 Good morning and welcome to the 37th meeting of the Health, Social Care and Sport Committee in 2023. I have received apologies from Paul Sweeney. The first item on our agenda is to decide whether to take items 3, 4, 5 and 6 in private and whether to consider in private at future meetings evidence heard at those meetings as part of our inquiry into remote and rural healthcare. Our members agreed. The second item on our agenda is the committee's third oedd y peth yma sydd yn ffordd o'r sesïn fydden nhw'n meddwl i gyllidebeth a'r rôl i gael y dwyllgor yw'r rôl i'r cyffredinol, ac mae'n gweithio o'r ddiolch yn ymweldol yw'r yr lleidol, i'r perthynau a'r naes. Fy fyddwn i chi'n ddweud, mae'n gweithio'n meddwl o'r gweithiwn i'r newid Cernaghe, ymgyrchu gyda'r oeddiad o'r newid Cymru, i'r ymgyrch, i'r cofidol i'r gyllidebeth, Fife Health and Social Care Partnership, Royal College of Occupational Therapists, David Laidler, professional lead physiotherapist in Ergyll and Bute, Lorne and Islands Hospitals, Chartered Society of Physiotherapy. Catherine Shaw, who is joining us remotely, lead advanced practitioner for the remote and rural support team NHS Highland, and Sharon Wiener Ogilvie, vice chair of the Allied Health Professionals Federation Scotland. Welcome to all of our witnesses this morning and we'll move straight to questions and Sandish Gohani. Thank you very much. Thank you very much, convener, and good morning to the panel, and just to start with the declaration of interest as a practicing NHS GP. There's a lot that we talk about when it comes to rural healthcare, and one of the big things is the 2018 GP contract. In the contract, the whole point was to ensure that we had a lot of allied health professionals in primary care. The idea was to, in quotes, take the pressure off GPs, which I think allied health professionals probably do a better job in quite a lot of specific things that they choose to do. Physio, for example, I think if you do MSK work it's much better. But the contract, and I've got a quote here, it says, the new Scottish GP contract has been a complete failure based on unachievable promises. At a national level it appears a sound plan, but in rural areas it was never going to work because there weren't enough pharmacists, physios, mental health workers and nursing staff to make this work. I turn to Sharon first, please, and ask if you feel that this is true, and if it is, what is it that we should be doing? I represent allied health professional federation, so it's 14 professional bodies, so around 14,000 staff around Scotland. What we are seeing are significant recruitment challenges in remote and rural areas. We're seeing some areas with 35% of the staff due to retire in the next five to seven years, with up to 20% vacancies. What concerns us particularly is even when we do get new graduates applying to posts, they come, they stay for a very short duration and they tend to leave after two years, so Jesus is a stepping stone to get some experience and then go and work elsewhere. This is for two reasons, I think. One is because in rural areas you require more generalist skills, general practitioners to work there, and sometimes that seems less attractive to staff. The second reason is less career progression often in remote and rural areas. There is no way for remote and rural areas to incentivise people to come and work in those areas and then to stay there. If you're taking into account the cost of travel because people need to travel into different locations to deliver care, that's very expensive for staff, the difficulty in getting affordable housing, so we had stories about people actually applying. My colleagues will be coming in on the theme on travel and housing and other things, but if I could maybe focus you a bit more into the contract and that difficulty in getting the numbers that you need. What we are seeing from the universities there is reduced numbers of HPs coming out, from universities that are Scottish students, we are seeing less graduate applying for those posts and what we really feel some of the solutions that can be put in place is really developing a kind of more grow your own workforce initiatives, earn and learn, but for that we need the universities to deliver training to allied health professions in a flexible way, so to deliver those training remotely, online, to condense the academic curriculum, so it's delivered for example for three days with two days practical work and kind of wear in your hosted health board, so that way we can actually recruit people from the area who very much want and need jobs in those remote and rural areas, but then they don't have to relocate to the central bayt belt to do their training, which is very costly for people, so I think there's appetite from boards to deliver those solutions, but the universities at the moment do not provide those opportunities, so they don't provide those hybrid learning that allow us to do that. Thank you very much, I don't know if anyone else wants to come in for my next question. If I could do just in specifically to your point about that contract and I think it is fair to say that in a lot of remote and rural areas that contract wasn't welcomed with open arms by some of your GP colleagues, but certainly from a physiotherapy point of view, these were typically high-banded posts that we put in place and so they were quite attractive and actually recruitment into those posts hasn't been as difficult simply because they were attractive posts. What it has done, I think we were talking about between 200, 250 new band seven posts that were created and where we've recruited to those internally that's left a huge void behind in the mainstream services, so that has been more of an issue. I think if I can give you the example of NHS Highland where I work in the north area of North Island we actually cover every GP practice with a first contact practitioner. Now that has a huge impact in allowing people to access that specialist MSK knowledge close to home, so it's of huge value, but there will always be that undercurrent if the GPs are unhappy with that contract that they won't particularly want to see it as successful and so any issues will be picked up and moving to another part of NHS Highland in North Island but we cover 16 out of 31 practices but that actually covers 86% of the population, however there is still that cry of inequity and the cry isn't just about the inequity it's about the fact that the GP contract, the new contract is never going to work and it's using those examples so we've worked really really hard to deliver on that contract and from the CSP point of view we absolutely welcome that and having those practitioners in local areas for those communities has been successful and is working well but I think we have to understand the wider context of accepting that contract or disagreeing with that contract fundamentally but from a physiotherapy point of view we absolutely see the value of that and have worked very hard to deliver that. There are other models as well we've been trialling an electronic access and self-management plan to go and sit alongside our first contact practitioners and that will help provide additional cover for those people that don't actually need to see somebody face to face so there are other options there are developments that we can we can work on but the biggest void has been taken that huge number of very experienced physios out of mainstream services and putting them into GP practice with nothing following behind and as Sharon said and I'm sure we'll get a chance to discuss it at some point the number of AHPs being trained particularly physiotherapists being trained and coming through into the services is quite worrying. So I think as I think my colleagues will be picking up on that so we won't delve into that just yet you do talk about inequity and that's something that that's my the question I want to come on to I think physio though is slightly more unique to other areas because you've gone local from being centralized into locality and I think a lot of the worry is the opposite way you've got localization local things becoming centralized and that brings on to the question about inequality because again going back to one of the respondents the response says that AHP should be equally shared in all practices and they used Cathness as the example some first contact services are mostly in NHS managed practices so not equally shared with other or rural practices so patients aren't able to equal have equal access to care so my question is do you think that there is inequality clearly for physios that doesn't seem to quite be the case but do you think there's inequalities when it comes to other allied health professionals especially looking at our vaccinations? I just come in from an occupational therapy perspective there's pockets a good practice I would say across Scotland in different areas where occupational therapists are employed within primary care but it's very patchy for example in Lanarkshire recently they recruited to I think it's something like 36 posts so that every GP practice would have an occupational therapist attached to it this was after successful pilot projects that showed that actually having occupational therapists in primary care was reducing the burden on GPs so it was literally reducing by hundreds the number of referrals that GPs were having to deal with taking a lot of pressure off the system we've got some other good examples outside of Lanarkshire in likes of Ayrshire that's where again they've managed to recruit quite a few but then where I'm from in Fife there's not a single occupational therapist in primary care and my understanding is throughout Scotland that's perhaps unusual that there's none but there are very few areas I've gone down the route of Lanarkshire now when speaking directly to GPs and seeing GPs tributes in Lanarkshire for example they spoke to the GPs and they recorded videos where they spoke incredibly favourably of what occupational therapy actually bring to primary care and the difference that they make how much stress that alleviated from the GPs themselves I've shared that with some of our GPs locally and they very much will actually what one of them actually said to me Dr Glen McRickard said to me was it seems like a no-brainer and that's what we should have but it's not included in the contract that Fife have to go down that route or anywhere else has to go down that route so I think you know out there the GPs that in the know do recognise occupational therapists as described by the GPs in Lanarkshire themselves they described us as being general practitioners that we bring something unique in our holistic approach that we deal with people's physical difficulties as well as their mental health issues but unfortunately yeah as I say there's nothing there that that says that the primary care has to employ occupational therapists so it's incredibly patches I see some really great examples out there of the difference that occupational therapy can make but yeah that's the position we're in thank you so so I think there is that oh Catherine show let's take a look good morning I would want to echo what the first speaker said and that was that we're very much governed by the academic year very much at the mercy it isn't particularly friendly when we're looking to take on staff and educate them to the level that we need sometimes having to wait up to a year for that academic year to come round again so that we can get them on courses I manage a team of advanced nurse and paramedic practitioners scattered across the west of Highland but we have teams all across the Highlands and it's been incredibly successful starting it over seven years ago and while there might have been a little bit of pushback from some staff and from some community is at the beginning of it it allows us to deliver care to islands where we couldn't before and to the very very remote and rural areas as well I think the problem we have in remote and rural areas is that we have small pools of staff and we're spreading them very thinly when we want to take staff on and educate them to a higher level we are taking from the same pool of staff which obviously puts pressure on some of the hospitals and GP practices and things like that so I think that's our problem we need to look how we can manage that safely while still allowing staff to be able to study and work at a higher level to come in just in terms of the inequality so I think it's quite a mixed picture in terms of you know there are for example in the borders it's not it's actually it's the not we don't have any health board practices or I think one or two but the first contact practitioners are in the general practices so it's not that it's like they are everywhere I think the issues is with the really remote and rural areas where the GP practices are quite small and it's perhaps less cost effective to have and very difficult to recruit an allied health profession to work there as part of the MDT team you know particularly you know if you want to expand it beyond physiotherapists if you see the models in england where you know you have where you have podiatrists you know OT is working and the OT model has actually evaluated very well both in terms of staff satisfaction but also impact but yeah there's challenges spreading that in remote and rural areas because of the workforce issues we're having I mean that's my last question but I just want to state for the record I've worked in AIR I've recently done some shifts in Fife I've also worked in the central belt and when I have allied health professionals it doesn't matter who they are it's amazing and my life is so much easier and then I go out into shifts when I did in Fife there is no one and my shift is so much harder so it's a very difficult thing. Come in with one more point that you mentioned the GP in Keith Ness who said that they felt that the access was inequitable there is a little bit of pushback and you also mentioned vaccinations and c-tech services and I have noticed that the pushback from practices that aren't supportive of the contract really ramped up a little bit when the c-tech services were introduced and they were possibly the first of the work streams primary care work streams to be excluded from practices but since that happened we've seen a number of examples where GPs are not just ones that didn't want to accommodate the HP services in the first place but ones that have had an established FCP service have now turned round and said we don't want we will not host them in our practice anymore you will have to find alternative accommodation you will have to find alternative services and it's almost like these services are being used as a bit of a a football to demonstrate how demonstrate their dissatisfaction with that GP contract so there are times issues with finding accommodation but even where we've had that accommodation we're starting to find a little bit of pushback and some of the surgeries are now actively exploring whether they can have the the primary care work stream staff removed from their practices now and what that will look like one practice in particular of the only alternative accommodation we've been able to find is is 10 miles away and so now the patients instead of us trying to get closer to the patients were having to go further away and that's actually further away from the main physiotherapy services as well so but that's the only alternative we've had to provide the service we've committed to so it's it's not just a case of us picking and choosing where we put those services there's we have to work in collaboration with our GP colleagues and when there's a level of dissatisfaction with the overall contract that becomes quite difficult at times. Thanks convener good morning to you all it's just a brief supplementary convener for Neil you talked about pockets of good practice and I know we've heard from CEO of NHS Borders Reeve Roberts about rehabilitate prehab and also reablement so it's that part of good practice I mean can you give us an example of what happens on the ground that makes a difference in what OTs contribute? I think we're occupational therapy is fairly unique as I say is that holistic approach so when you have occupational therapist involved in primary care you're getting that early intervention approach but it's looking at every aspect of that human's life you know so you're not just looking at their medical conditions you're not just looking at any psychological issues you're looking at their social issues you're looking at their housing and I think it's that unique approach that makes the difference I think in terms of one of the things I've looked and done a lot of research on recently is that the link between unsuitable housing and ill health and the impact that that can have in terms of if it can be people having falls at home you know people that are disabled if their houses are not suitable but also in terms of when it comes to hospital discharges too so occupational therapists out the community pay a big role in ensuring that people's homes are actually suitable for them and safe for them and promote their independence if you have somebody that's living in a home that's actually suitable for them that's able to carry out the activities of daily living that they need to for self-care every single day then that lifts a huge burden on paid carers unpaid carers it prevents people going into hospital it prevents people needing to go into residential care or go into residential care too soon so that maybe gives a little flavour of the difference occupational therapists can make but we deal with people's mental health issues as well and support people with that it's not just the physical support it's not just adapting people's environments but it is the fact that we are looking at every aspect of a person's life what I think we do make a you know a unique difference and we have a unique offering thanks thanks Gillian Mackay thanks convener and good morning to the panel what are the specific challenges for your different disciplines of working in a remote and rural area in relation to the need to be able to provide both routine care as well as specialist care for less frequently encountered conditions and I jump in there thank you um yeah this is a this is a big issue for physiotherapy there's a a bit of a misconception sometimes that we will have these generalist physiotherapists in remote and rural areas that can provide specialist input into absolutely everything and it's just not the case the biggest the hardest job input in the team together in a remote and rural area is making sure that you have those specialist skills within your team and that they are available um health boards remote and rural health boards will often have only one or two real high highly skilled specialists but they could be as far as two three hundred miles away that's not really an accessible service um so we need to ensure that we we can have those specialist skills um a really easy example of that is um neurology services um if you've if you've had a stroke if you have MS and we have very high numbers of MS patients in our remote and rural areas you need that specialist input you don't need a generalist input who can kind of nibble around the edges of your problems you need someone with that that in depth knowledge and skills that can fix that but there's not always the understanding amongst the health boards that that is what is required and there is an assumption that um physiotherapists can morph into a range of different specialist skills and we absolutely can't our undergraduate training is is is general and then to develop specialist skills takes a number of years of experience and training postgraduate um and if you don't have that you cannot effectively support some of our complex patients and you're right a lot of the work is quite generic and we can manage that with with generalist teams but if you are that person in a remote and rural area who's had a stroke that's not going to cut it you need we need the ability to highlight and train staff and have that space time and opportunity to provide that training so we can we're seeing exactly the same types of patients that you will see in in big central belt hospitals they're just fewer of them and even that in itself leads to the problem of how do you maintain those skills so it is it's a real challenge um but we work really hard to do to ensure that we do have appropriate skills in place anybody else want to come in i think even in some areas where we do have some specialists it's often sole practitioners so it's enough you know that they're down they're sick there's no access and they'll be in a specific area of that you know rural board so so it's a real issue the other thing the other question your other question was around the routine to you know question um what what we are finding that because i allied health professions now have to really focus on patient already very sick patients they are already in hospital trying to get them back home we actually really diverting resources from our preventative services so we're not tackling the the issue really further down the line before people become very acutely ill so if i'm looking at my service my podiatry service i need to divert you know my workforce to focus on um acute you know saving limbs on acute you know foot and leg ulcer to save limbs i can't divert my workforce to do the prevention work that would stop people from getting to that slippery slope do their own really and that's a really issue for all allied health professions because of the workforce and the acuity of patients post-covid i can come in just echo what charn was saying yeah what where we should really be focused and more resource on early intervention and prevention and trying to stop this cycle um we are unfortunately having to divert too much resource to um meeting critical priority where people are at the highest risk and a lot towards um facilities and hospital discharges um recruitment retentions an issue which obviously accentuates that and i think particularly in a lot of um rural areas i think is um both Derek and Sharon um i've already alluded to i think that the cost of housing in so many areas um makes it very difficult to attract and retain staff because he just can't afford to live in these areas because um mainly because the prices have been pushed up by tourists you know a lot of people own in second homes things like that um and i think i know we'll probably come on to it separately as well but i think you know one of our solutions that we really need to put forward on is um training people that already live in that locality you know when they're embedded in that locality they're not going to go elsewhere and you know utilising opportunities as you know earn as you learn um apprenticeships to try and you know solve these recruitment and retention issues which are only going to get worse because as i think Sharon quoted some status earlier we have an aging workforce we have a lot of people in the last few years um and that was probably exentuated by Covid you know after Covid a lot of people have left allied health professions we haven't got enough students coming through so that's definitely exentuating the issue and i think without um us taking some action and doing things differently um that's only going to get worse a couple of you alluded to the fact that quite often some of these workers are are lone workers and are often out in the community and things or or are working in quite small GP practices and maybe the only one of their profession from the multi-disciplinary team are we properly supporting these individuals at the moment and if not and Derek i think i'm going to come to you first because you should get ahead um and if we're not what needs to be put in place to support these people and actually to develop them into some of the skills that um that you were saying that maybe in some other health boards we take some of those training and learning and support pathways for granted yeah it's we do take it for granted and again i can only speak for physiotherapists most physiotherapists go into the profession to be clinicians and given the chance they will see patients morning noon and night um and so the value put on their non-clinical time by both themselves and their employers isn't always as it should be and i think it's there are no national guidelines around uh other there are no scottish guidelines around uh how much time should be dedicated to um non-clinical time to this training and so it's left to the clinicians and you know i know managing teams um i've tried myself to include non-clinical time at one point we had a big almost like hairdressers diary for one of my teams and and the patient and we used that as a patient diary and i would put different colours on for the non-clinical time and they would just write patients in and so i started making it black and they would take little white labels and stick the little white labels over and fill in with patients and there is when you've got long waiting lists and and cues of patients that is the pressure that is on the clinicians particularly in remote and rural areas if you're the only physiotherapist in that area and you have a huge waiting list you know that's on you or you feel that that's on you and so we need some way of almost legislating okay this is your clinical time this is your non-clinical time because that non-clinical time is important for development not only of yourself but of services um so that would be that would be real useful and the other thing is necessarily everything's been cut to the bone um the amount of times we're asked to try and recruit to part-time posts in remote and rural areas or one single post because that's all the funding that's available and the funding you know the establishment funding might not have been reviewed for 20 years and it's certainly until April next year um there's never been a mechanism to match that capacity with demand um so you know it's really welcome that we have that staff and legislation come in so we can actually start to do that um but it's it's unlikely we're going to recruit to part-time posts it's unlikely that we're going to recruit to very isolated posts and I think at some point there needs to be a little bit of acceptance that if you you know we did we looked at a workforce establishment process and in our community remote and rural communities we found that up to 50% of time for our community physiotherapists was spent driving around it was spent driving between but the workload might say we need one whole time equivalent so we would employ one whole time equivalent but we only got 50% of that clinical time because that wasn't considered so there's lots of rural considerations that aren't taken into account and if and I sincerely hope the staff and legislation next year will help us to address that because we'll be able to articulate it better but from the clinicians point of view some guidelines around okay this is what we expect of you in terms of your clinical contact but this is also equally important the non-clinical contact town I'm just very conscious that we're already having our intercession and there's lots of questions so if I can ask witnesses to be concise with their answers please that would be very helpful Catherine oh sorry I wasn't sure I'd been unmuted yes I was just going to say that probably our biggest challenge is the fragility of the teams so very remote and rural areas have very small teams so it doesn't take much to destabilise that the team I manage works in remote and rural areas out of ours so they work in isolation and they do require a good degree of resilience and a generalist knowledge um so our biggest our biggest um our biggest problem really is the fragility we keep being asked to do establishment reviews but the footfall would indicate that we only need one person however in order to support the service um it more than likely needs more than one I think probably exactly has just been said by the last speaker we're not taking into account that need to support the need to travel etc thank you thank you convener I'm very interested in the notion about trying to recruit people from the area because we know the evidence suggests that and I have had some discussions with nests and stuff around that if you were to give us one or two pieces of advice on that what what is the stumbling block because since I have been elected I have been asking how we move this forward and I can't seem to get to the point of finding out what the stumbling block is to do in that universities okay that's funding as well isn't it I mean my understanding is in England where they have these courses already in place and they've been in place for a number of years um is that the the funding for these courses is ring fenced and you know you'd need to check the accuracy of this but my understanding is that whilst they had ring fenced money that money didn't come to Scotland ring fenced I think it may have been calculated as you know went in with the Barnett formula no money came here but because it wasn't actually a ring fenced it's just gone into a general pot um and I think we would need a similar arrangement in in Scotland where the funding was in place because the universities are not going to run these courses unless that funding is there for them so the apprenticeship levy the way it's used in England is given back to the boards and then they can develop their own apprenticeship programs in Scotland it's went into skill development Scotland so that are political decisions around that but putting putting that aside I think the real issue for us at the moment because a lot of our boards sitting with underspends so I'm sitting with £300,000 underspent in my budget I would have money to develop those earn and learn initiatives but I can't do that because the universities will not deliver the train the learning online and would not condense their their week into three days week which will allow me to do that and we only have three universities in Scotland to develop the deliver allied health profession training two of them are in the central belt so that of no help to me when I was a man a you know a manager in the boarders it's no help to my colleagues or managers in the Freeson Galloway you know because people can't travel three hours and you know afford not to work and so on so there need to be pressure on the universities to transform the way they deliver training that is your sampling block I'll try and keep it very brief two pieces of advice so if I can give you an example we've talked a lot about that apprenticeship scheme we have a lot of very good physiotherapy assistance technical instructors they are embedded in our teams they are embedded in our communities we don't have to worry about housing we don't have to worry about them moving on for example in NHS Highland we have 14 technical instructors that want to be physiotherapists they have no route to do that if we followed an example for example like Sheffield Hallam University have a 27 month programme to take very experienced technical instructors assistance to qualified status 27 months in 27 months we could have 14 new physiotherapists embedded in our teams in already working in our teams in NHS Highland that would be absolutely transformational in just under two years the other issue I see is we still have our master's programme is now more popular than the bachelor's honours degree route and despite Napier University coming online and having very few overseas students we're still looking at 60% it's been as high as 80% of overseas students particularly from Canada on these master's degrees 80% of the students going through that master's degree are going to go back to Canada we are doing a brilliant job at training Canada's physiotherapy workforce but we kind of find staff for our own areas so that would they would be my two bits of my two pleas if we can have that earnestly learn that apprenticeship approach model part-time study model that would be brilliant and if we can please try and fill our own courses with UK based staff that would be brilliant I think that the panellists have answered it differently. Thank you. We'll move to Tess White who's joined us remotely. Thank you, convener. If I follow up on that funding question to Sharon, Sharon you previously told the committee that short term funding and lateness of funding was an issue because it wasn't getting to the boards and it really negatively affects recruitment and retention of staff. Is it still the case Sharon or has the issue gone away? Did I say it just now? No I think you said it in 2021. Okay yeah okay right that was in relation to another inquiry so so whether short term funding yeah so so I think there are something I can't really answer at the moment unfortunately I'm not experiencing that in the board I'm currently working in but I'm not sure about you know I can't really without looking into the details I can't really you know give you the answer to that without checking with other boards. No that's fine that's an answer in itself um so thank you so my second question is to to the panel and if we can start off with um I think if we can uh Derek yes so the Scottish Government published so it did publish a national workforce strategy for health and social care and a workforce policy review for allied health professionals so but as we've established neither cover rural or remote areas and this this is due to be published by the end of next year so that's 2024 so given that a one size fits all approach to NHS workforce planning clearly isn't working for rural areas should this strategy have been published sooner and um also what do you think should be included in the strategy and the reason I'm asking Derek first is because you talked talked about rural considerations needing to be taken into account thank you. Thank you yes um if I can very briefly go back to your last question uh that was for Sharon um I can confirm that the impact of delayed funding or short term funding is having a real issue we have a very good example in Argyll and Bute where an HP led ACRT process is is reducing the number of patients being referred to orthopedic services by 60 percent and that had to run from uh April until last week with no funding whatsoever and because the waiting initiative funding that was issued or was supposed to be issued in April did not come to our board until last week so there are still impacts like that you know really good projects that are at risk of falling apart because the funding is delayed sorry to go back to the what are the considerations I think articulated as best I can we did a kind of mock-up of the workforce establishment process in preparation for the staffing legislation and it gave us clear indications of what was happening in in terms of what our remote and rural physiotherapists are doing with their time and a lot of it was up to 50 percent of it was travel the administration and the IT support isn't always in place to support lean working in remote and rural areas and then there is that big issue of the fragility and the sustainability if you have one practitioner that is providing no services and that one practitioner is off that means there is no service now in in central belt areas more densely populated areas that might put pressure on the rest of the team but there will be some ongoing service so I think from a remote and rural area we have to be aware that if that workforce is off and bearing in mind there's not the vacancy factor built into HP budgets that there is into nursing there is no HP factor so if you hire one physiotherapist they're there for 42 weeks a year you already have a number of weeks where there is no service and I think we have to understand that if you want that 52 weeks a year sustainable service that doesn't disappear when one person is off sick then we need to find a way to factor that in. Yes thank you come back to your question because I now remember what it was about you've got me a bit off guard so one of the issues where we have significant issues with short term funding and that's across Scotland is around a nutrition and dietetic weight management funding so they're always short they're always short terms and we're really finding very difficult to recruit into those short time contracts so we can't feel those posts because there are short terms and there are not enough dieticians to really pick up those posts so they're often you know we pretty significantly underspend but that's a thing that's broader than just for remote and rural areas so that you know that I know that existed in borders that existed in many areas unfortunately. Thank you that's really helpful and before I pass back to the convener if I can just that question on what you think should be included in the strategy if I could just ask Catherine if you could give a view of that that that would be really helpful thank you yeah thank you I think it needs to be recognised that delivering as equitable a services we can possibly do in these remote rural areas is incredibly expensive and without investment into into this service we're not going to be able to do it we're very fragile we have small teams we're trying to bring people in it takes a long time um to train people um but if somebody with experience leaves we have a month to fill that post um so to bring somebody in we have to go outside uh generally because we're not investing we're not investing um in our in in our own services at the moment are you suggesting Catherine that you you almost have to overstaff in rural areas yes I believe we do I think we have to recognise that there are times when we've got to be proactive and not just react to any given situation because that puts pressure on the communities it puts pressure on the staff left behind um and we then are busy chasing up everything and trying to cover the gaps um with staff if we can which puts pressure on them I think we in some areas we absolutely need to be proactive um and overfund over stuff okay thank thank you back to the convener thank you thanks Tessa now move to Emma Harper thanks convener I'm interested in um issues around continuing professional development because I think one of you alluded to that already and the importance of it and we've taken evidence in this committee before about the things like the clinical skills managed education network so the mobile skills unit that will go out to rural areas and do simulation training and things like that so I'm interested in what your thoughts are around the requirements to value education and I say that as a former clinical educator I am still a registered nurse my job was to go and work with allied health professionals and nurses to teach clinical skills across NHS and Friesen Galloway so I'm interested in what you think it needs to be valued when it comes to continuous professional development it's vital for all of our registered HP staff that they continue you know we we are registered we are regulated we absolutely have to undertake continuous professional development as I mentioned that becomes difficult when you feel the pressure of waiting lists and there is no one that there is a little understanding within the health boards of the continuing professional development needs of age pays training budgets have pretty much disappeared so we actually have no funding within our budgets in most cases I've become very good at finding alternative sources of funding which I will continue to do but there's almost an acceptance over there's no money and we've made huge leaps forward in terms of being able to do to accomplish training online which is really welcome particularly for a remote and rural area but if we don't have the budget to pay for online even online training it becomes very very difficult and training budgets are a bit of a low-hanging fruit they're easy to remove from budgets and that's happened consistently across AHP budgets I'm also I'm thinking about picking up what what you said Sharon about moving well traveling great distance in order to engage in education so whether it's paramedics as well as other skills learning and I'm also aware of the reduction in spirometry being delivered now which can be done by nurses, gps, physios but the quality outcome framework didn't reduce the payments for that for GP practices so spirometry now isn't conducted so that means there's going to be a lack of ability to assess for COPD and asthma diagnosis in a remote or rural setting so that's just one thing that has come up so I'm also wondering about I suppose what what do you think Nez's role is to support education and continued professional development? Can I just come in there and just highlight that for occupational therapy, occupational therapy is unique among Dalit health professions and it's the only allied health profession that spans both health and social care so I find often with these conversations it's overlooked that occupational therapists are not just employed in the NHS but they're actually employed in the local authorities too so I think that what we often experience if you're employed by the local authorities I am is that Nez does do a lot of development work it's very valuable but that's very much delivered to the health service and I think whenever we have these conversations it's often forgotten that local authorities also have a responsibility for supporting the continuous professional development of their occupational therapy staff but any initiatives always go through Nez but they don't necessarily then make their way through the local authorities so where you've got some joint boards you will find for example in Fife where there's some some really good work in relationships some good integration that say my staff could go into turas and access some training that Nez have developed but again that's I think pretty patchy I'm not sure that's consistent practice across the country and I just think it's important that when we have these conversations we remember that we're not just talking about the health service we're not just talking about Nez and we have to think about local authority employed OT staff at which there's a lot and just picking up on an earlier point that I think you know Derek was making in terms of pressure on staff the same's felt in the local authorities too where you know budgets for training are very small as Derek highlighted all AHPs in order to maintain their registration and practice have to evidence continuous professional development and they can be asked on a two-yearly cycle to present that evidence otherwise you know they can't maintain their registration but those budgets are under pressure and staff are under pressure if you've got hundreds of people waiting to be seen you've got people potentially been waiting for a year depending on what area you're in then staff do feel that pressure on themselves so even if you're giving them permission that you know take time out spend a bit of time doing some continuous professional development they do feel that pressure on themselves they do feel a responsibility they've come into caring professions because they want to help people and so the first thing they often choose to do as as Derek highlighted was give up that time so they can see somebody else and you mentioned to us and it's so digital training i'm familiar with that as well and that is really valuable for some things but also there is a value of face to face as well and the point that you made Neil about the integration it means that patch you work is happening so so you mentioned that OTs are employed by local authorities so that's something that probably needs to be investigated so that this kind of silo approach doesn't happen yeah i'm in a bucket highlight again to one of the things that Derek spoke about with the safer staffing legislation so it's highlighted within that obviously covers the NHS and it covers social care settings within the NHS specifically highlights that occupational therapists come under that legislation but what the legislation fails to in the guidance behind that fails to recognise as occupational therapists working integrated joint boards and integrated teams and integrated services where you've got a mixture of local authority occupational therapists and NHS OTs and i see that has been quite problematic if what you're trying to do is safeguard staff and safeguard the delivery of services how can you do that in integrated services where you're only including you know a percentage of your occupational therapists okay yeah i was just going to ask about figures for OTs that are local authority employed versus NHS but we can get that info later yep perhaps if Mr Carnegie could could I don't actually have those figures in fact i was speaking to the Royal College Occupational Therapy Board to see if anybody held them and we don't have them unfortunately you know that because local authorities are separate you don't have that you know you could for example go on a tour ass and get the national figures for the NHS OTs staffing but there's there's no similar arrangement for local authorities that you can easily get that information okay thanks David Torrance i'm sorry we need to move on David Torrance thank you good morning to panel members and somebody touched on the issues earlier but can you expand on what infrastructure improvements would help encourage people to apply for posts in remote and rural areas the big one is one we've all spoken about already is is actually there and as you learn opportunities and actually your existing staff i think we could all pinpoint within our own staffing groups there's a huge appetite within tis technical instructors or or assistants that we'd love to be able to have that opportunity of career progression and these are staff that will stay within the area except families there you know that's that's where they live that's where they have homes that's where they have lives um and that would make the biggest difference but even if that's introduced then that has to be as i think sharon already alluded to there has to be that opportunity for that to be distance learning um but for me i think that would be the biggest difference the the the big change maker um few areas for to me it's something around travel a compensation from travel cost a lot of the time the the distances the people you know have to travel you know it's more costly for them uh housing is a huge issue in terms of uh i had staff to try to move to the area and couldn't find house and couldn't take you know jobs because of because of that uh so that's a really issue so we need to have some incentives around travel around highest and the other thing is it so you know internet patch internet that makes it not just less attractive for people to move into the area but it's also impact on our ability to deliver services in a more innovative way to people so it's the it internet coverage in rural areas but also the appetite around um around risk of implementing a innovative sort of solutions that would use um you know information technology the appetite around risk around health port is very very different and we're seeing um some of the rural health ports actually being quite averse to that so you can see some models of um of using it technology being developed in some health boards while others are not you not not going anywhere near it so there's some discrepancies and it might be to do with the IT infrastructure that health boards have thank you for that um sharn you mentioned about grow your own workforce earlier on but what impact is a depopulation in rural areas having on managing to get that workforce i'm not finding that that's a huge issue we know that the population is aging but one of the things that the pandemic showed a lot of people was that there's huge value to living in remote and rural areas in terms of what that gives you in terms of um areas to bring up children and i think what's i think housing issues are the biggest problem to actually um repopulating we've you know we're building new housing stock but if half of that housing stock is empty throughout the winter months it's of no value whatsoever so i think that i don't find i think there is a willingness for people to move to these areas but they need to feel connected and it goes back to the last question slightly what can we do to um to to facilitate people and they need to feel connected whether that is professionally whether that is with systems that allow them to work in remote and rural areas quite easily and freely um or whether that's having a suitable housing to to move into those areas but undoubtedly the you know the population is aging and we need to positively we need to encourage people to move to the to remote and rural areas but i think there is a there's certainly a desire for that the problem is the people who can afford to do it are doing it in the summer in second homes what we're seeing is some of our non-registered posts you know healthcare support workers we can get up to 30 applicants for these sort of posts so you know so we know we've got people that we can take and develop it's the registered staff that we can take so we have you know we have signs that will have people to train if we had those opportunities okay thank you and sandwich go honey thank you convener so we're hearing a lot of wider infrastructure issues we've heard a lot about incentives so i suppose my question and it sort of relates to the work of dr gordon baird in galloway do you feel that having a rule and remote advocacy service would be helpful in ensuring equality and helpful in ensuring that we hold boards to account and also we hold other areas to account to ensure that things are in place for people to go and work in rural and remote areas certainly that would that would be helpful and even to the level where funding that's provided for rehabilitation services which is predominantly your hp workforce isn't always when it goes to the health boards isn't always used for that purpose i think there was one health board that the integrated care funding well not a penny of it was spent it just went towards the savings and it's not ring fencing and holding to boards account to account for delivering the funding to the services that it's intended for would be incredibly useful it does become frustrating when we see that there is a a willingness on the part of the government to provide that funding but by the time it gets down through the health boards you know it's been diverted to putting out fires elsewhere thank you okay and ivan mickey yeah thanks very much good morning panel um the the government and the nhs education for scotlandness have launched the national centre for remote and rural health and care um and i'd like to get reflection from yourselves about how you understand that centre is going to operate what its priorities are going to be whether it's going to be focused on the right kind of things given the wide range of issues we've already talked about about this morning so i don't know who wants to go first on that i work with nests quite a lot on a variety of different areas and the one thing that always strikes me is that i would like to see a lot more connection between nests and clinicians um it seems to be the involvement in nests is at a is at a higher level and it would be lovely to see the priorities driven by clinicians in the remote and rural areas uh us a bottom up approach uh rather than sometimes the top down approach that it appears uh sometimes happens with nests so is there a sense that when they're putting when they're putting together the national centre um that the way that's been structured and the priorities that's got aren't necessarily reflecting what i think yeah i think we we need what we need nests to do is to kind of meld those um government national strategic priorities for remote and rural areas with the reality of clinical provision on the ground and that's very much where i see that nests can be incredibly incredibly useful any specific examples of that you'd want to highlight um so i've done some work around a variety of different projects in terms of frailty and in terms of falls um but that's because i've um i've kind of stuck my nose in rather than someone can look in for an opinion um and so we have a game we have lots of pockets of of good examples of work on the ground that aren't necessarily even known to to nests teams um so i would like to yeah i would like to see greater engagement i would like to see that almost outreach of nests coming into going round hospitals going round rural areas and saying what is it you need from us we have the overarching strategic priorities that we have to address but how can we help you to do that in a remote and rural area and again it's welcome that there is a remote and rural centre being set up because we've already discussed the one size doesn't fit all for healthcare across scotland we have very different priorities in central belt and and rural areas okay thanks very much anyone else want to what slightly worries me is actually that we have seen a hell of a lot of strategies going around so we had workforce development you know strategy for uh hb now you're talking about another strategy for a remote and rural what we're not seeing our implementation plans and that's what is really going to make the difference not just another strategy you know that's in that's in my view yeah so we need to see what are the implementation plans around it and as Derek said to involve staff but going back to to your your your point i think in terms of the courses and you know what nests can do i think there are some role there is some role for generic courses but you'll never take away the need for some hands-on practical you know courses like that would really allow advanced practitioners to develop and support you know gp practices and support rehabilitation and prevention so there is limitation to what nests can actually offer i think in terms of some of the courses you know they can't deliver joint injections they can't deliver ultrasound scanning courses you know specific courses that we need but what they can help us with is really supporting boards in developing work work plans for staff to do their workforce planning that's where they can really have a role okay anyone else want to comment on the national centre thank you i just wanted to bring a positive note in with regard to remote and rural education and that is the new course that started in the highlands that is open to all advanced practitioners and it's the rural advanced practice msc and that started i think in september it was this year it's been a number of years in the making and they actually did speak to people in remote and rural areas they spoke to me on a number of occasions and members of my team before they developed this course so we're all keeping our fingers crossed it is a rural advanced practice course it's not a rural nurse advanced practice so we're keeping our fingers crossed that they're going to focus more on the issues and training that people require to work in the more rural areas okay thank you anyone else get any comments on that okay thank you very much thank you and we'll go to Tess White thank you thank you convener so i represent north east scotland where the challenges of delivering remote and rural healthcare can be acute especially in recruitment and retention issues so a couple of times have you given the example of d-side and brema where they're unable to recruit a gp despite a huge community wide effort to do so and i think that i understand the practices due to having back its contract to nhs grampion today so we know housing is a big issue kathryn what what are the infrastructure improvements would you welcome in these areas thank you i think most people most people come to live remote and rural for a lifestyle so we need we need to be looking at the schools we need to be looking at child care child care is an enormous issue because people do want to come up to work and then they can't find anybody to look after the children work for partners career progression is massive think they come people come up and we can't keep them because there is a glass ceiling on where they can go in the area that i cover i suppose if you look to sky for instance and and the hospitals there we have one band seven post so if you're a nurse that comes in and you're working at band five on the wards the reality is that to progress your career you need to leave not necessarily leave the area but certainly leave where you are so i think we need to look at career progression we need to look at child care housing is massive again it is about the affordability although i have to say just that skyla calcia doing a still-in-job housing association are doing a still-in-job at the moment trying to support us and the community tried to support us but yeah we very much need to look at housing and child care great thank you and just two quick follow-ups i noticed in an article from 2019 you highlighted that ANPs in rural support team can't use green lights vehicles to speed up travel time to see sick patients is this still the case and if so how has this affected response times massively i mean i suppose i get the argument back constantly that even with the blue lights people won't pull over and there is always going to be people that do that but the areas that these people work in are generally tourist areas so in the summer it is impossible to move and if we've been told flash your lights and bit beyond and people just think that you're a bully so they get combative so people won't do that and and it just seems to be a ridiculous situation that you can't put a green light on the car unless you're registered with the GMC great thanks and just finally convener in that same article you mentioned a nurse who'd hit a deer with a vehicle if you remember that and could you share your team's experience of using their own vehicles in remote and rural areas in terms of accessibility and cost thank you so what we try to do because of these remote and rural areas are difficult is we try or we tried to bring vehicles in for them because there's an awful lot of equipment that they need to carry as well as incredibly bad weather that's proven difficult with some of the new legislation now that the costs and things like that so more and more staff are having to use their vehicles and more and more staff are not wanting to do so at the the allowance with the gender for change that they're allowed their fuel allowance just isn't sufficient to cover any repairs that may be required the petrol and also the loss of value to their vehicle when they come to sell it because it's got those additional mileage so yes that is that does have an impact if we've got an area that doesn't have a vehicle staff unless likely to want to go there thank you Catherine back to you convener thank you thank you Andrew McGuire thank you convener just to follow up with Catherine Shaw on something she said in a response to emtess white there you spoke about Sky and Lochalsh housing association doing what they can to assist you is that around an allocations policy perhaps preference to key workers or local connection or what specifically are they doing to assist so we've been working closely with them after the Salwys Ritchey report as part of that so with anybody coming in the first thing that their advice to do is to contact the housing association in Sky and Lochalsh identify the fact that they're coming to work for the NHS for NHS Highland there and they're given points on the system I believe it doesn't necessarily take them to the top and it's not allocated housing um but if we're if we're likely to lose staff because of lack of housing then there are a number of things that they'll help us with and that isn't necessarily just providing the housing association properties it's putting us in touch with people in the community that they're aware may be able to help us so we work closely at the moment I've just had over the last six months three new staff join the team that I manage and one of them is in a housing association and two of them found accommodation through the housing association and word of mouth working together thank you and just want you might not know the answer to this but if not we can find it elsewhere the to the housing association and the local authority have a common housing register in in Highland do you know or are they sorry I don't know okay fair enough no we'll find it I can speak to that around certainly our gaelan but there is one housing list for our gaelan but so for example in obon they're building up to 900 new houses but what that means is that anyone from helensbreit cambeltown if they are at the top of the housing list it will be offered housing in in obon they also the housing associations have tried to help us and they have said that um that healthcare workers will be given 15 points towards the housing list but they're talking about over 50 points to be at the top of that housing list um they have offered kind of mid-level rent rentable property as well but it tends to be two or three um so from the 900 houses that they're building I think healthcare staff have secured 10 of them and the other issue around the infrastructure means that if you're you know even if it's two people per household that's still you're adding um 15% to the population of obon there is no additional medical practice there is no additional resource for the hospital for the schools for all of the other infrastructure around it so it's great to opportunistically build a large amount of housing to bring people into the area and support them with that but if you have a common housing list covering a large area and you can imagine if it was the same for any just highland that would be very difficult to to target that to support healthcare I think I think it's an idea we could probably look at further and then understand it's the same for many um public sector work areas that there's the housing issue yeah could I just come in with a specific point when we're talking about recruitment retention one that's very specific um to local authority um occupational therapists as um in terms of you you spoke about agenda for change um agenda for change is you know seeing significant increase in and pay for staff across the board which has been very welcomed but obviously because you have occupational therapists employed by local authorities um and their pay negotiations are through COSLA um what we've seen is a significant difference in the the wages that um NHS staff receive um compared to their local authority counterparts so that creates um issues for recruitment specifically to the local authority post because when we already as we've all described said there's a shortage of qualified staff out there it's very difficult to attract somebody to a local authority post when you could be working shoulder shoulder in the same team in an NHS post um and being paid thousands of pounds more a year and actually as well something else I'd want to pick up on is the travel expenses I just ask you a specific question on that um local authority occupational therapists the sort of work that they'd be involved in I suppose the thing that sprung to mind when we were talking about housing and the importance of housing for health was in around aids and adaptations and assessing people's homes for moving them out of hospital would they tend to be local authority employees to see the impacts that's right yeah that's where the division is but under integration you do actually have now quite a number of um joint teams joint services so you could have a a team where you literally have occupational therapists they're on different contracts they're managed by the same manager um some are NHS some are local authority but you've got people doing the same job very similar conditions otherwise but you know one's being paid thousands of pounds more than the other and in terms of travel costs as well I can't speak for all the local authorities but certainly no one fife that they only pay the the basic 45 pence a mile which then land revenue specifies where I think in in health at the 64 pence a mile that you get so you know that makes it all the more difficult for us in the local authorities to be able to attract staff because you know we're all trying to fish from the same pond but obviously the paying conditions currently in health are a lot more attractive so um that just exacerbates issues when you're trying to deal with waiting lists and waiting times and you're trying to move towards a model that should be preventative and the other thing I just want to pick up on because you mentioned it we've run out of time we've already gone over and we have more committee business after this so if you can be very very brief very brief you mentioned equipment and adaptations too easy a target and too many local authorities to make savings despite the fact that the scottish government of hollywood I think back in 2016 they made the point in this chamber that it's a spent to save policy every pound spent on equipment adaptations equates to a six pound saving across health and social care yet equipment adaptations budgets across the country are being slashed thank you our next meeting next week will be continuing our inquiry into healthcare in remote and rural areas and hearing from further representatives of the healthcare workforce and that concludes public part of our meeting today thank you