 Welcome to the 25th Meeting of Health and Sport Committee in 2017. Forgive everyone to ensure that the mobile phones are in silent, and it's acceptable to use mobile devices for social media, but please don't photograph or record proceedings. The first item on our agenda is a final evidence session on technology innovation in health and social care. I welcome to the committee, as shown in our office in Cabinet Secretary for Health and Sport, Jeff Hразериyn's director for health and social care integration and Grahamенты it with Vor quickly, General Manager, ICT, NHS Dumfriesen Galloway, and head of eHealth at Scottish Government. Could I invite the cabinet secretary to make an opening statement? Thanks, convener. I welcome the very timely focus of this inquiry as we develop our new digital health and care strategy jointly with COSLA. For many years, our health and care system has been underpinned by IT. Indeed, there are very few aspects of care that does not involve, at some point, the use of electronic tools. Whether it is to enable the capture of patient information for clinical decision making, to enable communication between professionals or to record data for vitally important research, our existing eHealth strategies and investment over the years has resulted in every clinical or care professional requiring and using ICT to do their jobs effectively in a modern healthcare setting. However, very little of what I have just listed is to do with how patients engage with the health service or manage their conditions remotely. In virtually every other industry, digital has transformed the customer experience in a relatively short order of time. For example, we have gone from watching someone else book our holidays at a travel agent to having a mastery of choice and control over what and how we book online. Not only that, thanks to advances in mobile technology, we can do so from the comfort of our own homes or at a time and place convenient to us wherever we may be. The evidence received and heard by this committee, along with the extensive feedback that we have received through our own engagement, suggests a growing expectation for the same sort of flexibility, choice and control in health and social care underpinned by effective core infrastructure across Scotland. It is with that in mind that we shaped our draft vision around the individual and I am pleased that it has been well received by your correspondence. Previous e-health strategies largely delivered the infrastructure that was required to deliver safe and effective care within the NHS. Our new strategy is shaping up to develop and deliver the infrastructure tools and products that is now and will be required to underpin the radical transformation across health and social care, which this Parliament has supported. Our new focus on digital health and care in the round will lead to greater information sharing across health and social care. It will enable people to take greater care of their health and wellbeing and it will lead to the shifting of the balance of care out of hospital and into the community and it will lead to greater remote working for staff and remote access to services for patients. Fundamentally, it will equip our health and care services with the tools needed to deliver transformation into 21st century place-based care. In doing this, it will build on the excellent work that progressed over the past decade. We have successfully rolled out mainstream telecare within social care. The emergency care summary provides a vital electronic summary of everyone's GP record for out-of-hours care across Scotland and the number of remote interactions handled by NHS 24 continues to grow every year. Every secondary clinician in the west of Scotland can access a single clinical portal with excellent examples of clinical portals everywhere in Scotland. Some services are routinely delivered via video conferencing, including vital life-saving stroke thrombolysis, delivered over the national VC network. Primary care records are now entirely digital and we are well on our way to digitising all secondary care records. We have established a number of innovation centres, including one of the specific focus on digital health and care. Almost all referrals for primary care are electronic. Our renal and sky diabetes systems are recognised as world-leading and we are starting to develop scalable approaches to remote monitoring and remote management of long-term conditions and we have an NHS-wide email system allowing for instant communication across staff teams. That goes some way in highlighting the scale of what has been achieved over the past decade. They are all essential systems and approaches that require continued development and use. It also provides an indication of the scale of the challenge that we face in shifting our focus and tools for our citizens. Further more, as the Wanna Cry ransomware attack highlighted, the sheer volume of devices and systems that are now connected to the internet presents a challenge in and of itself. Our new strategy has to balance the need for continually innovating and developing approaches to the delivery of care with the real pressing safety issue of ensuring that our existing infrastructure remains secure and fit for purpose. In order to achieve that, we will set out an implementation plan and an infrastructure plan to accompany our strategy. Finally, there are some good global exemplars in terms of some of the individual digital uses, solutions in use, including in Scotland and in countries such as Finland and Estonia, which the committee has heard about. However, every healthcare institution in the world now needs to manage the change in emphasis from a 1990s IT-focused approach to a 2020s digital citizen-focused approach. I look forward to discussing that with you in more detail. Thanks very much for that. Before we get into questions, we have apologies from Marie Todd and I remind members to declare any interests that they have, and I will begin in that a close member of my family works in the health IT sector. I remind everybody that I am a director of a collaboration communication platform across sectors that includes healthcare and that I do not take any remuneration from that post. Anyone else? No. Miles, would you like to begin? Thank you. Good morning to the panel. Listening to your statement, cabinet secretary, I think that one of the things that I would like to speak for the whole committee, but I think that from the evidence that we have heard, there seems to be a real frustration within clinicians that changes in technology and the way of harnessing some of the technology that could transform the way that we deliver healthcare is not happening. The missed opportunities and frustration that we have seen from clinicians has been quite clear on that. I really wanted to start with what is the Government's vision on that, and specifically when you mentioned Estonia in Finland and its approaches. Is that where you see Scotland going? Specifically, do you think that resources have to be allocated to achieve that? I get the frustration in that we all want things to have happened yesterday rather than tomorrow, but the scale of what we are trying to achieve here is huge. In my opening remarks, I tried to lay out some of the successes and progress that has been made, but for a second claim that the job is done and we are laying out in our new strategy the focus very much on the service user and the end user and their interaction with health and care services. We have spent a lot of money and time making sure that we build infrastructure up and have laid out some of the successes in doing that. Of course, the infrastructure and general practice, but there is a huge overhaul of that. Graham can say a little bit more about that if you want more detail, but we have talked about that at committee before. The focus going forward is really in taking a huge big step forward as the strategy lays out into how we make sure that we can support our service users in health and care services to interact more readily and make use of not just their own data, but their interactions with health and care, whether that is an outpatient appointment that is delivered through a remote system. At the moment, we have had quite a lot of success with the roll-out of that. I think that there are around 2,000 users now in terms of the attend anywhere video consultation. That is a big shift in the way that very simple interaction happens, but it saves a huge amount of time for not just the consultant, but the patient who might not have to do a five, six hour round trip for that appointment. That is one example, but the focus is very much on that interaction rather than necessarily the infrastructure. We have a lot of the infrastructure in place and are putting the rest of the infrastructure in place, particularly in primary care, but the focus is on that end user and how we make it easier for people to interact with our health and care services and indeed how the point you made around the clinicians' use of the system and making sure that we drive the most efficient effective use for them as well. I really just to add the cabinet secretary's response there. There are a lot of frustration in clinical areas. I do not think that we have to apologise for not trying to keep up with the latest, either gadgetry or innovative state of the art, because that brings with it a whole bundle of management around security, around risk, around information governance and whereby a lot of common practice says, well, if I could just do this quickly, I'll get an app that can do this, I can do this on a very small scale. We're very conscious of trying to embrace that world, but at the same time trying to make sure that we're not disclosing or making sure that we're managing all the digital assets that we're building in Scotland. Thanks. It's been a while. I guess a couple of ideas that are probably fairly central to what I think will be in the strategy. The first is the idea that we have a common platform across Scotland, because at the moment if you have an idea or an innovation, you have to customise it 14 or 17 times to interact with the existing system. The idea of a single platform is pivotal. The second key idea, and it was very much at the front of what the cabinet secretary said in her opening remarks, is the idea that digital isn't a separate thing, it's partly how we do things. In things such as the modern art patient work or the work that we're doing around elective care more generally or the work that we're doing on unscheduled care, it needs to be built into the thinking about how we're designing and planning services. It's not something that we do after, and that's a key shift in terms of where digital fits in. I think that those two ideas are central to getting clinicians more front and centre in terms of the style and the nature of innovation that they want. One of the aspects that was really pressed home to us was a once-for-scotland approach, and the fact that, especially from a patient's or individual's perspective, just telling that information constantly to different professionals doesn't seem to be changing. Do you think that you've heard that message and that's actually being changed? Yes. As Jeff just said, we do need to move away from 14 times or 22 times, including the national board, from a board-level implementation towards a once-for-scotland national system. We're looking at how we do that, and the implementation plan will set that out, but that may require us to do more from a strategic point of view from Government, and that may mean that we hold more of the resources in order to do that on a once-for-scotland approach. Discussing that very much with NHS chief executives, they agree that there are certain aspects of taking this forward that are better done on a national level and done once. Clearly, there will still need to be resources flowing to boards for some infrastructure and making sure we have the training personnel in place. That's a critical part of this, but without a doubt we have we'd already heard that message very much and learned some of the lessons I think around around that. As Jeff also said that the fact that this is going to be built in as a key part of every transformation we make, well every transformation we make will be a Scotland-wide transformation. The modern outpatient changes, the new models primary care are Scotland-wide reforms and transformations, so it's quite right and proper. We do things in a consistent way, and of course there's economies of scale in that as well, which are important. The short answer is yes, and we'll be laying that out very clearly. Can I just offer something? The particular example that you asked about was when you turn up at your general practitioner or at A&E, and you have to tell your story again. It's quite an interesting one because for many people that is exactly the reaction, why do I have to keep telling my story, why do I have to keep taking the data, and there's clearly some data which you can probably hold in a way that enables it to be available. At the same time, certainly the experience that I've had of working with people in the mental health and other spaces is that quite often people are surprised that you know things about them and are concerned, so the interaction between being able to have that functionality but also protect people's wishes as to how they want to be worked with is really quite tricky. One of the big challenges around governance is that it's not like Amazon or something like that where you can decide something good with the shops. We're pretty much a monopoly supplier of health and care, so we have to find ways to interact with different people and their different expectations. Once for Scotland, although it's a new canned term, which is a good concept for people to embrace, Scotland has been doing a lot of Once for Scotland for a lot of years now in NHS. There's a single network across the entire NHS. There's a single way to refer patients between primary, secondary care. We've got a single emergency care summary. We've got single business systems around payroll, HR, time management solutions. We're already pretty far down that road. The important part is that if you want to push that to the clinical work for the cold face of where the clinicians are interacting with the patients, that's where the exciting part is for going forward. The cabinet secretary picked up on just one thing. He said that GP records are on, primary care records are now digitised. We had last week, I think, from one of the witnesses from university who said that some practices don't even have Wi-Fi, so is that a correct statement, an accurate statement? Most of our held patient records within general practice are already digitised. All general practices networks allow access to those via their local computer servers within the practices, using the form of all communications, all documents, all bits of paper, handwritten, as well as communication in and out of the practice between primary, secondary care and social care. All digitised and accessible instantly when you are presenting at in front of a general practitioner. The reference to Wi-Fi is different, because a lot of practices don't have Wi-Fi enabled at this point. There's two parts to that. The first one is about making sure that the environment is secure, but that's not a functioning part of having records digitised and accessible at the point of care delivery. That's already pretty much taken care of. I'm reading some stuff here from the Care Commission about primary care records. They're saying that it's being done on a priority basis, the digitisation of records, and that going back historically is very difficult, and it's patchy. What that's probably referring to in context, is that what happens over tens of years when you and I visit our general practitioner is that we build up a case record that sometimes can go to a relatively thick volume, if you like. What has been running alongside that for now 12 years is an electronic processing of the exact same pieces of paper, and over that period people have now migrated from receiving paper coming in, either scribbling or actioning it from paper to now doing it all online. That's happening now. What then has happened to some of the care record for you and I in the practice? Some of the paper records are still in storage and perhaps not been backscanned, and I think that's probably the point there. What they're saying is that many of the acute and primary care records that we scrutinise were hard copy paper records, often with handwritten entries by clinicians and other health professionals. Some hard copy patients' records were lengthy and covered treatment over decades from a wide range of health specialities. The care inspector is saying that that's what they're finding now, is that they're still finding large numbers with hard paper copy records. I think there's a difference between, you know, there's a basic level of patient record that is digital, but if you go back decades to every bit of paper relating to that patient, not all of the every bit of paper will have been scanned, but there'll be a basic level of information that is digital for every patient, and I think that's the difference. I don't think that's what it's saying. It's saying many of the acute and primary care records. We scrutinise were hard copy paper records. They're not saying that it's just long historic ones. They're saying many of them that they've seen. So maybe we could look into that and maybe further... Okay, we'll do that. Just look into that and give further information to the committee. Sorry, I didn't intend to bring that up, but it was just the right moment for it. No, we'll come back to you on that. Brian. Good morning, panel. I'm interested in the process after tech technologies are proved for use within the NHS. The evidence that we've heard is that then the issue is around roll-out and encouraging kind of adoption of that technology because there's so much of an autonomy within the individual clinician. If we're going to really bring technology up to date, what's the plan then to roll out to encourage that adoption within the clinic? I think this is where the balance is going to shift to a more strategic once-for-scotland approach, as we've just been talking about. The things that we agree need to be done and need to be everywhere are the things that will be done on a once-for-scotland approach and we'll make sure that those things are done well and done everywhere. There may still be some innovations testing the water on some other aspects, but the core things that are absolutely essential and need to be done everywhere will be done on a consistent basis. I think that's where the balance will lie and shift more to a kind of national strategic approach. I'm probably just supporting that. The Government of funding and their different approaches is to look at a different approach to clinical leadership in this area. We're looking to appoint a CCIO, a chief clinical information officer, and that will be the pinnacle of how we disseminate standard practice and try to get that once-for-scotland deployed in a truly once-for-scotland way. To support that, we're appointing five new staff to go through a digital academy with the other four nations. We're all contributing financially to allow that energy to be good. I think that the point that you make is real. At times we do allow too much variation and I think that the time is now through our once-for-scotland approach to try and improve standardisation. Would you then envisage giving clinicians time within their working day to learn about innovation and technology and to encourage that adoption? Is that what you're thinking? Everybody's got a basic level because they all interact somewhere or another with electronic digital systems. Of course, the roll-out of any new systems brings with it a training requirement for those who are using it. If you look at the secondary care clinicians in the west of Scotland accessing a single clinical portal, that saves a huge amount of time for them because they're able to access test results and so on remotely. That saves a lot of time. Investing the time up front to enable those clinicians to do that is well worth while because they then gain a huge amount of time back because it's of easier access. That's one example. The other element is thinking about how we take the change process forward. Historically, what we've done is change around service design and service delivery in one space, quite often through Healthcare Improvement Scotland. Then we've done support for change around tech in a different space. You really need to bring those together because it needs to be part of the workflow in terms of how you approach it. I think one of the big ambitions is also to be able to automate more so that there's less time taken in data transcription, data entry, so that people are actually getting time back as part of the process. I guess that's one of the things that you always hear and we don't always get, but it's a clear objective to actually see that as being part of the process so that the time does come back. There's a real design component to this and that people will engage with technology where they believe that it gives them value. A lot of people's experience at the moment is that it doesn't. It's seen as an additional task over and above what they're there to do. Until you're at the point where this is part of how you do clinical care and you're seeing the return from your engagement with the technology, it will always be hard. That's again part of the change that we have to make. That's probably why the West of Scotland thing has worked so well because clinicians were talking to each other about the benefit. It just took on a kind of momentum of its own and everybody wanted to be part of that. I think that we heard about the adoption of quite a simple technology by an NHS trust that bought a fair vast number of these instruments, but the clinicians remained with the old ones because that's what they were used to. As you said, they didn't feel that it would be beneficial for them. How do you overcome that inertia? I think that there's got to be clinical buy-in. Clinicians have to see the purpose and the benefit for themselves and for their patients. All of the innovations, there's clinical involvement in them to make sure that they're the right things. Otherwise, there's a dislocation between the coalface and using that technology. Clinicians are very much involved. The clinical leadership of then taking that forward and rolling it out and scaling it up is hugely important because they're the best advocates for change. Ultimately, that will be a critical part in doing this. The modern outpatient example is a good one. Clinicians get the purpose of being able to, particularly in the highlands and islands, of using technology to have straightforward, simple interactions with patients in an outpatient context. It's a bit of a no-brainer. You've got to make it easy to do, and you've got to give the sense that they'll offer better care. I imagine that the clinicians who have talked to you on this are probably not going down to the high streets and booking their holidays anymore. They're probably buying most of their books online. In those areas, they've made the switch. They haven't said, I'm going to hold on to going down and speaking to somebody across a desk who'll book. It has to be a design problem and it's a benefit problem. A lot of that comes back to how we take the change forward. I mentioned the appointment of chief clinical information officer. A number of the submissions that we have identified that there was not any named accountable body or person for scaling up and implementing new successful innovation in technology. Is that what this person is going to be accountable for? Is there a named person who has the responsibility that ultimately lies with, or is it still going to be all the health boards and all the IJBs and everybody else in this crowded field? It is a crowded field and that's one of the areas that needs to be fully resolved through a simplifying of the governance and accountability structure. That is happening and will happen. The chief clinical information officer will be, if you like, at the head of the pinnacle of driving forward all these changes. They will have a strategic role in making sure that they drive forward the strategy and make sure that there's a pace to the delivery of it. Within that governance structure there will be, obviously, linkages into boards and IJBs in terms of making sure that that happens. That leadership role is going to be really, really critical. For me, that's going to be important because I'll have a single point of contact with somebody who is kind of het, if you like, for driving this forward and making sure that there's a pace of delivery. It has to be seen as part of a package in that that sort of technical knowledge and expertise is a part of a package but the other components are appropriate governance at national level for how the system in terms of interoperability standards and respective data but having overall oversight in respect of the architecture and then being probably part of the process by which innovation rolls forward because not all innovation is IT innovation. Some of the innovation that we're looking at here is also other types of products, new types of scaffold, things like that, which wouldn't be exactly in this space but, again, we've recognised the need to have appropriate governance which allows quick and safe adoption of new technologies within the space but I think you're going to see quite a change in terms of the overall governance of how this is taken forward. Hey, Alex. Thank you for coming to see us today. I don't, for a minute, doubt the integrity of your vision in terms, in respect of the deployment of tech and innovation in the health service, absolutely. My sense of it, however, is that it seems to be happening at different rates and that in some fields we are racing ahead and to great effect and to great impact but there are other aspects of the health service which are still stuck and dragging along behind and I think that the greatest sense of that came from GPs who made representation to this about individual practice software which is still sometimes stuck on operating systems that are 15 years old perhaps and we heard quite eloquently a representation last week about a GP who's literally having to wait for the hourglass to tick round before they can access patient records or prescribe software, the rest of it. We interrogated that and learned that that's not the fault of the GP practices, that's bought in by the health board. How do we, as your Government, how do we, as a Parliament, get that right? That strikes me that that's having an impact not just on patient experience but on GP morale, throughput and time taken appointments. I think you're right in that there are different rates and paces of things that have happened and I would have been surprised if that hadn't been the case given that some things are harder to do than others. When you think about the extent of the primary care estate and the GP estate, there are a lot of sites in a lot of different areas and some of those have more challenges than others in terms of connectivity. However, it has been an absolute priority for us and Graham will lay out some of the detail around the procurement that is just taking place around the GP IT systems which will make a huge difference. There are a number of things that I think what you've observed when you picked up was correct. There are a number of things that we're doing. First and foremost, the technology layer delivering general practice software is changing and it's now all going web based. As you probably know that, that means that the reliance on local processing, local hardware, becomes a lot less. It's all done remotely. To support that, an upgrade to the Scottish Wide Area Network, which every general practitioner is connected to, is being implemented and that's got minimum upgrades and download speeds now to support that. Again, that's a big improvement opportunity. There is no doubt that in the extreme areas where general practitioner services are delivered in very rural Scotland, there are some challenges with infrastructure, even getting signals at very basic transmission rates. There will be an on-going challenge in that area, but everything that we're doing regarding infrastructure for general practice is aimed to give radical and essentialised much better improvement. The commitment on broadband will also help in terms of making sure that connectivity in those more remote and rural areas is improved, which will have a huge knock-on effect for health and care. The other thing that we've recognised is that if we are moving to a new type of architecture, there will be quite an extensive transition that will have to be made with legacy systems. One of the things that we've asked the expert panel, which is chaired by David Bates from Harvard School of Public Health to do, is to advise us on prioritisation within that, so that we do the things in the right and the best order to get the best outcome. The other challenge that we have is, at the moment, much of the time, certainly within my directorate on digital, is spent probably doing what you might describe as small fixes and fixing small problems. While there are some of that that we will need to do, we need to get more focused on the big strategic changes and the architecture that we need to make. It's that balance between things that we absolutely must do now and things that take us into the next stage, which is really quite important. That's, again, one of the shifts that we're trying to make through the strategy that we have this clear platform on which we can do better things, but that's some fundamental architecture things, rather than lots of small fixes. Thank you. That's very gratifying to hear. It links to my next question, really, which is about the siloed—not the siloed mentality, but the siloed nature of IT systems that exist across the whole health service, and by which I don't just mean primary care, I mean allied health professionals, other community pharmacists, the rest of it. We have heard, not just in this inquiry, but in inquiries previously, that that is a barrier. For example, community pharmacists having no compatibility with software or access to patient notes and that being an actual structural problem in terms of what IT systems use is getting in the way of patient care and is the barrier to perhaps giving more role to community pharmacists. I use that as an example, but there are many examples of that kind. We heard a representation about a system that NHS Greater London is using, which is described as a kind of spinal column of software platform into which all these other necessarily different software structures that these other groups use can plug into and via which they can share a lot more easily. How far are we in NHS Scotland from doing that, and is it a priority? Just an observation for anality, those guys do more of the detail, but the technical solution to that is probably not the biggest challenge. The biggest challenge would be the data sharing and making sure that that is done within obviously the public governance and that we obviously need to make sure that we satisfy all the standards required in order to have the sharing of data between professionals that need to share enough of the data for the right purposes in order to deliver a safe service for that patient. Those are the issues that are absolutely critical and are being worked through. There is a huge appetite, as you know, to get on with the multidisciplinary working and primary care, but in order to facilitate that, these are absolutely the things that need to be done at enough of a level in order to have that data sharing. Before you bring in Jeff, I agree with you, and as a Liberal, naturally I would, because it is important for me that patients ultimately have a right to confidentiality. They need to know how their data is being used and how that data is being shared, but would you have examples of being used that occurring elsewhere? It must be happening in NHS way to London, and it is about getting that right. We talked a bit about citizenship of health data, that they, either through giving their permission by inputting a password in, say, a community pharmacist, or actually having something on which their data is stored on their person, and there are solutions to that. Is the barrier to that here, that we just have to enact a primary legislation that sets that out, or is that something that we just need to adopt through a more piecemeal approach? I do not think that we want to do piecemeal. I do not think that there is a necessary requirement for different legislation, although there are EU regulations that are around the governance of all of this, which we all have to comply with, which are important. An interesting spire, which is a good example of involving patients in what their data is going to be used for, has been quite a good lesson for us that it is about transparency and making clear what data is going to be used for, and importantly what it is not going to be used for. I guess if you were to encapsulate what people's fears would be, is that their data is somehow going to be passed on to third parties for use for. We have got to be absolutely clear about the purpose and the governance and safety around that. I think that most patients would expect health professionals to have enough information about them to share in order to deliver the best quality care to them. I think that most patients would not have an issue with that. They just want assurance that that is the purpose. At the moment, it is one of the areas that is probably the most tricky in terms of working through the issues in terms of data governance. It also interacts with the different way in which you might structure data in future. At the moment, we have hundreds of systems that we then have to make choices about whether you share or do not share. If you reduce the number of systems, then the question becomes one of governance, access and control. You have different questions to answer. As the cabinet secretary says, as we bring that up to national level, we would expect to have greater clarity and maybe less of the occurrence of this is information that is shared in this area, but it is not shared in that area because they have come to different views as to what can and can't happen. The big question that you had there was how quickly can you move to that new style of architecture? You described it as a spine or a platform. It is a good way of understanding it. The building blocks of those types of systems are relatively in place in other industries and other businesses. It takes time to do the architecture and to build it. The bigger challenge is around the transition, particularly with lots of legacy systems and legacy contracts. You have a two-part process. One is to build a new, but the second is to work across the system to bring the data and the systems that are there safely onto it. The challenge with that is that the pharmacy example that you gave is a really good one. Historically, our answer would have been to go out and find 17 different solutions for that, one for each health board and the ambulance service NHS 24. I am sure that there is another health board that uses data. We have to get into a situation where we try and solve the underlying problem by having an appropriate platform, rather than just doing fixes all the time. Jeff referred to prioritisation. What sequence do you do things in order to do them in the quickest, most effective way? These are the best brains in the world that are advising us. We are very, very lucky to have them. They are advising us on exactly that. You start with this, then you do that, then you do that and then you do that. That is your quickest route to getting those tricky problems resolved. It may well point towards what has been done elsewhere. We are not shy of taking good ideas. I do not know, Graham, if you would say. No, I just think some of the references to England with its spine. There has been a history behind the creation of a spine in England. Out the bad of a lot of bad or failed achievement, if you like, there has been some little benefits or significant steps forward. I think that what you refer to is one of them. It is something that is good, it is something that is on our agenda. It is not something that you rush towards, it is something that we have to take at pace and bring people with us. A number of people want any more very short of time. Just one point in the information sharing that I was wanting to raise was that the information commissioner's representative last week said that it was not the information commissioner that was stopping the data sharing that was actually the reluctance based on a bit of fear within different sectors that they are allowed to share information. I am not really asking for a comment on that. We might be commenting on that when you are answering later, just to try to catch up on some time. Cabinet Secretary, you mentioned earlier in your opening comments the issue of resources and the major investment that has already taken place. The committee has received quite a lot of written and oral evidence, however, still expressing concern at what has been described as the limited resources that are spent on IT. Andy Robertson, NHS NSS, commented that we put 2 per cent of our NHS revenue into IT, but the US is at 6 per cent. He goes on to say, we have to spend more on technology and innovation in order to fund the service transformation that has to take place. Will the forthcoming e-health strategy include specific detail on what resources will be allocated towards it to make sure that it is delivered? I think that you make a fair point about sometimes people are very fearful and sometimes that fear goes beyond what the reality is. One of the issues that we are addressing is trying to be more permissive in terms of what can be done within the existing legislation. I think that you make a strong point there. At the moment, if you take the global amount in terms of what is spent, it is around £257 million. If you look at the e-health division budget, the £69 million of e-health funding allocated directly to boards, £160 million spent by individual boards themselves on IT, and then on top of that, you have the local government spend on IT and digital systems, which will take that figure further. First of all, what we are saying is that you have to have the right spend in the right way in the right places and prioritise that. What we are saying is that the £69 million, particularly that we allocate directly to boards, some of that will have a more national strategic direction in order to get away from the 14 varieties or the 22 varieties, including the national boards. There will be a reprioritisation of the existing funding in order to make sure that we spend the right money in the right places. Of course, in terms of any additional spend required for the new digital health strategy, we will want to make sure that we have sufficient resources. Obviously, that will be part of the budgeting process going forward in order to make sure that that is adequately resourced. Reprioritising existing spend to be more effective with that. Obviously, if more spend is required to deliver the strategy, we will set that out as part of the budget process. In terms of the strategy going forward, as well as specifying specifically what additional resources will be provided, will it include specific detail around objectives and evaluation? I think that that was again something that came from the written evidence like NHS. In fact, Dumfries and Galloway Graham talked about the need for making clear evidence of positive outcomes and benefits should be mandatory. Will there be specific outcomes in that strategy? How will that be measured going forward? Yes, it will. I am very much a firm believer in having milestones. You do not start off saying that we are going to go from there to there and we will see if we get there in five or ten years' time. We actually need to plot a course and have milestones. Where would we expect to be in a year's time, in terms of all the complexity of this, in terms of infrastructure, in terms of systems, in terms of governance, and to plot a course, so that you would have very clear milestones and the outcomes that you would expect to achieve along that way? Graham, you are closer to the detail. I will extrapolate the idea that, have we spent money in the past as efficiently as we possibly could have? The answer to that, maybe, would be no. We have pushed money out to health boards and that was a plan about just over a decade ago, seven years ago, when we did that. That is about maturing local health boards. A decade ago, there was a lot of immaturity in terms of IT delivery and that allowed the local boards to get together and cluster, get their own environments up to a level. That was what the last sort of looking back has delivered. What about going forward, as the cabinet secretary is referencing to, is that if we have now got a level playing field and people are able to embrace new ways of working, which is where we are at now, then the spend profile should be more efficient, notwithstanding the challenges we have in that area. We have mentioned previously about procurement challenges. The minute we scale things up, it becomes tougher. However, the efficiency in how we are able to now take things forward and doing things once—single contracts for software suppliers and hardware—sharing things is certainly the way that we want to do it. Measured outcomes are essential. We will be looking for a measurable plan by region to make sure that the national standards are achieved. The new chief clinical information officer will have a role. I will have a role in making sure that we are delivering at pace what we have set out. I am sure that the committee will take an ongoing interest in that as well. Jeff, you are reporting mechanism as well. The intention is that there will be a national governance group that I will chair that will monitor implementation of the strategy. We will have clear milestones. As the cabinet secretary said in her opening remarks, one of the issues that you identified in the evidence that you have taken was the absence of an implementation plan for the 14-17 strategy. We will intend to, when we publish the strategy, have a clear implementation plan with milestones within it in terms of when things will happen. In terms of the return on benefit, things that are in the space of outpatients or unschedule care or what happens within A&E, those are more likely to sit within other strategies and with other lines of work. That comes back to the idea of looking to embed technology as part of the process by which you do normal business rather than being a separate thing. The strategy is intended to be an enabler and a platform. That is a major undertaking in itself, but that enables you to take the benefit in those other areas of delivery around things such as cancer or primary care. In terms of reporting, I do not say any reason that we could not do either a yearly report to the committee or to Parliament. That would be in line with your thinking. I am sure that we would appreciate that. Thank you, convener, and thank you to the panel for coming along. I want to pick up on the issue of data sharing that was touched on briefly earlier. We had a lot of written and oral submissions to the committee about access to data, and we have heard some discussion about that already. However, one of the proposals that was put forward was that perhaps the individual owned their data, and it was them who made a decision about who to share that with. I was wondering if the panel had any comment on that. I think that our starting point is that we do work on the basis that the individual owns their own data. It is complicated because then you have the situation that the NHS in some shape or form or particular other bodies will be the controller of the data. Our challenge at the moment is that, while we are doing the work on the patient portal in the west of Scotland, the idea that you own your data does not give you a lot of value. It does not give you use value of your data, so you are not able to interact with it. You are not able to use it meaningfully. We think that the process of both putting the idea of the person front and centre of the strategy, but also prioritising the use value of data for individuals is one of the key components of transformation in this area. Once you are able to use your data, you will manage your health in a different way. That has been the experience of all other areas. We would agree with that proposition. It does take you into the space then of understanding—we have had some conversation already—about issues to do with consent and management and control and understanding that different people have different expectations in that space, but we are increasingly familiar with that. When I go on to the Scottish Parliament website, if I have not been on for a while, it asks me, do I accept cookies? Do I allow some of my personal data to be shared with your server somewhere in this building? I then get the chance to say yes or no to that. We are increasingly literate about those issues, and we need to build systems that are as simple as that to enable people to consent to how their data is used. We welcome many of the responses that you have had in that space, and we think that they are part of the way forward. Can I ask a picking up on that? I think that there was a Miles Briggs raised about community pharmacies—sorry, it was Alex Cole-Hamilton—and interacting with data GP practices. It is certainly something that has been raised in my constituency with community pharmacies. How much added value they could give to patients when they present there, if they were able to access that data? GP's are currently data controllers, and you raised an issue there about data controllers. Has there been any thought given to changing that position? I will check that. The situation is that the referencing from community pharmacies has been accessed to the emergency care summary data, which is a summary of an extract from GP systems, mostly of medication. That would go hand-in-hand with pharmacy work. The logic at the moment is that there is the governance behind the emergency care summary. What it was designed for as to what its use cases is potential is in conflict at the moment. The important part is that the emergency care summary was designed for emergency care and secondary care. We have now pushed that boundary a little bit further into clinical portals to make that information available within and throughout secondary care. However, to push that out to individual pharmacists and independent contractors, the GP, as the data controller, has shown major concerns about that at the moment. We are working through that with them. There is also forming part of the new discussions with the GP contract, which is going to be announced. That is a discussion point as part of that. It is a positive landscape going forward, because everyone recognises the value in the need. It is just that how we have set this up and what we have done in the past is not quite straightforward to roll forward, just willy nilly to anybody. We are pretty confident that there will be a resolution that will be a sensible one. Thanks, convener. Good morning, panel. You have covered a bit of this already in your answer to Colin Smith's question a minute ago, but it was round about clearly what we are doing in this IT, because it gives us better patient experience and patient service, but we are also doing it because we think that it makes things more efficient. With some examples of other countries and the evidence that we took earlier, there have been savings as a consequence. We have just understood what you have taken of you on how much potential there is in terms of cost savings or freeing up resources to go into more effective directions. It is probably better that we are putting it if people are not spending all their time doubling triple keying stuff and they can actually treat patients instead. We do not need to help solve some of the resources that we have got and other efficiency gains that are there to be had. If you have a kind of macro view of that, what kind of mechanism have you got for tracking that at a more micro level? That will be built into each transformation outcome, if you like. If you take modern outpatients, the saving is time. If you are able to deliver particularly return appointments through either telephone or VC interaction with a consultant, it saves a huge amount of time. We know the pressure on the system with increasing demand for outpatient appointments. So, the reform of that system and interacting with patients and making sure that it is done in a safe way, the safety comes first. Without a doubt, the idea that someone for a routine return appointment is doing a six, seven, eight hour round trip is not good for the patient, but also the clinicians time can be better spent seeing more patients who need that face-to-face contact and those who could have a phone or VC consultation. That will become routine. That is one example of one change using technology. Yes, you can put a number on that and the modern outpatient programme outlines the efficiency gains from that in terms of the system. You could time that by a thousand, by a hundred thousand, if you can get this right. It is absolutely about delivering a more efficient system. For a purpose, to then reinvest that time in better patient care. The other thing that you need to think about is the fact that you will do different things. You will not simply run the existing system more efficiently, you will do things that you currently cannot do. That is part of the challenges to get to the place where you are now enabling people to manage their care directly themselves, making choices about lifestyle, making choices about how they engage, understanding better how to manage their condition using feedback from monitoring in the house, being able to stay in contact with friends and family, avoiding isolation and loneliness. All of those things mean that you are now delivering a different health and care service. A simple comparison is not that straight forward. John Himbus, who is one of the expert advisers again, and one of Obama's advisers from Harvard, does not presume that you will take a cash saving from doing this. You probably will not. You will be able to do better and different things. You will give time back to people. You will take a lot of the hassle of having to enter information into different systems, the things that wind people up. You will take that out of the system. You will empower people to do better. Most of the gains will be in that quality space. If you use Amazon, you buy more books. You will see other changes in terms of what happens. You will see different ways in which they interact with how people engage with health care systems. I think that it is very reductive just to focus on, are you going to save money, with apologies? I said that at the start. The patient experience will improve and understand that you will move at a different dynamic. Things are done differently, but at the end of the day, time is money. If you are making consultants 10 per cent or 20 per cent more efficient, it means that you can see more patients or whatever it happens to be. That means that the other end you have not got those weight unless you have not got the pressure to hire more practitioners to the same extent. I do not think that you can get away from the fact that there has to be a pay or a third. Frankly, if you have not got a view on that, then it is hard to quantify how successful you have been as well. We have expectations of what would be delivered. Again, if you take the multidisciplinary team and the support of the pharmacist to general practice, on average, there can be a two-hour a day saving potentially for the GP and having the pharmacist doing the medicine reconciliation. First of all, it is something that frankly is probably very frustrating for the GP in having to do all that at the end of the day. Someone else whose skills are that doing that. The benefit gain is that if we can gain anything up to two hours a day of a GP's time, then it does not take a lot to then imagine that whether that is in terms of the being able to see more patients or in terms of recruitment and retention issues, it has a huge knock-on effect. We are working through the efficiency gain of what does that mean. Yes, there will be a projected number at the end of that somewhere, but everybody knows that it is there, and it is there at a price to be gained, potentially over a fairly quick period. That is absolutely the territory that we are in here. It is all for a purpose, not some kind of theoretical. It is absolutely for a purpose of continuing demands on a system that is absolutely needing to get all of those efficiency gains in order to be able to keep the quality of care being provided. Thank you, convener. Good afternoon now. Alex Simmer Scotland and the Mental Health Foundation emphasised the importance of staff skills in training to ensure that we could make the most of digital technology and to make sure that those new interventions were used as effectively as possible. Other submissions have commented on a digital skills shortage in this country, so I would like to understand what importance the strategy will place on making sure that staff are trained properly. How are we going to ensure that staff who are already very busy and pressurised have the time to undertake that training, and just if you could tell me a little about any steps that you are taking to address a skills shortage? You make an important point around making sure that there is no point in having the technology, the systems, if people are not trained to use it, and so clearly making sure that the workforce is trained. There is a subgroup called the Digital Enabled Workforce subgroup, which is really about ensuring that we know what the skill level is and what the additional skills and training would be. It is making sure that that is done as part of any transformation. Jeff said this a few times and it is a point worth re-emphasising that it is not an add-on, so you do not put all the things in places. There is your one-day course on that. It has to be built in to the changes in the way that things are done, whether that is in primary care or whether it is through the outpatient changes. It has to be on-going, so it cannot be a one-off. Graham, that is a key part of the strategy. I think that, as the cabinet secretary said, it is so key, and I think that we have replied earlier around if you get the product correct, the consumption of it then is easier. Is that concept of who shows you how to use your iPhone? We have not went through formal training for things like that, so it is about getting the correct solutions. Nes, Scotland and national education have a really interesting role in that, because they have already identified themselves and set up some of the groups that the cabinet secretary referred to and are looking to explore new ways in which we can enable the workforce. It is early days, but it is certainly high on our thoughts at the moment. I will ask for specific information on that skills shortage that has been raised by a few submissions. Do you agree that there is a skills shortage and is there specific action being taken to address that? I guess that there are two things. One would be the technical specific skills that are required in order to deliver the clever stuff that you like. There is a huge competition for those skills, because everybody's private industry is looking for those same skills that the public sector is. There are those skills that are particularly technical and we have to make sure that we can get those people. Then there are the skills of the workforce that are going to use this technology. The two things are slightly different or are different. In terms of the specific digital skills. We have got challenges. Again, standardisation and doing things together as health boards is one key way that we see ourselves getting through this. We have not got an abundance of highly articulated, educated, experienced staff in Scotland. There are a lot of health boards at the moment where people are being trained up. It's about investing in our stone staff, which is a big part of what eHealthleads discuss. That's fundamental because although we are an IT-driven business now, our industry now, what we do is pretty specific to health. It's not just a general widget processing environment we work in. It's about making sure that our end users are bringing them with us. They design the systems, we work with them to do so. That whole skill set is already well under way in terms of how we embrace our staff and support them to become the champions of the future. I was going to ask, traditionally, a lot of the systems and platforms that we work with are older platforms that have been upgraded by bolting on a lot of software. Inevitably, that can lead to declining integrity of that system. Given that, as the cabinet secretary alluded to earlier on, it's not the architecture, building an architecture that's the problem here. Are you confident that the current system has the scalability within its architecture to require the overhaul to deliver the Government's initiatives, or are we looking at perhaps delivering a new system here? Yes, so there are some fundamental systems that span the whole, you know, our national. The national chi is a good example of that. Now, that's a mainframe computer, which I think is to date now 23 years old. Now, to the man on the street, that might sound like something you wouldn't want to use, but you know, without a fail for 23 years, that system has never been offline and it delivers a robust platform to allow us to deliver care safely and effectively through offering unique numbers on every interface of healthcare. It's not about how old these things are. It really spans into how interoperability they are, and the reason that chi is getting reformed at the moment is not so much that we don't think it can carry on doing what it does very, very, very well. It's the interoperability of it. It's not as flexible as we are for seeing the future needs. For supporting things like innovation, APIs for the small business enterprise to interface to the NHS, so there are APIs that we need to try and build and enhance so that we can maximise the investment from the economic side of Scotland to contribute towards some of these great ideas that small businesses can come up with. So infrastructure in itself is at the age of its, maybe a bit, is not to look at that in isolation. I think that the most important part is to look at how interoperable things are, and certainly for the last half a dozen years that's been a key plank in everything we've done to make things standard, to have sharing, to have interoperability, using standards that actually allow us to do that when we're doing that for the future. I think beyond that, though, as we do the development, certainly with the reform of CHI, what we're looking to is a product which gives us significantly more than the previous product, so it'll be something which gives us indexing and other services which enable us to do more. I think you should expect to see more of the activity within health and care to be based within the cloud rather than in physical systems, and that again is quite a transition. So there is an existing architecture, many elements of which we'll be taking into the new system, but fundamentally to have that platform you will have a new architecture there, and that's not a single big IT project, that's a number of small projects, all of which work together. But things are different than they were 15 years ago when people went out and bought big mainframes. You now buy services, you don't buy kit, and you don't buy product, you buy products, not product, and so I think you are looking to quite a change to have the sort of capability that we want for the future, and some elements of that are in the primary care modernisation already, but single identifier through CHI that operates across health and care, not just across health. Also looking at things such as single logon, single sign-on, so you don't have to sign on to 27 different systems, remembering 13 different passwords, so things that enable you to interact with the system go beyond simply preserving what we've got. It's about how you tie it together, and so there is quite a change there. I feel your pain on that because I recently got a password manager to manage all my passwords, then forgot the password to the password manager. The final point that I would make is on health inequalities. Obviously within Scotland there is quite a significant digital inequality and IT inequality in communities. Is moving down this route going to further exacerbate health inequality or is it going to narrow it? We want it to narrow it and we need to make sure that we take that on board in terms of how, particularly when you are looking at how patients interact with the systems, and making sure that it's not just for those young folk who are able to use smartphones, it has to be for everybody. We're very mindful of that, Geoff, in terms of how we make sure that there's an equality of access and being able to use your own data. I was glad that you thought of me as one of the young folk there. I think that the work that's going on in terms of the social security agencies is really good on this, in that they are looking for highly digitally enabled services but understand that it doesn't work for everyone. They're thinking about navigators and people who support people through the social security process, where they don't have that degree of literacy or aren't comfortable with it. I would have chosen, I have to say, in terms of the social security system when we see the problems that people are experiencing. I was thinking in terms of the developments and the proposals that are being brought forward by the Scottish Government. They are looking for a digital first approach but one that understands that it doesn't work for everyone. For those very reasons that you're thinking of. Again, that's the same sort of space within health. At the same time, we do know that, while there are challenges around deprivation in terms of how people interact with services at the moment, that also has the potential to change as you offer services in different ways and as you have different platforms. People do use smartphones. There are challenges around different cohorts in terms of use of technology but you need to be able to play all the different lines. You need to have the technology as well as the face-to-face. Okay. Thank you very much for your attendance this morning and I'll suspend briefly until the panel leaves. A jade item 2 is a chance for the committee to discuss the informal evidence session that held this morning with NHS patients to discuss NHS clinical governance. Could I invite any comments from members on the session that we had earlier this morning? You can be now. Firstly, thanks to the clerks for arranging it. I think it's important for us to have those sessions periodically to meet patients who've had bad but also good experiences of the NHS. I think it's important to keep a balance in getting those perspectives and also proportionality as well. Claire and I were with a group of patients or their supporters who'd had very bad experiences of care in the health service. The one kind of overriding theme was a cultural problem in some cases where the procedures within certain hospitals were just not fleet of foot enough to deal with particular aspects of care that were individual to those patient needs. We had one gentleman who had to have medication at a certain time but because the practice in the hospital was only to give out medication at medication time, he was suffering as a result of that. It didn't seem flexible enough to accommodate his particular needs. Similarly, there was a very concerning view that another family that we saw who had almost a lifetime's worth of experience with the NHS given their daughter's condition had caused complaints several times to the point where the daughter had asked the parents not to complain any more because she felt that it was impacting on the relationships that she had with NHS staff. I think that that's a very worrying reality. If parents or patients themselves are concerned about complaining if they think that it will have a tangible negative impact on their care, then we're doing something wrong. I'd like to put on record my thanks to the many patients and carers and family who came along today. They were very honest with us and shared some very difficult experiences and some very personal details about what had happened in their lives. That must have been quite difficult for them to do to come along and speak to strangers about such intimate details. I'd like to put on record my thanks for them sharing that with us. I think that we would all agree with that, most definitely. I was going to put on record for the two ladies who gave me their evidence, given that it's very raw to them that both their husbands died a year ago on the same day of sepsis, in the same ward. They were very forthcoming in their experiences and it got kind of uneasy. It was around a serious incident review and their understanding of a serious incident review that they felt that, although they hadn't made an official complaint at the time, a serious incident review was instigated, they felt that it was driven by them. There was very little information coming back from the NHS Trust themselves and, ultimately, when the report came out, they felt that they were put under pressure not to complain and they were given the results of the report almost on the year. The report, if you hadn't had a medical background, was very difficult to understand. It didn't run in chronological order. There was no conclusion. Worse than that was that the report itself, the internal report, was quite damning on the processes that they called them missed opportunities. They don't like that great terminology, I have to say, and that led to the death of those two men. However, there was an external report that went completely against that. There were two conflicting reports and there was no process in place to try and see why that was. There was no that the NHS themselves are not coming forward with any next steps. They can't tell the ladies the recommendations that have been put forward, who is going to do that, how it is going to do that and how it is going to be measured and that they saw a report five years ago that stated exactly the same recommendations that still haven't been implemented. I think that there is a cultural issue here. I also think that, for the record, it would be quite useful to be able to speak to the trust in question, to get them to give their side of it and also to see how they are going to reconcile those two different reports and how they are going to take that forward. I think that other members thought that it was a very good session. I would place on record thanks to those who came along and gave evidence. Ivan and I had two very harrowing experiences from family members, but there were two very different outcomes when it came to how the health board approached it in the long term. One example was given where the family member played a key role after the harrowing incident in helping to shape services in the health board and implemented changes to the way in which the hospital was run and changes that are being rolled out across that particular health board. From something that was a very unpleasant harrowing experience for a family, they were able to deliver some real change. It was a good example of a positive outcome in the long term that it would certainly be worth considering how we can see that being rolled out elsewhere. From the other case, it highlighted some of the real cultural challenges that we face in which patients and their families are not being properly listened to in a lot of examples. I want to give thanks to the two women who came along, relatives of patients, and gave their particular take on the situations that they had been involved with. Both are continuing to work very hard to drive improvement for the benefits of the health service as a whole, which is commendable. I think that there was one thing that came out that was the need for the care to be person-centred, and how we talk about that, it was clear from the evidence that they gave us that that very, very often wasn't the case. We've got, in certain cases, a long way to go, but it's called and said very positive that a lot of concrete specific things had happened in one case. In particular, in that, it boils well and shows what can be done. There's a significant scope to roll those improvements out right across the whole health service in Scotland. Thank you. As you'll be aware, convener, you and I met a gentleman who was representing his family's tragic case and his experience with his NHS health board. It was very difficult listening. He was incredibly well prepared. His notes would do a committee clerk justice. They were immaculately presented. They were well researched. He is certainly someone that the committee, indeed, Parliament and probably Government, could learn a lot from. Despite the emotional difficult nature of his evidence, he taught us a lot this morning. We learned that the way that he and his family had been described by professionals, clinicians and management, was completely and utterly unacceptable. It should be looked into. I think that no health board should feel challenged by questions, but they should welcome them when they have to be in a position to answer them fully. That has been lacking in this case. He brought up the fact that a lot of data gathering isn't up to scratch. He mentioned that 11 per cent of Scottish data is illegible. There are real issues there. He also pointed out that, as Mr Whittle mentioned earlier, the draft data would look remarkably different to that that was accepted and published as the final report. I would like to say thank you very much to him for the evidence and information that he shared with us this morning. I met two groups who specifically hadn't put a complaint in. My experience was that, because on-going treatments were taking place, they didn't want to share their negative experiences. As Alison has said, it was highlighted in both cases that it was a mental health concern that they felt that they were being blamed for part of their experience when they were meeting with professionals and, to some extent, seen as troublemakers if they were. What I took out of it, certainly, was that, although there is a welcome move towards a very much patient-focused side to our health service, in many mental health cases the family focus needs to be really key priority for those who are putting in place support because they felt that they were cut out or their experiences and that the care and support that they were providing at home wasn't being valued. I think that, finally, it was just again, as the committee has heard consistently, pathways to getting mental health before it becomes a crisis. We certainly were not in place. I would add that the two points that Miles makes are related because, if the concerns had been taken seriously at an earlier stage, an intervention could have been made and that opportunity was missed, something similar to what Brian Whittle was highlighting in his remarks. Thanks again to the individuals that we spoke to this morning. There was a disconnect highlighted in terms of accessing mental health for children and not listening to family members in that instance. That is obviously a specific issue that needs to be looked at because your family members are those closest to you and often are able to flag up concerns to the relevant professionals whilst, if it is affecting you, you might not be able to. I think that the system does need to be more cognisant of the impact that families can have in terms of sharing that information with relevant professionals, be that in the medical sector or be that in schools and joining that information together. What we were hearing this morning is that the information was not being shared. Specifically, on mental health early assessments was something that feeds beyond this piece of work. If that was put in place, they might have had early interventions. What was really concerning, I think that we heard, was the fact that, although their GP was doing a huge amount of support to them, his referral finally resulted in this individual not being seen but a letter coming back saying that nothing was wrong and the language within that about the family being unacceptable, even though they had never actually met this person writing that letter about them. That was something that certainly needed to be pursued. What was alarming was that there was only a substantive intervention when the individual's physical health was threatened, and that could, as I said previously, have been avoided. However, the fact that there was an intervention validating to the individual's mental health was only at the stage where it got to where life was threatened as a consequence. That was a family as well as we were trying to seek help. They were putting their head above the parapet, asking for the assistance and being batted away for whatever reason. I said that that was a true pee. Okay, thanks very much for that. I think that the case that Alison and I spoke to, there was very serious issues around governance, particularly around serious significant adverse events, and that is something that we will speak to the committee clerks about so that we cover that. If MDs have individual issues that came up during the conversations that you think may be missed, then please speak to the team. However, it was a very worthwhile session this morning, and I would certainly put on record all our thanks for the people who came in. It must have been very difficult given some of the circumstances that we discussed, but they certainly very eloquently put forward their cases, and I think that that has been very helpful to inform our discussions and deliberations. If we could ask the clerk and team to write to them, just thanking them for their efforts this morning. Okay, we will now, as agreed earlier, go into private session.