 Welcome to the 17th meeting of the Health and Sport Committee in 2019. We have received apologies this morning from David Stewart MSP and Anna Sarwar is attending as a substitute member. Can I ask everyone in the room please to ensure that mobile phones are off or on silent and not to use mobile devices for recording or photography? The first item on the agenda today is subordinate legislation and consideration of a negative instrument. The negative instrument is the national assistance assessment of resources amendment scotland number two regulations 2019. These effectively allow advanced payments to survivors of sexual abuse who are over 70 or terminally ill for those payments not to affect local authority assessments for charging for care. The Delegated Persian Law Reform Committee considered this instrument on the 18th of June and determined that it did not need to draw the attention of Parliament to this instrument on any grounds within its remit. If it is approved, it will be due to come into force on Friday of this week. Do members have any comments on this instrument? If not, does the committee agree to make no recommendations? That is agreed. Thank you very much. The next item on the agenda is an evidence session with NHS Fife. This is part of a series of evidence sessions that the committee is holding with territorial health boards. Can I welcome to the committee the right honourable Tricia Marwick, chair of NHS Fife, and I resist the temptation to add MSP at the end of that name. Paul Hawkins, the chief executive, Michael Kellett, director of health and social care and chief officer of the Fife IGB. Carol Potter, director of finance and performance. Barbara Nelson, the director of workforce. Chris McKenna, the medical director. Can I welcome you all to the committee? I look forward to your evidence. I start the evidence session by asking about the financial position of NHS Fife and in particular what progress the board is making to ensure that savings are achieved on a recurring and sustainable basis. As context for colleagues in the room, NHS Fife, we spend around £2 million on a daily basis, providing health and care to the population of Fife. Over the past financial year, in terms of working with our staff, our budget holders and obviously the public, we have had very strong and effective financial management and financial control that we have delivered our financial targets once again without any additional funding support through brokerage from Scottish Government. We have been very focused on balancing our financial position with our operational performance as well in terms of waiting times in other particular areas. As we go into the new financial year, we are coming into the end of the first quarter. The financial position for this year is challenging and absolutely prevalent, particularly within our acute services, where we are facing around about a 6 per cent efficiency requirement this year. On a positive, we have started this financial year. Although there is a recurring gap in our financial position, what we have seen since 2016 is that, year by year, we have been moving to reduce that, so this financial year we have started with a £17 million recurring gap, so that demonstrates that move over the past few years. What we have done for the current financial year is that we are working to refresh what we call our transformation approach, working with colleagues in the health and social care partnership on a system-wide basis. A very good example of where Fife has delivered effective recurring savings through a system-wide approach, as I would describe it, is in relation to our medicines programme. We have seen significant savings of the magnitude of the millions in terms of looking at our medicines waste, reviewing our formulary and also formulary compliance. It has been a very positive piece of work that our pharmacy colleagues have undertaken alongside our GPs and our acute clinicians. It is challenging, but we are making progress around what I would describe as good housekeeping, looking at all areas of supply, procurement and supplies, for example, as well as getting into conversations about redesign and transformation, which some of my colleagues could also comment on. Thank you very much. Clearly, those are challenging times. I wonder if Michael Kelly wants to add anything from the point of view of the IJB. Thank you, convener, not to add anything to what Carol says is a challenging position. We work very closely with colleagues in NHS Fife. The financial position of the partnership has been a challenge, but we are very focused on working in partnership with colleagues in NHS Fife and Fife Council to move the partnership towards financial balance in the medium term. That is an absolute focus for us, but Carol sets out the position very well in terms of the position of NHS and also the position of the health and social care partnership. Clearly, some of those are shorter-term perspectives. I wonder what the board would like to say about the prospects of developing longer-term financial planning, what steps have been taken towards that and whether there are any barriers to taking that forward. We have another number of transformation projects that we are working on. We are looking at mental health redesign and transforming the acute services. Some of the areas that we have started to work on are how we can provide care for patients faster and quicker in-cues. We have implemented some new ways of doing ophthalmology that is leading edge in terms of Jack and Jill theatres, which means that consultants can walk between theatres to speed up some of the services. We have done in a day hip 23-hour hips, which is moving across Scotland now for patients that are fairly healthy having their hips done. We are evolving a process of clinical pathways and change, but on top of that, we are trying to transform our services as well. We have got care in the community work that we are working through. We have got lots of long-term goals. Obviously, the financial sustainability is the issue to get there and the workforce issues, which are becoming more difficult in terms of recruiting consultants and other staff at the same time. Yes. Thank you very much, convener. It is a pleasure to be here. Can I just say that there is a high degree of confidence within Fife NHS Board in terms of the executives and the non-exectives about our financial position? We recognise that it is challenging. It has been challenging for the past two years, notwithstanding that, we are one of the few boards in Scotland that have actually broken even, and we have not required any brokerage at all from the Scottish Government to do so. While the situation is challenging, we are confident that we have got the financial strategies, plans and housekeeping, the gripping control that we need on a day-to-day basis, to ensure that there is a high level of confidence that, when we come to the end of the next financial year, we will continue to be in a good financial position. I am interested in set-aside budgets. We have taken a lot of evidence from various boards, and we have even heard that NHS and Freeson Galloway do not even call set-aside. Set-aside uses a completely different model. I am interested to hear whether you think that the set-aside budget is being managed effectively. How has it been managed would be a fair question, as opposed to asking, if you could give us some background about that? The set-aside budget is a conversation topic that is very prevalent at the moment. We are working with Michael and colleagues in the health and social care partnership in the IGB around the set-aside, and with the chief operating officer in our acute service. I think that the transition to move those resources into the partnership is a challenging one. It is early days at the moment. The recent submission that we provided in relation to the health and social care, as we called it, is a stock take. We have described in there that there is further discussion required. We do not have a definitive timescale around moving those budgets, but what we are very much focused on is that, rather than having a conversation about the set-aside budgets per se, it is very much about the clinical model. What does that actually mean for the care and provision of services for patients? When we talk about unscheduled care within the acute setting and the front door of the hospital, etc., and changing that model, how does that then align with our health and social care model? The conversation is very much one about what is the clinical model and what gives the best quality and safety for patients, and then the budget setting should follow that. At this point in time, the conversation with colleagues across the acute sector and with the partnership is one of the clinical model first and foremost. Is the set-aside controlled by the IJB and held by the NHS? Who manages it? The set-aside budget present is within our acute services division, so it is under the oversight of the chief operating officer. There is a range of different budgets across medical specialties and A and E and other unscheduled care areas. It is a conversation at this point in time, but it is very much managed and overseen by the chief operating officer, but we are moving towards the direction that is certainly set out in Government direction of travel. Do you have timescales for that, then, for moving forward? From recollection that is later in this financial year that we have got that, I am going to perhaps confirm with the chief executive or Michael if he can confirm that. Michael Carrill, I think that given the line of question that Emma Harper has answered, if you could confirm the detail but also the wider question of your responsibility for this budget. I am very happy to, and I will set the position out. The ministerial steering group recommendations about integration, as the committee will know, made a specific recommendation that set-aside was something that partnerships—by partnerships, I suppose, whole systems—need to take active action on and, in particular, put arrangements in within six months of this financial year. That is the timescale that we are looking at. It is a challenging agenda. I understand and I know that the Scottish Government is working with colleagues in Ayrshire around set-aside and how set-aside might be managed there. The indication is that guidance and advice will be produced on the basis of that experience in Ayrshire, and we are obviously looking to learn lessons there. It is a priority for us over the first six months of this financial year, but, as Carrill said, it is a challenging agenda. Being in a position given the demands on the acute service as well as the demands on health and social care to shift resources is a significant challenge, but one that we are engaging with in terms of the clinical model and also making progress that was required by us in the ministerial steering group recommendations. Some of the big numbers in the financial reporting are around the risk share between the IJB and the NHS board. Can you tell us what action is being taken in that area in regard, particularly in the way in which it appears that overspends are set against the IJB rather than against the board? We are working with the council, which is obviously the parent body, as is the health board, to look at the opportunities of reviewing that. At the moment, it has cost us a significant money in terms of transfer to the council. We are hoping that, in our assessment, we can look at whether we can change those percentages, whether we can work differently about how that works. In some ways, the money follows the patient, but the difficulty is that, with the amount of money that is needed in home care packages, it will outstrip some of those numbers. We are trying to understand how we can work with the transformation plan within the acute to try to mitigate some of that as we start to go through working a true integrated way, but it is a piece of work that we need to come to a conclusion by the end of the year in terms of moving that forward. The percentage share of the overspend is 72 per cent with the health board and 28 per cent with the council. We recognise that if there is an overspend within the IJB, then 72 per cent of that will have to be funded by the health board. That is why there are conversations going on with the health board and the council and others to see whether the formula that we have and the way that the IJB was set up can be looked at once more. The figures show substantial underspends in some areas, particularly community health and overspends in others. Does that give you a cause for concern? Michael Callott. That is the case, convener. What we seek to do is look at the budget as a whole across the whole partnership, as well as understanding clearly the impact of the overspend on our funding partners, both NHS and Fife Council. We manage the budget as a whole. There are a number of areas of underspend and a number of areas of significant overspend, and we are seeking to understand that. We are also seeking to, as I have said, plan for the long term. We set a budget for the IJB this year with an acknowledged deficit of £6.5 million but gave a clear undertaking to our funding partners that we would do everything. We could bear down on that overspend in-year but also plan earlier for future years so that we can move towards financial balance and therefore the impact, the financial impact on our partners, is mitigated. That is something that we are doing in partnership with the IJB Council and NHS, and those discussions are on-going. I know that Brian Whittle will come back to those questions later in the session. Annas Sarwar. Good morning, everyone, and a particularly welcome to Trish Marwick. Good to see you back in the building. Can I ask a general question? How would you rate NHS Fife's financial performance compared to other health boards or IJBs across the country? We have been very clear that the financial position needs to be balanced against our clinical performance. In terms of how we are doing, we are one of the few boards that have not had to have support and brokerage from the Government. Our performance in terms of waiting times, et cetera, sits within the upper quartile of all the health boards in Scotland. Both in terms of finance and performance, we are doing fine. I will come back in a moment about the brokerage. In terms of performance, be that either financial performance or clinical performance, where do you see the balance in terms of economic pressures or budgetary pressures versus workforce pressures? Do you see the balance in terms of how that impacts on the challenge? The two are inextricably linked. We have a number of workforce challenges in particular specialties, for example, and my colleagues and medical directors and director of workforce are better placed to talk about specifics. The balance of ensuring that we have the right staff in the right place for the right patient groups sometimes comes at cost. We have supplementary staffing costs, for example, but we are trying to look at innovative ways to support the workforce model at the same time as sitting comfortably alongside the financial position. We have a very effective relationship with colleagues in loading around radiology. There is a particular shortage of radiologists across Scotland and the UK in general. Through a technology solution that allowed colleagues in loading and borders to report on five images, we have been able to put that mechanism in place. It came, as I say, delivered on our quality, if you like, and our operational performance in terms of reporting on images. At the same time, it solved help to seek a solution to a workforce problem, and it came with a lower cost than potentially paying significant rates for supplementary staffing. We need to see more of that, more working across health boards to try and share capacity and share resource. Absolutely. It is finding innovative solutions that support our financial position as well as workforce, but using innovative solutions technology or other ways of working. On two points that were made by Trish Mawr, the first one was about an earlier answer that you said about how the IGB was made up, and perhaps something needs to be looked at about how that was made up. Are there any particular reforms that you are thinking of in terms of how that is set up and what lessons can be learned across the rest of the country? I think that the IGB has been there for four years, three years, and the formulas and the way that it worked from the beginning. I think that all the partners in it need to have those conversations and look and see if we are doing the best thing that we can. That also includes the funding formula, and those conversations are taking place. We need to get to a state where the IGB is in a good financial position as well as making sure that we can give the care to our patients. That requires a properly funded national health service and a properly funded local government of that partnerships. You are asking me, Mr Sarwar, to indulge in politics, but of course— You would never do that, of course. I would never do that. It is certainly not in this role, or the previous one. What I am going to say is that, of course, we need proper funding. At the moment, the NHS Fife is doing okay in terms of the funding that we have, but we could always do more. Final question, depending on what you say. How does it make you feel that you have financial performance? You do not ask for a bail-out. You do not get brokerage. It is then not written off, whereas other health boards do. How does that make you feel? I do not think that it is any surprise that I was miffed that we have worked very, very hard with Fife to ensure that our financial performance has been the best that it can be. It is frustrating that some of the decisions that we have made along with the fantastic support of our staff have perhaps meant that there are other things, and do not ask me what they are. However, there may have been other things that we could have done if we had gone into financial… Do you feel that bad behaviour is rewarded? Mr Sarwar, I will not allow you to put words in my mouth, but what I will say is that it is a matter of great pride in Fife that we have managed to break even. I would certainly have liked more money than perhaps some other health boards were getting in terms of brokerage. I would have liked to have seen some sort of recognition for the fact that we are doing fine. I am interested in hospital-acquired infections. Reading the information, it says that you are exceeding the CDIF targets, which is great. I am asking as a former clinical nurse educator who used to specifically teach central line infection and cannula-related best practice and management. I am looking at Dr Chris McKenna as somebody who might be able to help me. What are the steps that the board is taking to ensure that NHS 5 produces the hospital-acquired infection of the staff that worries back to Remus to achieve the rate of 0.24 per 1,000 occupied beds? We are taking a multi-professional approach to reducing hospital-acquired infections. As you said, we are one of the best hospitals in Scotland for the reduction in CDIF infections in NHS 5, and that has been a fantastic achievement through multi-professional working with our infection control colleagues and our microbiology team, good anti-microbial stewardship. That has been a fantastic success for us. Thinking about staff worries back to Remus, those remain a challenge for all health boards. We have a multi-professional vascular access group looking at how we manage vascular access devices within the organisation, how they are cared for and how they are documented. We have focused pieces of improvement work in certain parts of the hospital, where we recognise that improvement was required in our cardiology unit and in our reno unit, such that those pieces of work are looked upon nationally as areas of excellence and for learning. By taking the approach of learning from those events in a systematic way, we are able to introduce step-wise improvements into our services to ensure that we can reduce those infections. One of the innovative ways in which we are able to ensure effective governance around the insertions of peripheral cannulas is the use of electronic documentation for each of those devices. NHS5 is the only health board in Scotland that has patient track, which is our electronic fuse. We call it the early warning score, which is all documented on iPads and available to anybody at any point across the hospital. We now document the insertion of cannulas on to that system, which has alerts and reminders such that medical and nursing staff know when those need to be reviewed and changed. That has led to significant improvement across our organisation. Staff-oriented bacteriumers remain a large focus for us. The challenge remains around community-acquired infections. Those are infections with the staf aureus bacterium that are brought into the hospital from patients from the community. Those are multifactorial, and the improvement plan around addressing those infections is much harder to implement. Those might be infections with patients with diabetes, fairly random skin infections, and there is the other part of that, which is those members of our community that inject drugs. That remains a challenge for us looking at how we work with that group of patients to try and reduce their risk of infection. We are working with our addiction services to understand how we better influence that group of patients to reduce their risk. We have a multi-focussed, multi-faceted strategy to reducing hospital-acquired infections, but we are also going beyond that for staff-oriented bacteriumers to how we reduce that total rate. I want to peel apart the out-hospital infection, and the community-acquired infections are necessarily not something that was caused by a healthcare professional causing a person to have their cannula or their line contaminated. If we dug or peeled apart those numbers, we might be able to see that the hospital-acquired infections are not really hospital acquired and that there might be patients coming from the community. Some of those infections will be patients who present to hospital with a condition, who are unwell, who subsequently turn out to have a staforius bacteremia, but that might not be hospital-acquired or device-acquired. It may be related to random infection or infection as a result of a precious war or an ulcer or something like that that has gone into deep-seated infection. None of that explains why your performance is poorer than the Scottish average. Our performance has improved significantly over the course of the last five years. The total number of staforius bacteremias is higher than the Scottish average, but that is complicated by a higher number of patients who are coming into our organisation with infection. However, we recognise that there is still work to be done with our hospital-acquired infection, and we are working on that. I want to focus on performance around mental health waiting times, especially with regard to CAMHS. The current performance of NHS Fife is at 74.1 per cent against the national target. I was just wondering why performance has worsened over 2019. I will take that question. Mental health and CAMHS is a function that is delegated to the IJB. Improving our performance in CAMHS has been a real priority for us over the last number of years. Our performance in 2019 at 76 per cent was almost 10 per cent higher than it was in 2017-18. I checked before we came this morning that the latest figures that we have in performance in March were at 80 per cent. The figure moves about slightly, but we are pleased that overall the trajectory of the past couple of years has certainly been an improving one, and that has been the result of a real focus on CAMHS performance in the board and in the IJB. We have also increased investment. We have increased the number of clinical sessions in the specialist CAMHS service by 15 sessions a week, particularly to target those children and young people with the longest waits. The other significant endeavour and development that we are pursuing is thinking about a very broad-based approach across all services. We are working in partnership with colleagues in Fife Council, who are responsible for education, but also with the third sector. We have developed a strategy called our minds matter, which focuses on supporting children and young people at the very early stage in school in the community where they are expressing distress or challenges around mental health and wellbeing. We believe that we are seeing some real results in that. We are investing in supporting the training of school guidance teachers and school nurses and other staff in schools and in the community. We have also used Government resources under the action 15 banner to invest in primary mental health workers, one in each of the seven sublocalities in Fife. That means that, as from the first of April this year, where a GP refers to children and young people, they will be seen within one working week. That primary mental health worker will either support the child or young person themselves, refer them on to a voluntary sector provision or, if it is required, make sure that they are referred as quickly as possible to specialist CAM services. However, the advantage of that approach is that, for the first time in many years, we are now seeing a slight reduction—it is only a slight reduction—but we are now seeing a slight reduction in the monthly referrals for CAM services because we believe that we are supporting children and young people earlier in the universal settings but also in additional settings in the community. It has been a real focus for us. We have further to go. We are not at the target yet, but we believe that we are moving in the right direction. I know that, in some of the inquiry work that we have done in the past, we have heard from parents from Fife who have outlined their concerns about access to services, especially for children who are self-harming. That was one of the key issues that are highlighted to us as a committee. In terms of measuring outcomes from mental health services, it seems that you have already been undertaking some change in that area, but how do you measure outcomes as someone goes through the health service? We need to track those cases on an individual basis. You are right that CAM's target itself is an important target, but it is only one measure of the efficacy of the service. We need to look at how those services are supporting individual young people. I know from speaking to the team that that is something that they take very seriously. The other thing that we do even within specialist CAM services is to make sure that children and young people in urgent need are seen quickly. In urgent cases, the target is that people are seen within two weeks, and we endeavour to make sure that that happens where at all possible. We need to track outcomes across the board, and we do that. The team does that and seeks feedback from families and carers. We recognise what more to do on that, about capturing the views of the people that we serve, both the children and young people and their families, but that is a focus for the team moving forward. I am thinking about mental health in any organisation. One of the key questions that I have been asking health boards as they have come in to do this sort of MOT is what sort of culture they have built themselves for their staff around mental health. I know that you have high sickness absence rates compared to other health boards, so I wondered in terms of mental health support for NHS staff what is the current picture like in Fife. Thank you. As you would expect, looking at mental health, there are multi facets for a workforce in terms of looking at mental health support within the board as an employer. We are undertaking a number of work streams in relation to that. Obviously, one of our highest sickness reasons is mental health issues. As a board working in partnership, we have introduced an element of mental health training into our joint promoting attendance training that we do in partnership with our staff side representatives. We currently have our Gold Healthy Working Lives award. Part of that is assessing the support that we give to our workforce in that area, and we are looking to go beyond Gold. We secured investment in supplying mindfulness training and good conversation training for our staff. One of the benefits that we are getting from that is that staff are looking to use that, not just in the sense of the clinical placing in terms of their work or when they are at work, but also outside of work. The other thing that we want to look at is whether we can look to increase in any way that we can the support that we do give to our staff in terms of mental health issues. A lot of the mental health issues that our staff experience from the work that we have done with staff is that it is not work related. It can actually be related to life events outside of work. We are looking to see how we can broaden, potentially input from external support to again give our staff other options to allow them to remain at work. We have also introduced a very quick referral system to our occupational health service and are continuing to develop the awareness of our managers and staff as colleagues. If they see colleagues struggling to also help them, it is not just the managerial aspect as a colleague part as well. We are looking a really holistic way in mental health for our workforce, not just policies and practices, but beyond that. We have a number of work streams looking at that in partnership with our staff side colleagues within the board. I just have a final follow-up. You said that there was external support. What does that look like? I know that in Lanarkshire they are using a company that provides, as you have mentioned, assistance not necessarily around mental health but also around financial support if people have financial difficulties for lower-paid NHS staff. Do you already have that in place? In terms of a very fast referral that you referred to, what is that? Is it next day or are we talking two weeks? In terms of the fast referral, I take that point first. Because it is our internal occupational health service, if we have someone who is really needing an urgent appointment, we can arrange that internally with our occupational health staff. If they are not able to do that, we can secure occupational health support from neighbouring boards, so it is that collaborative element with other boards as well if we are unable to meet that need. In terms of the support for staff with external support, we have a credit union in place and that was very successful and received, again, introduced in partnership with our staff-side colleagues. However, we are also looking to say that we could bring some advice on-site to give that support and begin to broaden the on-site support for staff who are at the very early stages of looking at that and what that may look like. I will come back to you in a moment. Just before we do that, I guess for Michael Killett, the primary care transformation fund and the primary care mental health fund have been established by the Scottish Government to assist in precisely these areas. Can you tell us how they have been used and what impact they have had, or do you expect them to have on demand for specialist mental health services? I will take each and turn if that is okay, convener. In terms of the action 15 money on the five share of the 800 extra mental health workers across Scotland, we have been pursuing that very avidly and we are on target to meet our share of those 800 workers. There has been a particular focus on supporting children and young people, so the primary mental health workers that I talked about in terms of the answer to supporting the CAMHS service is part of that, but we are also investing in mental health support for GP practices more generally for the wider population. We are also thinking about how we can support A&E and ensure that people presenting A&E with mental health and mental health crisis can be supported. One example of that, we very recently opened a premise working with Sam H and the voluntary sector in five called Sam's cafe, which is a cafe that is open from Wednesday through to Sunday. It is a place where people in mental health distress can be taken that is an alternative to either being taken into police custody or being taken to A&E, and there is a peer-based approach that is working there. It is very early days, it has only been open a month or two, but we are seeing good results there and it has been well received. In terms of the primary care improvement fund, again, we are working hard with our GP practices across Fife to agree that plan. Last week, at our IGB meeting on Friday, we agreed the plan for the primary care improvement plan for year 2 of the plan on what that investment will look like. We have made good progress, so we have invested, for example, in that phlebotomy service for all GP practices across Fife. We think that we are the first board or IGB in Scotland to have that comprehensive phlebotomy service that is funded through the primary care improvement fund. We are also concentrating on pharmacotherapy so that pharmacy support for GP practices is supported by the fund as a priority. We are pleased with the progress that we have made. Clearly, as more funding in terms of the primary care improvement that comes year on year, we will be able to invest in that multidisciplinary team approach surrounding GP practices more, but we have made good progress and we are focused on maintaining that progress as we move forward. Briefly, there are 90 per cent targets for referral to treatment, both for child and adolescent mental health services and for psychological therapies. Yes, indeed. When do you expect to be an obsession to meet those targets? In terms of psychological therapies, that is more of a challenge for us than CAMHS has been. It is not because we have not focused on it but our performance is not as good as it should be and we recognise the need to improve. On that front, we are redesigning the service to make better the range of needs that prevent. We are making good progress in supporting people with less complex needs through group therapy, through community mental health teams and all through using IT support. Our focus is on how we improve performance for adults with more complex needs, and that has been a real focus for us. We are working closely with a combined mental health access improvement team that ISD and Healthcare Improvement Scotland have in place. They are supporting us in that redesign. In terms of our trajectory, that is set out in the AOP. I think that we are quite clear that we make faster progress in CAMHS than we have in psychological therapies, but we are focused on making progress in relation to both. Okay, thank you very much. I welcome to Trisha Marwick, as Anna Sarwar said. It is good to see you here on the other side of the fence, as it may be as well. Could I just pick up on what Miles Briggs mentioned about the sickness and absence and what you had mentioned yourself? I know that, in 2017-18, it was worse than it is now, and you have made slight improvements. Audit Scotland said that there is a risk that sickness and absence will remain at a high level and impact on staff and morale quality of care and the achievement of gestatory performance targets. In evidence that Miles Briggs replied, you mentioned what actions you have been taking, such as mindfulness, occupation, etc. Do you have any other reasons of why there is a high-standing sickness and absence in your particular board? As I said, there are a number of factors in respect of sickness and absence, because it is a bit like a jigsaw. There are a whole number of things that can contribute to that, so we really need to look across the whole piece. It can be a range of things, so we do look at and critically examine our short-term and long-term statistics. Our absence performance is discussed every month at our area partnership forum, our staff governance committee, so there really is quite a lot of discussion and scrutiny of our performance in that area. We have looked at doing a bit of a deep dive and a bit of work around looking at particular surveys in certain areas, so we have looked at discussing with our older workforce in terms of demography of our workforce and other specific issues that are contributing to that, regular discussions with staff in terms of whether there is anything specific within certain areas. We can look at our areas in terms of how we get our data, and we can begin to see if there are particular hotspots, and that allows us to have a bit of a more specific discussion, is there anything to do with the particular workforce and the work environment? Again, we have to look at it regularly across the piece, so it is very difficult to give that kind of one answer, because I think that there are a number of factors that do contribute. Within Fife, we have a good number of work streams that are being taken forward, as I said before, in part from the staff side, who equally want to work with us to make sure that we make Fife the best place to work and look at how we can support people back to work quicker. We have a number of very supportive policies. We want to ensure that they are being used absolutely to the full to allow staff to come back to work quicker in a more flexible way, and we have lots of good examples of that. I think that the assurance that I would give is to say that we look at it on a monthly basis. We look at it across the year when we get our end-of-year figures in. We know that it remains a challenge. It is a challenge to quite a number of boards. We have to keep that dialogue and discussion going in terms of getting to the bottom of what it is that we can do as the employer to assist staff to be supported to remain at work. Some of the things that I have mentioned around mental health, early awareness and early support, colleagues looking towards staff and helping them as well. There is a whole cultural aspect as well about supporting colleagues at work. We are looking at every element of it to see what we can do to improve our performance in that area. We are going to run a series of workshops. We are getting direct feedback from managers, supervisors and staff about how it feels for them in terms of very promoting attendance, not just about the application of the policy but generally what they want to feedback us as the employer that they think would help. That was very positively received. We will be running more of those throughout the year, along with everything else that we are doing in terms of multi-generational work, particularly looking at issues in certain areas if we can support those. There is a huge number of things happening to allow us to get to the bottom of that. We have very positive issues. As I said, the mindfulness training, good conversation is really beginning to have an impact in terms of staff understanding just what that looks like, how it helps them with conversations with staff who may be having difficulty or may be experiencing some problems even if they are not within work. We are running a number of very different work strands to try and get to the bottom and to try and improve our performance. Is there anything even as simple as transport? I had a meeting with staff at Glasgow Royal Infirmary just the other day and transport is a huge issue, particularly parking and parking charges. Is that something that people are absent, whether it may be transport issues, trying to get into work or leaving late or working at weekends? It may be that. I am saying that we need to look beyond the issues that are just within the workplace and the work environment that we can control. Some of it may be that, or it may be a temporary impact on staff that is happening because of something that is happening in their family life that we might be able to be flexible and help them. I think that there are a number of other things that may not be directly related to the workplace or the environment that we provide, but I could not say that that could be. It may be financial issues within the family. There can be a number of things, such as illness within the family. Again, there are some of our policies that we can use to help staff in that situation, but we want to have a discussion that is broader than that and to say that we can provide a broad support. I might be out and out with work-related things that we can help staff. When you mention the fact conversations, are the staff consulted to do a tick box exercise? How do you have the conversation with the staff in relation to why they cannot get to work and the sickness or the absence? Is it a tick box exercise in that respect? I hope that it is not a tick box exercise. I think that there are a number of ways that that conversation happens with staff. You can have a very formal conversation with a member of staff when they return to work as part of the policy, and that should not just be about the return to work in relation to the absence. It gives the opportunity for broader discussion around other things that he wants to raise, out with the normal management conversations that are happening with staff. It also gives the ability and the opportunity to have those discussions. That is where the good conversation training that we ran last year, and we are looking to continue this year. Some of those topics are quite sensitive for staff to come forward and speak about. That good conversation training is equipping people to have those conversations in a very sensitive and supportive way. We hope that the normal management relationships that people have, or even colleagues that they work with, will then be confident in raising those issues. The number of that particular one is what financial cost is it to the board in regard to sickness and absence. Do you take that into account? On the reports that we provide in terms of absence, we are able to look at what that means in terms of financial figure. It is one that has to be taken with a health warning because getting the true cost of absence—I think that my director of finance would agree—there are a number of factors that you have to watch how you calculate that. For us, there is the cost aspect and lost productivity. The more important one is about how we help our staff to stay at work and support them at work so that they are not off or get them back quicker. We have to recognise the fact that it has an impact, but it is that part of how we support our staff to be at work, to be off for a shorter period of time, to get them back quicker and to be in a situation where they may not need to go off at all if we are able to intervene quicker. Broadly, I was very concerned to see the fall in participation in the staff survey in iMatter. I think that Fife is now so low that you do not have any official returns for last year. Is there a reason why that is arisen? I think that, with the iMatter tool that you are talking about, I think that there is research that shows that actually iMatter, once you are into your second intercycle, there can be a drop. I am pleased to report that, certainly, the iMatter cycle that we are in just now, we have increased our petition level and the board will receive an actual board report, which will allow us to look at the issues that iMatter covers and be able to develop an action plan in respect of that. I think that, with that, to give the committee an assurance that, in the year where there was no report, that did not mean that we did not have the ability to consider the issues of why we did not have a report to ensure that those were picked up on as well. Although there was no board report, we still, as a board, considered what you are saying, why did that happen, but also that encouragement to managers to have that engagement, to re-energise that engagement with the staff, and that has been proven in the recent return that the reports are just out this week. I was actually about the dementia referrals. Is that okay if I can come in on that particular one as well? It is an area that interests me, the dementia referrals. Obviously, there is information with the social care partnership in regard to the referrals, and the patients waiting for contact for a link worker can arose sharply in the last quarter of 2018. I just wondered if you can explain the number of patients waiting for contact for a dementia worker in why it rose so sharply in 2018. What is the current situation in relation to waiting list for dementia posts and diagnostic support? I will deal with that. That particular figure that you have talked about is something that came up at the IGB's Finance and Performance Committee just last week. We had some detailed discussion about it. We are not sure that that figure is accurate. We think that it could be about recording around that increase in waits in relation to referrals for post-diagnostic support and contact with a link worker. It is something that came out of that discussion with the Finance and Performance Committee. We agreed to look at that with a matter of urgency. It has not been an area of challenge for us in the past, and we do not really understand why it is now, so we are seeking to get underneath that. Dementia is a real focus for us in Fife, both in terms of the targets around post-diagnostic support, but we also have a broad campaign that we describe around making Fife a dementia-friendly community. We had a first dementia-friendly community in Glenrothes, and we are investing and supporting other communities to come on board. I was at an event only in the last couple of weeks where we recognised that somewhere around 150 businesses and organisations across Fife, everything from chip shops to bowling clubs and big commercial businesses, supermarkets and others in between, have put their staff through dementia-friendly training. We also have over 4,000 individuals who have gone through that training. Dementia is a real focus for us in building awareness of dementia, tackling the stigma around it and ensuring that those individuals and their families who are diagnosed get that support. I would be very happy to write to the member if that would be helpful when we have that detailed understanding of that figure, because at the moment we are not convinced that it is accurate. I would like to take the discussion back to organisational health and staff morale. One of the determinants of staff morale is how staff feel supported, how safe they feel, and how they feel their concerns will be dealt with if they are raised. How many whistleblowing complaints is NHS5 currently dealing with? In terms of the current year, we have received one identifiable whistleblowing that has come into the level of the board and the chief executive of the board. In terms of whistleblowing throughout the organisation, we are currently looking at how we can strengthen how we get that data. However, any whistleblowing that we have received tends to escalate as we know about them. We have one formula at the moment in terms of 1920. That seems quite low for being the second biggest territorial health board in the country, not the second but one of the biggest. How does that compare to previous years? In previous years, in terms of last year, we had five. That data is provided through our Collation of the Data, but we also have the national reporting line that was set up for NHS Scotland. That provider has now changed, but in the previous years' reports from the previous provider, our reports always sat at 0 to 3. That could be anything from not receiving any which was 0 to 3, because we never got the detail behind that. It always has been low in terms of the Collation of the Data. From the previous formal Collation not to 3, we had one year, as I said, where we received more than that. This year, in terms of being dealt with, we have one formula. Can I move to the organisational health at the top of the organisation? You have had quite a lot of churn in the past 12 to 18 months in terms of board members and senior members of staff, members of senior management. Scott McLean, for example, was your former chief operating officer last summer, but it was not entirely clear why. Can I ask what were the reasons for his departure? The reason for his departure is that he resigned from the board on what grounds? What precipitated his decision to resign? He made a decision that he wished to resign and take up another post somewhere else. Some of the background noise around the churn at the top of the organisation has led to suggestions of bullying in the organisation. How would you respond to those? I do not believe that there is bullying in the organisation. When we hear of any issues around bullying, we clearly deal with it immediately and we investigate it. If that comes through whistleblowing or it comes through the normal way of managers working through things, we pick it up and we will deal with it through the HR channels and other systems. We will work in partnership to work through that as well. In staff at every level in the organisation, if they felt bullied, sidelined or marginalised, they would know who to speak to within the organisation. It can be quite difficult if they feel that they are not being listened to at the top of the organisation and they do not have faith in the organisation's leadership. Who do they raise those concerns with? I believe that we have done significant work with individuals to understand that their line manager is the key person to go to. If the line manager is a problem within that, they have other people to go to as well. We do that in partnership with staff side in terms of making sure that information is freely available. We have very open conversations with staff side about how we can support staff with those issues. Anybody else in the panel? I was just going to point out that when you talk about a channel of senior staff, in actual fact you are right. We have lost a number of senior staff recently, most of whom have retired. We have recruited equally wonderful people. We have a new director of public health, a very new medical director. That is part of the channel. Our senior staff are part of that channel and we are recruiting. In terms of directors within the board, you seem to have more chain than other health boards. Is that just happenstance? Partly, it is an ace profile. We have had two senior members of the board who have retired. Paul, do you want to talk to them? Yes. Being a medium-sized board, there are always opportunities in bigger tertiary boards or other things that directors want to do. Directors get to director level at an earlier age now and want to have more of a portfolio career and want to look at different things to do. Chris Know just said that he is a very young medical director and may want to do other things in his career before he retires at some point. I think that we are in a different world of much more mobile directorships that are going on across Scotland and across the UK. One of our director of performance left us very sadly. She is now the chief executive of the Golden Jubilee. That is the point that Paul is making. There are opportunities that come up. Part of our role as leaders of the organisation is to make sure that we give the support, we give the mentoring and we give the confidence for people who, if they wish to take up other positions, they go with our good wishes. We hope that we can entice them back at some point in the future. However, Scotland is a small place. Fife is relatively a small board area. When there are opportunities, people will go. However, we have had an age profile that has led to seeing a director retiring. Wasting time for urology is some of the highest in the country. For what reason is that? We have had problems recruiting urologists. We worked very closely on our cancer work using the robots with Lothian. We have managed to recruit a new urologist that is coming through now. It is one of our critical areas in terms of pressure on the system. It is a national one. We are looking at ways of dealing with urology patients. We are very lucky to have one of our urologists who is working and pulling forward something called EuroLift, which is a different way of dealing with patients with prostate issues that are pre-cancerous. We can do those works in a treatment room so that we can get some of the bigger operations through the system, whereas we are not using theatres, length of stay and beds to do that with. We are trying to innovate at the same time as trying to recruit. Ultimately, the strategy around that is to link up with Tayside and with Lothian and have shared sessions so that we have consultants working in both so that we can recruit some of the higher-level work that can be done in Lothian and see some of the district general work that we are doing as well as a part of that plan. Do you have a sort of time window for how you expect to see your improvement roll out? Well, I am hoping that by the end of the year we will be able to recruit some more urologists by doing that practice with Lothian, but sometimes what you end up with is a churn of somebody retiring simultaneously as you manage to recruit someone, but urology is one of our key areas as it is in Lothian as well and we are working with that. In terms of recruitment, the board has been quite innovative in trying to recruit specialists and our nurses. We have been very successful at where we have had boards in recruiting and we are over recruiting at the moment. If we get people who are above the line, they will all be offered a job. That means that we will make sure that they have a job so that when a vacancy comes up, we are not having to recruit again in terms of recruiting and nursing. Barbrann has done and Helen, our nurse director, who is not here, has done a fantastic job in recruiting nurses. Have you got figures for that, Barbrann? We are talking about within this year there will be over 200 nurses recruited into NHS Life, which at a time when we are challenging with other boards around about us because we are all facing workforce challenges is really impressive. That is through the very proactive work that my nurse director and her colleagues do with the universities. They have also successfully had discussions on reintroducing training and placements that have been within Life for specialties like mental health, which previously had not been the case. So there is a lot of positive work happening in life in terms of nurse recruitment. Thank you. I just wanted to add to the urology conversation because I think that it is important that we recognise that the pathway for management of urology cancers in particular across the state has changed and is significantly more complex and cross as a result of that cross health board. So not all of the treatments that would be delivered for one patient would all be delivered in five, so part of the pathway would be in five and part of the pathway would be in Lothian, and that is where complexities around waiting times do arise. One of the things that Fife does fantastically around the urology pathway is access to MRI imaging, and we have one of the best—in spite of our challenges around radiology—access to MRI scans and reporting of the scan in Scotland. It is a complex issue, but as Paul said, we are working with our local team but also the multi-professional team across Fife and Lothian to help to improve and streamline that pathway, and I think that it is a work in progress. So in terms of over-recruiting, it does sound a little mad, but it is actually not, because as we over-recruit, we minimise some of the agency use and bank use of some consultant staff, because as the churn happens, we have somebody to walk into that post. That improves quality, it reduces cost and also gives a sense of the organisation that we are listening to them with the pressures that are in the system at the same time. Brian Whiffle. Thank you. Good morning to the panel. My interest lies around the integration of health and social care, and I notice from the revenue budget 2019-20. I think that the convener already alluded to that there is a net budget gap predicted just north of six and a half million, so I wonder if you could start off by just telling us how you would intend to close that projected gap. Thank you, convener. Yes, as I said, this is a real focus for us. One of the things that we recognise that we need to do is plan both for the short term and for the long term, and we are doing that in partnership with our partners. We had the first of a number of sessions earlier last week with a broad-based management team across the health and social care partnership, and we had a dual focus on how we can bear down on the £6.5 million overspend in the budget for this year. How can we take out more efficiencies? How can we cut cloth to make sure that we deliver on that but push it down? How can we look to the longer term and recognise that in terms of the longer term? That means redesign, that we will not achieve financial balance through efficiencies. We need to redesign ourselves and change how we deliver them. We need to have a real emphasis on early intervention and prevention, and we have begun to do that but recognise that we need to do more there. We need to support people to support themselves, to be supported in their communities and the work that we are doing in localities in Fife. We have a network of wells, a new one-stop shop for support for people in need in terms of health and social care, and a network of those wells right across Fife. That is the approach. We are taking focused action, but we are also investing in early intervention and prevention, recognising that if we do not change the shape of our services, our ambition to deliver financial sustainability is going to be very hard to reach. I note that there is an underspend that has already been mentioned in community services. You talked about early intervention and prevention, which would suggest that the shift towards community is where most of that redesign is likely to be. Can you explain the underspend in community services and how we are going to address that? I am happy to do that. The significant underspend that we had last year was around our community healthcare budget. The underspend was just north of £4 million. That is largely around vacancies around community nursing and general dental services and administrative support. That is an underspend in the community healthcare budget. That is something that we will keep an eye on. Clearly, we do not want the position of not having community nursing posts filled, but the new developments in that preventative space that I talked about are around supporting people before they need or require statutory services. That is about how we can connect people with third sector organisations and help them to support themselves. The network of wells is beginning to do that. We have seen quite innovative practice around how we are supporting people to support themselves. There is active well in Cercodi in the town centre that is open for a number of hours a week. It is doing innovative things about supporting individuals who are isolated to come together around the local costa that is across the way in the town centre. It is really an innovative means of connecting people who would otherwise be isolated and trying to build support in those creative ways. That is one example of how we are trying to ensure that we are in that preventative space. Where are you in terms of adoption of technology? I imagine that the shift towards, again, from secretary to primary care and into community technology would play a big part in that. Where are we in terms of adoption? We make lots of use of technology. We have a very extensive network of community alarms across Fife. We also have telehealth care that supports a large number of individuals. It is an area of focus for us. We are just in the process of revising the strategic plan for the health and social care partnership. One of the priorities is that we need to take a step change around our use of technology so that we can deliver services differently. There is innovation happening. SNAP 40, which is a device that can monitor people's vital signs, is being piloted in our hospital at home service at the moment. We are also looking at other examples at the moment of working with a company that has developed an app that supports and prompts people to take medicines so that people who are living at home need a reminder to take medicines. There are a number of approaches here, but one of the things that we said in the strategic plan is that we need to focus on improving that digital agenda. We are working with the eHealth and ITA in both Fife Council and NHS Fife to help us on that agenda. We are doing a lot, but there is certainly more to do on that digital front. I just wanted to give you the opportunity to respond to Audit Scotland, who is suggesting, perhaps, that health and social care arrangements in Fife are not operating as effectively as they possibly could. I think that one of the interesting things that they note here is that staff and members are sometimes predisposed towards the interests of employing organisations rather than the partnership. I do not think that that is an unusual position that we have heard across other IJBs. I just wondered if I would give you the opportunity to reply to that and let us know how far along that has been integrated with the pathway. I have six or eight members from the health board on the health and social care partnership. The health board does not tell them what to do. The legislation is quite clear that, although there may be members of the health board, they are there in their own right. They do not ever go with a mandate from the health board to the IJB. They know, of course, what the issues are, and they have to make up their own minds and make their own decisions about them, but there is certainly no pressure from either me or the health board for a particular outcome. I suppose that, from my perspective, I see a group of eight voting members on the IJB, the health board and the five councillors. I see an increasing willingness and an understanding for those members to come together to understand issues in a private space, to spend time together identifying what the key issues are for the partnership. The ministerial steering group review, its recommendations and the self-assessment that we had to do in Fife, I think, was quite helpful in allowing us to come together across the system to look at the priorities. Interestingly, we brought those 16 voting members together last week in the suggestion of the chair and vice chair of the IJB to develop that sense of togetherness and shared endeavour. From my perspective, that feels like it is making progress. I know that the chair and vice chair of the IJB are determined that that approach will continue and that they will continue to build that culture, recognising that, from both bodies, the voting members in the IJB are clearly aware of the pressures on their constituent organisations, but they need to come together in making decisions that are in the best interests of the people of Fife when they are around the IJB table. I personally think that that will make good progress in that regard. Before I bring in Paul Hawkins, can I take it from the contributions of both Tricia Marwick and Michael Culloch that you accept the view of Audit Scotland that more needs to be done in this field? I certainly would accept the view of Audit Scotland. The view of Audit Scotland is reflected alongside the IJB table. I get it from the members of the health board who are on the IJB. Everybody recognises that there needs to be more work done. It is a pretty new organisation. It is only three years old. What has got to happen is that the two cultures of the council and the health board have got to be melded together. It is fair to say that they are probably not there yet, but what I have seen, as Michael Culloch says, is that there has been progress made. I think that there is a great willingness to try to work the best that they can for the good of the people of Fife. Michael Culloch, do you want to add anything? No, I agree with what Tricia Marwick says. It is fair to say that there is more to do. I think that everybody around the IJB table would recognise that, but I think that progress has been made. Paul Hawkins I think that just to confirm what the chairman said, it is a three-year-old organisation that has shown maturity but needs to further mature in terms of understanding exactly what it is there for and how we move forward in some of the deliverables at speed now, which is needed in terms of where we are with some of the finances as well. I think that there is a good future coming. I think that putting House and the council together is the only way forward. It is how we make it work and continual changes in different people that are on the IJB as politicians move. It is about keeping that brand and that process of how we move forward with integration. Really just to echo, I guess, is the only voting member on the IJB sitting here today. As a new member to that group, I think that there is extreme willingness to learn and to grow together and develop those relationships. That is what I have found. I think that that is a reassuring thing. I think that there are difficult aspects to bringing in the governance aspects of care and the governance aspects of health together in one place. I can see the challenges that that does bring with it, but there is a willingness around the table to manage those in a really professional and productive way. I think that that is a positive thing. We are forced out of five. We have one council and one health board and one IJB. That is not the situation in most parts of the country where there are five or six IJBs per council. We are in a really lucky position, but with that comes responsibility. We want to make it work. We know that it can work. If it does not work in five, with all the advantages that we have, then it is not going to work anywhere else. Everybody is absolutely committed in five, whether it be the health board or the council and the people who are in IJB, to make sure that it works for the benefit of the people of five. Paul is right. The bringing together of certain aspects of the health board and certain aspects of the council is the right thing to do. We need to make sure that the transformational change that we all recognise needs to happen happens now at pace. It is important that we take people with us. If there have been problems, it is about the two different cultures. As the organisation itself is bearing down, I think that the problems will be lessened. That is an interesting perspective. Clearly, some of what we are hearing today are things that we have heard from other IJBs and health boards earlier in the process. It seems to me that, despite the co-terminosity, you are behind the pace in some ways in achieving that change. I am sure that something will reflect on that. David Torrance Thank you, convener, and good morning, everybody. Increasing delayed discharges, can you explain why it has happened and what measures that IJB is putting in place to sustain improvements in this area? I will take that. Mr Torrance, if that is okay, thank you. Delayed discharge remains a real focus for us in the health and social care partnership working very closely alongside colleagues in the acute hospital. You are right that the figures most recently have increased, but if you look at the position over the last few years, we have succeeded in reducing the overall numbers of delayed discharge in the system, as well as the numbers in long delay. However, as I have said, challenges remain the total delays in our system because I thought that this issue would come up. I looked and were 68 yesterday, higher than we would like them to be, but an improvement on the position that we saw over winter. The way that we tackle delays is multifaceted. We have a discharge hub located in the Victoria hospital in Kirkcaldy. That is run by a team that I have responsibility for of the health and social care partnership, but that is a multi-professional team with social workers, health staff and others whose daily focus is on working with the acute hospital to ensure that we have flow across the system, both ensuring discharges to social care for those people, but also that we can discharge people efficiently from the acute hospital to one of our community hospitals where that is clinically required for them. Over time, the discharge hub has evolved. We see it as being a real source of strength and innovation. We have worked with Shelter in terms of how we support homeless people who come into the hospital system. We have also got a particular project on how we support military veterans and support them working with the Divents Medical Workforce Service. It will remain a constant focus for us, but it is a joint endeavour between ourselves and acute colleagues. It is something that we focus on daily. Senior managers are involved in a weekly meeting in terms of performance and we have a system of escalation to bring things to my attention and ultimately pause if that is required and if delays are not moving in the right direction. We have made significant progress, but we recognise that there is always more to do. The current level of a delayed discharge, how much is that costing? In terms of those 68 beds, I do not have a figure for that immediately to hand. I am sorry to say that we can certainly get that. I had figures in terms of the number of bed days that were lost in the year 1718. The Scottish average was that 7.8 per cent bed days were lost because of delayed discharge. The five figure was 7.5 per cent, so just below that Scottish average, but in terms of costs, I do not have that figure immediately to hand. I can certainly supply that. The committee has heard in previous evidence that the supply of care home and care home places have affected delayed discharge. What actions are you putting in place to try and alleviate this problem? The validity of care home places is not a significant challenge for us in Fife. We have approximately 3,000 care home beds across the kingdom. About 10 per cent of those are in council-owned care homes. Thankfully, our trajectory is that we are making less use of residential care than we have previously, and that is in line with our ambition to support more people at home or close to home. The biggest challenge that we face in dealing with delays is our care-at-home capacity. Our capacity is both in our in-house service and, thirdly, independent providers to support people with home care in their own homes. That is something that we are working on. We have innovated in that regard. We introduced a system called Total Mobile in our in-house service that made scheduling much more efficient so that we can make sure that we are running as efficiently as possible. That service is now being extended to the independent and voluntary sector, and we expect to see the same improvements and performance there as well. We also work closely with the providers to encourage them to develop their services. We have 27 providers of care-at-home services in the independent or private sector that we work with in Fife. I have a team that lays with them very closely about improving their capacity to meet the market needs. We have challenges in particular areas that you might imagine. We have our challenges in recruiting care-at-home staff in North East Fife. At the moment, we have a particular challenge around the Cowdenbeath area. Again, we are working with providers to try to encourage them to bring more provision to market so that we can meet those needs as quickly as we can. David, do you have any further questions? Different subject? Yes, please. Out-of-care services in Fife, can you update the committee on the redesign of them? That's me again. As Mr Torrance knows, the IGB was debating this issue at his meeting of Friday of last week. I am pleased to confirm that the IGB took what was a difficult decision to approve a new clinical model of out-of-hours GP care. It did so last week on the basis of unequivocal clinical advice that was the right thing to do. The new model that we will begin to implement our plan is to have that in place before this winter is an out-of-hours service with three centres, one in Cercodi at the Victoria hospital, one in Dunfermline at the Queen Margaret hospital and another in St Andrews in the St Andrews community hospital. The service in Dunfermline and Cercodi will be open 118 hours a week. At all points, when GP services are not, the St Andrews model will be more flexible, focusing on when there is greatest demand at the weekends and evenings. That service will also be supplemented by increased capacity around home visiting. When people clinically require a GP or practitioner to visit out-of-hours, there will be more capacity to do that. The other thing that the IGB approved on Friday was a new transport policy to support the out-of-hours service. For those few individuals who can't travel to a centre where that is clinically the right place for them to be seen, we know that, for example, 94 per cent of people who access centres out-of-hours do so are either driven by themselves or are driven by a family or friend, but for that small number who can't, we have now approved a policy where they can be supplied with a taxi, and that was part of the decision-making as well. The other thing that we have done around out-of-hours, which is prompted by the challenges that we faced around sustaining the existing model, and Mr Torrance and the committee may know that we are in a contingency arrangement at the moment, is that we have had real innovation about bringing a multidisciplinary team to our out-of-hours GP service. We now have specialist paramedics working as part of the service. We have a number now of advanced nurse practitioners. We are also introducing recruiting healthcare support workers, so that multidisciplinary team around the GP is who is working out-of-hours is bringing a real innovation, and it allows us to be confident that the new model that the IGB approved will be sustainable in the longer term. I am happy to take any further questions, but I hope that that is a useful update. Is the follow-on to David Torrance's question? I know that we are looking at the statistics. NHS Fife has seen the highest percentage increase in emergency admissions of all NHS boards. Do you put that down to the fact that you have seen problems with out-of-hours, and specifically not renewing the out-of-hours service around Glenrothes? What work will go on there to see that patients are not being admitted when they do not necessarily need to be? I will start. In terms of Glenrothes, we have kept a very close eye on the performance. The service is currently called PCS, the primary care emergency service. We have kept a very close eye on its performance and the number of people that it sees since the contingency arrangement has been in place since April of last year. We have not seen a significant change. The contingency arrangement only applies for the overnight hours from 12 midnight to 8 am. We have been keeping a very close eye on the number of people that the service sees in that period, and we know that it has remained largely the same over time. We do not think that that is a factor. There has been concern from the Glenrothes community, and we have worked hard with them to explain the new arrangement and to explain the transport policy, because one of the concerns that MSP and MP colleagues had throughout the process is the point about whether somebody does not have access to a car and how they are going to get to the centre. We think that the transport policy is important in ensuring that we can get people seen in the right place at the right time. That is something that we keep a close eye on. Paul May wants to say more about the rate of emergency attendancies at A&E. Over the past three months, more than 20 per cent have risen in 5-5s. I have talked to other chief execs, and they have seen roughly the same thing coming through their A&Es. Obviously, that is a negative thing that we need to deal with. Prior to that, we were doing an analysis to look at whether PSS was a contributing factor in that pie chart of the number of people, and we could not see it significantly changing that. The only positive thing from that is that our conversion to admission has not moved. Even though we are seeing 20 per cent more, we are not admitting a percentage more. It is staying exactly the same. We are analysing that at the moment and working together to try to work out what is going on in the chief execs across Scotland and doing the same. I understand that in the UK it moved exactly the same right across, so it is about understanding that in its wider form. What plans do you have around that? I know that we have also seen increased admissions. We are looking towards minor injuries units being established. Are you looking to provide that locally as well? We have minor injuries at Queen Margaret hospital in Dunfermline. What we are doing is trying to signpost people to use that more actively to make sure that service is robust and provides another opportunity for a faster service at the same time. We are doing that signposting. The best signposting at all, though, is to talk about using pharmacy in the wider aspects rather than attending the A&E. How do you think that the GP contracts have also impacted on that? I suppose that it is early days in terms of the GP contract. We hope that GP contact will be a really positive endeavour and programme in the sense that it will support GP services during the day to be more sustainable by building a multidisciplinary team around them. That should help to support people across the whole system and should help to deal with people who might go to A&E if they feel that they cannot be seen quickly within the local GP services. We certainly think that it should be a positive factor in that regard, but, as Paul said, we need to do a piece of work to understand what is happening right across the system in terms of the volume of attendance that Paul has talked about. The decision on out-of-hours gives us an opportunity to almost reset our communications with the people of Fife around where they should go for assistance when they need it. We can clearly explain what out-of-hours GP services will look like, what community pharmacy can deliver when it is appropriate to go to A&E and where other support can be accessed as well. The network of wells that I have talked about. One of the things that we are thinking about right across the system is how, in the light of that decision about what the future looks like for out-of-hours, can we effectively communicate to the public exactly where they should go for assistance, depending on what the nature of their issue is? We think that that is an opportunity to move forward. It is kind of a sub to the cultural aspects of health and social care integration. Trisha, you said that NHS Fife is one health board and Fife Council is one local authority, to Frees and Galloway is the same. I hear on the ground that it is the culture, it is the culture and there are differences. I am aware of some research by Josh Crease, he is a principal analyst at Edgyserv, who talks about the cultural aspects of deep-rooted differences in language, governance processes, systems and performance management. What specific cultural issues are you looking at that can help to overcome some of the health and social care integration? Three years for me is not a long time to change a culture as a person who worked in the NHS, so I am curious as to what specific cultural issues might you have that might be different from others identified elsewhere. I think that what I was referring to is the way that the council operates and the way that the health board operates. At its most simple, the councillors who are on the IJB are elected. They are elected to serve their constituents, and the non-executive members who are on the health board are appointed, so immediately you have two different cultures sitting there in front of you. I think that what we need to do and what I see progress coming is that people will realise that they have all got to work together for the good of the whole of fife. That is what I meant about the cultures. They are quite different. I think that there are also differences in terms of reporting things to their parent bodies. For example, we have a governance system that we looked at a couple of years ago. It is quite different from the way that the council does things. I think that it is about getting to know what I do not see is any difficulty of the health board staff and the council staff working together. I do not think that there is any difficulty at all. I think that people get that, I think that they embrace that, I do not think that that is a difficulty. If there is the difference in culture, I think that I am talking about at the board level and not the work that is getting done on the ground, which I think is impressive and impresses me all the time. I think that it is about the coming together of the IJB as a single entity and understanding that it can have a wider voice. It may be exactly the same in other IJBs, but I think that the voice of the IJB owning the issues from both the council and health simultaneously is the key thing that we are moving into. We are starting to see that in the past six months we have started to grow more than ever in terms of moving those issues forward. Clearly, Audit Scotland talks about staff and members having that challenge of identifying a common interest above individual interests. I would like to echo what Trisha said. What I see on the ground is real examples of innovation and creativity among staff from across health and social care coming together to put the individual and their families first. There are a couple of examples that I would give. We have a particularly successful programme that we call High Health Gain Individual. That is a programme that has identified those individuals, mainly elderly and frail, who are making most use of health services, particularly those who are being regularly admitted to hospital on an emergency basis. We have identified now somewhere just south of 400 of those individuals and have developed an approach with social care and health staff coming together to wrap care around those individuals. We have already seen that in relation to those individuals. We have seen something like a 40 per cent reduction over the last year in emergency admissions for those individuals. That is a real example for me of health and social care staff on the ground coming together to put an individual first. The other example that I often talk about is that we had two services, two children's occupational therapy services in Fife before integration that worked quite separately from each other. Quite often individual children and their families would be on both waiting lists and there was not a lot of communication between the teams. In a position now where effectively those teams are working as one unit, we have drastically reduced waiting times, we have improved outcomes for the children and young people who are accessing that services. We are delivering better services quicker. So there are a whole range of examples of where staff on the ground are coming together and I think that that is really positive. As we have said, I think that there is room for manoeuvre around how we come together, I suppose, at the top of our organisations around governance, but I think that we are making good progress there as well as we have described. Thank you very much to all our witnesses this morning. For their evidence, we will now suspend for five minutes and resume in private session.