got really good processes leading to excellent outcomes and then perhaps there's a board over here which is perhaps struggling in that area from reading the written submission from HIS it seems to be more of a collaborative approach that you take with boards in order to kind of work on improvements is there any ability to compel should there be an ability to compel boards to share best practice Who would like to go first Robbie I think the point is that in terms of building commitment and building the world then compliance has some limitations in doing that so one of the things that we have have just published in healthcare improvement Scotland is our impact report which sets out a range of excellent examples of improvements in the quality of health services in Scotland so we know there's been a 72 per cent reduction in ventilator associated pneumonia we've had a eight and a half percent reduction in hospital standardised mortality and in that report which I'll happily share with the committee is in it's a public report is it gives lots of good examples and many of the examples come from colleagues who are here today around the table so I would really caution about something about a letter that comes out to implement this is a much more nuanced approach if I can though just say something about more broadly about sharing intelligence and good practice by healthcare improvement Scotland so touched on earlier by the ombudsman about sharing intelligence so we responded directly to mid-staffiture in Scotland by assembling the key individual organisations who had the intelligence in Scotland so one of the failures on mid-staffiture was a failure to share a failure of regulators to act and to act on intelligence so we now meet with Audit Scotland we have the intelligence from the ombudsman we have NHS education for Scotland who gives an overview of the quality for instance of the training environment for junior doctors and we have that intelligence now in Scotland in a room in which we can then decide whether we need to act in concert or act individually and that's the important safeguard but it's a safeguard in respect not just in terms of concerns and where boards may be having difficulties in their service provision but it's also increasingly an important part of sharing good practice so that's why we published earlier this year the annual report of the sharing intelligence group which outlines good practice but also it's quite overt about the challenges so there are a number of mechanisms and the Scottish patient safety programme is a great example of where we are actually sharing good practice and ensuring it's reliably implemented and spread across Scotland but one of the challenges internationally is how we spread good practice consistently and reliably there's no simple answer to it but I think we're making good progress in Scotland Rosemary are you previously there's been some suggestion that there's some legislative barrier to sharing information is that anything that you can shed light on? If it's anonymised can't be attributed to anybody personally just general intelligence type information then we're pretty much like others there are some named organisations that under certain circumstances we can share specific information with but as an ombudsman organisation my own legislation has restrictions which I think are a barrier and I could share more I think about at an individual level about patient care from what we've seen from complaints and I'm currently able to do because of that Can you ever be right to us with the detail of that? Absolutely Yes It would be very interesting on that I think Yeah Okay Ash do you any further? No Okay I wonder if I could ask in terms of accountability at board level Some people feel that in terms of territorial boards that there's a bit of tokenism in terms of accountability I had a look just for speed a look to NHS Lothian's board papers for the last couple of months October the board was presented with 307 pages June it was 568 and in April it was 514 pages of information to board members to presumably scrutinise and sign off or interrogate Is it realistic to believe that presenting a board with 568 pages those papers are going to get the scrutiny that they possibly deserve? I'm answering that since it was our papers that you looked at then I agree it's an awful lot of information to look at I think it's important to see those board papers though in the context of the wider way that the board works so where a governance committee is chaired by a non-executive they have as a set out in the submission in fact things that they're providing assurance against for the wider board and so there's a system that feeds down from that but there's also a board development seminar for example where we might explore a topic in more detail that would allow the board paper to then be more of a highlight report but the clinical governance committee healthcare governance which I guess is the most pertinent committee for this discussion this morning receives a lot of papers but actually my experience of sitting around that table is that members of that committee do read all those papers and they're I find that difficult to believe I seriously find that difficult to believe having sat on a local authority where we were presented with massive amounts of paper I know from experience that people do not and I don't believe NHS loading is any different or any other NHS board well I was going to say so I do know that sometimes my non-executive colleagues will ask quite detailed questions or if things are there that are not in a section for discussion they'll ask for that to be moved into a section for wider discussion so I can only go by my experience an average reader if they were reading a 568 page novel it would probably take them a week or so maybe I'm just a slow reader but I just think that that is not if we're looking for proper scrutiny and accountability then presenting that kind of volume of stuff to an annual is it a monthly board meeting or a bi-monthly? so the board meeting is bi-monthly yeah I just personally think that's not credible so I do understand that it's a lot of information so I think that is how we would try to for example where there are particular topics to have a presentation on that topic which then sometimes makes that easy to access for people the reason I'm saying that is that if you have an issue that's a very difficult issue or that you want to go through the board without much controversy it'd be very easy to hide them in 568 pages of documentation so that people would easily miss it or statistics that might be thrown up a concern you know I'm just a skeptical tasting sorry so let me back on that with we're not trying to hide anything Mr Finlay and we're not trying to cover up numbers that are contained within the board documents I haven't looked at those same pages that you have I imagine those board papers are divided into items for discussion which will be a smaller set and items for whatever the noun might be in there for voting for whatever and all of the member the board is the peak of that particular governance pyramid and underneath that are the committee structures so there's a committee of audit there's a committee of clinical governance and there's a and they will I imagine send papers to the big board meeting that they have scrutinised previously so the chair of the clinical governance committee will be around that boardroom table and will be able to very quickly say the governance committee looked at this and this is what we're doing you have a good generic point and that is what should the board do and I go round these board meetings and I often present at them or discuss with them and boards in the last 10 years have matured significantly in the health system and increasingly in the IGB world into a world where the quality report however you want to describe it is the bulk of that conversation now there's a big conversation about finance inside that quality efficiency but there's also now a conversation about the quality of the delivery system inside that and they're very very robust conversations I haven't been in a board where there isn't a robust conversation about the quality of the delivery system in relation to IGB's new comment about the lines of accountability there and how that operates very similar to the way that Professor Leitch has identified so again there's a Finance and Audit Committee there's a performance scrutiny committee that sits under the integrated joint board also just in follow-up to your other point I'm sure again others will have done similar but a number of development sessions with focused reports and presentations on certain areas particularly around finance but particularly also about how that relates to patient and service user care and the impact of or the potential impact of any changes so those development sessions particularly in the earlier days of the IGB have been particularly important so that members which are obviously non-exacts as well as councillors elected members within the city have had the chance to get information on perhaps slightly more informal type of presentation and encouraged to ask obviously and supported to ask questions and therefore have a better sense of the field of operation but particular emphasis on the impact of decision making on patient service user care service delivery Thanks very much I'm not going to argue with their point that you know 500 paid documents not a reliable single way to transmit information or to run accountability and I think what everyone's describing is that there are multiple layers of approach and we've heard some of them which is about tiered governance systems which start from sort of ward level all the way up to the board involvement of non-exacts in other types of sort of activity for us you know some of the additional things is that we've done quite a lot of work really about how do we present and interrogate data so development stuff with the board about how to actually look at data and ask the right questions we do stuff in terms of understanding our systems and processes for the board and thirdly which I think is most important is actually getting the board members to meet the teams that are involved in this because I think when you put together that sort of review of information and understanding a system and process and you meet the people that are involved in delivering that then you get a much better idea about whether you can be assured that what you are seeing or what assurance you're getting is valid or not Emma, did you want to come in? It's a quick point about near and missing significant adverse event reporting across the IJBs because we're focusing on boards but health and social care integration is major now for us so I'm assuming that we've got the correct or the same processes that we follow for the IJBs as far as SAEs or near misses? You've got processes which are compatible complementary maybe but not exactly the same so you have got exactly the same process within the health element of the health and social care partnership and you have critical incident reviews significant incident reviews and processes within the council and social care element of the partnership what we've worked really hard to do and particularly in my role has been to try and bring those together to make sure that we're following one overarching policy and to make sure as well that where a patient or service user is in receipt of a range of services and we've particularly looked at multiple and complex needs so for example individuals who are receiving addiction mental health, criminal justice potentially services through homelessness that we are looking across the way at the issues that have impacted on whatever the event has been we've taken a lot of learning from mental health particularly in relation to the emphasis on again some of the points that have been made before openness, involvement of the family wherever possible and certainly being really clear if there's not involvement of the family both in the process of the investigation and the feedback loop and then that bit around making sure that staff have the opportunity to learn from those events and learn through as indicated dissemination in whatever the appropriate forum is so one of the issues for the IJBs certainly in Glasgow and from the health and social care partnership is about making sure that you are not as far as possible not duplicating effort but also not allowing anything to slip potentially between two stools and that's that complexity of health social care relationship between the IJB and the health board and in a Glasgow context Greater Glasgow and Clyde six local authorities a number of services that have responsibility across have cross-cutting influence on all of those so it is about trying to pull all of that all of that together in the last five minutes so we'll need to be absolutely rapid fire here and I've got quite a number of people still wanting to come in so Miles thank you for me I wanted to return to culture and it follows on from a point you said because a lot of the evidence which we've taken from people has actually been about two things firstly from people who work in the health service the fact that they now feel that they have a culture driven a culture in the NHS which is just target driven and they're being forced to try to work towards that and secondly for families families not being included and actively excluded and we've met with a lot of people who've felt that especially within CAMHS and mental health so I just wondered around the table for people taking decisions what they felt actually the fact we've received that as evidence how they feel the health services Andy, I want to issues around the whole issue around the culture within the NHS has been a recurrent theme in this about people saying that there's a negative a kind of blame culture within it people afraid to report issues or feel that nothing happens when they do and that they're feel intimidated by that we've had that from middle managers and we've had it from people working on the front line I'm not sure that there's exactly a response but there is the thought process which Don Burk uses from IHI talking about three eras medicine the first era being the we know best the paternalist the second era which we are probably in now which is about measurement and standards and everything that can be counted is counted and what you count counts moving on to a professionalism and more moral era and that I think is the change which is being described by many people I think it is absolutely correct that the involvement of families has not been as good as it should be and we have picked that up and there is change on going so I'm involved in a significant adverse event review at the moment and it starts off with the question to the family what is it that you would like answered that create as Tracy pointed out a powerful check powerful question but actually we found other things as well that we needed to go through so it's not all of it but it's really important and in terms of a report back to the family that is specifically done with the offer of meeting so it is changing Jason I think some of what Mr Briggs describes I think we are on a a little bit of an evolution within western healthcare to be more inclusive of patients and families and carers and we've tried to do that in Scotland and if you read the Nuffield Trust report it would suggest that other countries should come to Scotland to see some of that it's not perfect and there is still lots to do the realistic medicine the CMO's realistic medicine report talks a lot about shared decision making about making those decisions with families and it goes right back to the beginning of our conversation about the individualisation of care though what matters to you work is globally leading about conversations from education services through care homes through hospices and primary and secondary care about how you would involve patients and families Sir Harry's report on targets and indicators last week helps us move the conversation on a little about that target driven culture how we might change that for front line teams in particular some of the scrutiny though some of the accountability that we've discussed seeks numbers seeks targets and indicators so we've got to get that balance right I think we have in this conversation we've had a good conversation about where that balance lies but we have to release that front line that the teams who are actually seeing the patients and families to do as much of that work as we can and yet still hold the system accountable for it Will we do that then? So at the moment what we are hearing is about staff under huge pressure because they're not enough with them they need resources and because of that pressure they are finding it difficult to for example nurses do their CPD they are finding it difficult when they do make suggestions to improve things that that is being stifled by from a top so how do we change all that culture? That's when that's true but there are other times when that isn't true I had a trip to NHS Gramping a couple of weeks ago where I went to a number of teams and I don't think they just took me to the nice people but they took me to a number of teams where they were empowered where they had chosen to improve things where they had had learning inside the environment I met the junior doctors in the evening for pizza and asked them what it was like inside that environment it was of course not all perfect of course there was opportunity for things to get better but in the main they were very very happy with the environment in which they were working they understood the resource constraint the staffing of course but they also talked about the reduction in infections the fact they hadn't ever seen a central line infection they hadn't seen a case of seed of sale because they were gone and the nature of the culture in which they were working in NHS Gramping did the same in Highland the following week it felt very similar lots of work on clinical efficiency lots of work now we need to make sure that applies universally across the 160,000 staff as much as we possibly can and we've touched today on how we might get a balance healthcare improvement Scotland's work the board's work on trying to do that but don't leave with the impression I think it's fixed or perfect I don't I spend my days trying to make it better Who was next? Colin Colin Can we hear the issue was on integration so I think it's been covered Oh it's okay Sandra I just wanted to ask about patient involvement obviously we know that I'm not saying your hands are tied but basically you don't have any legislative power over health boards in that respect and you know lots of people have said that they feel it's a tick box exercise when they're changing services and if I could give an example on my own constituency minor injuries unit where it's based in Partick Partick was the only place it wasn't asked to consultation and it was the people themselves who pushed to get that consultation in the area where they're going to remove that service so I just wondered do you agree with the people when they say it's a tick box exercise or is there something we can do to improve the fact that if it's not a tick box exercise how do you convince the people out there who are using it that they generally add consultation exercises if they're changing services? Colin Yeah absolutely it's a very important point and indeed in evidence I've given to this committee in previous attendances is the importance of the quality of the engagement from the very start as opposed to being presented as a done deal down the track and I think one of the the key things for me is we start to think about every bit of service engagement and redesign not just the bits which are controversial in the major cut-off threshold and that's really important in the context of the future work for me of the Scottish Health Council in that quality assurance that there is genuine and meaningful engagement in the redesign of services if we could just pick up the point that Mr Briggs made earlier about child and adolescent mental health services absolutely crucial about children and adolescents but their families being supported they're not just informal carers as one of my colleagues said to me the other day they're actually intensive carers for those individuals and today we're at an event for child and adolescent mental health services which would be an opportunity for these families and patients and carers to be involved in the design of CAM services in the future so I think we're on a journey but I recognise the points I was very speaking at this morning's point you trumped it Okay, we really are push your time we've got the minister coming in for a piece of work could I just ask a couple of very quick final things that we haven't covered and if you can answer very briefly on why some service standards are monitored and others aren't? Andy Wight wish to answer yep Robbie so we have older people standards monitored regularly through the programme of inspection we have HEI in standards monitored there's a matter of prioritisation convener is also an issue in terms of some of the standards that are out of date so it's an on-going programme of refresh as well prioritisation because for the patient they would obviously want to ensure that they're being treated to the highest standards but who then prioritises? so there's a prioritisation process involving patients, clinicians in that design but also there's an issue of ensuring that those standards are up to date and making sure that they're relevant so for instance the work we've been doing in the national screening programmes that were reviewing breast screening standards because technology has moved on the environment for breast screening services has changed quite considerably over the past five or six years so there's a process here of prioritisation but I'm not quite sure then so in another field who would then make the decision that that's not a priority? so it's not a priority about what's the standard it's actually a priority about how we actually deploy our resources so we made a commitment that in terms of the the £3 million that we spend on scrutiny that we should be actually investing time in inspecting quality assuring the dignity and respect afforded to older people in our hospital so that's why we have a very comprehensive inspection programme for older people and indeed in the context of the Vale of Leven that's why we have a very comprehensive and rigorous inspection programme for HAI Two final things I want to ask I'll just put it on the record if people can maybe provide as we information afterwards is the issue around CPD that Alison raised about how we ensure that under staff pressure staff are getting the opportunity to ensure their practices kept up to speed and we've heard evidence that's not the case and the final thing is about how we ensure dignity and respect is absolutely built into the system so if maybe people could follow up the information after and send that to the clerk and team that would be really helpful we are really pushed for time so thank you very much and we'll suspend briefly The second item three is subordinate legislation we have one affirmative instrument to consider as usual with affirmative instruments we have an evidence session with the minister and the officials on the instrument the instrument we're looking at today is the public worries joint work in prescribed local authority functions et cetera Scotland amendment number two regulations 2017 draft welcome to the meeting Eileen Campbell minister for public health and sport Peter Stapleton carers policy Brian Nisbeth health and social care integration and Ruth Linne lawyer all Scottish government can I have a brief opening statement minister thank you convener and thank you for the opportunity to speak briefly to the committee about oh sorry in stereo Neil yeah thank you again then to for the opportunity speak to the committee about these amending regulations you'll all be aware that when this parliament passed the carers Scotland Act 2016 in February of last year the integration of health and social care was already under way across Scotland as the joint committee will recall the the purpose of the public body joint working prescribed local authority functions regulations 2014 is to provide for the mandatory delegation of adult social care functions to integration authorities so that these functions must form part of their strategic commissioning plan for delivering health and social care services locally we've put forward this instrument to further amend the principle regulations so that they take account of the provisions in the carers Scotland Act in the same way if approved this instrument will remove section 3 of the social care self directed support Scotland Act 2013 from the schedule of the public bodies joint working Scotland Act 2014 as provision is repealed by the carers Scotland Act 2016 when it fully comes into force on the 1st of April next year in addition this instrument will prescribe the functions conferred on a local authority under section 6, 24, 25, 31, 34 and 35 of the carers act as ones which must be delegated to integration authorities these sections of the carers act cover a range of local authority functions in relation to carers section 6 for example will require integration authorities to offer and prepare an adult carer support plan for identified adult carers section 31 will require that they prepare a local carer strategy which will outline how carers will be identified and supported in their local communities it's important to note that in line with existing integration legislation the requirement to delegate these functions only applies so far as they are exerciseable in relation to adult social care delegation of these functions in the context of children's social care remains a matter for local decision I want detail for the committee all the functions under the carers act that must be delegated as they are laid out within the supporting policy note for these regs but I would like to emphasise that the prescription of these functions will ensure that there is legislative synergy between the carers and public body's legal frameworks and allow functions with stem from the carers act to be carried out within an integrated health and social care context supporting these changes will allow integration authorities to continue with their strategic planning and commissioning priorities and it will ensure objectives to improve outcomes for carers which we as a Parliament put in place when we supported the passage of the 2016 act can be taken forward as an integral aspect of the integration of health and social care so thank you again convener for allowing us to give evidence and happy to take any questions you have on the regulations okay any questions from any member nope okay if that's the case we move on to the next agenda item which is the formal debate on the affirmative SSI in which we've just taken evidence could I remind the committee and others that members should not put questions to the minister during formal debates and officials may not speak in the debate can I invite the minister to move the motion formally moved thank you any contributions from member nope I'm assuming you do not want to sum up minister no it will pass on that okay thank you so the question is that motion S5M 09005 be approved are we all agreed thank you very much and I'll suspend to allow the minister to leave the fifth item on our agenda is further subordinate legislation we have one negative instrument to consider the instrument is the public bodies joint working prescribed health boards functions Scotland amendment regulations 2017 there's been no motion to annul and the delegated powers on law reform committee has not made any comments on the instrument is there any comments from members nope then that is agreed thank you very much and at a previous meeting we agreed that we would now go into private session