 Llyr Thats Unlike preliminary meeting on 13 October of the public audit and post legislative scrutiny committee. This is the first time this session that a Scottish Parliament committee has met outside Edinburgh. I welcome the members of the public who have joined us today in Dundee and thank Dundee City Council for letting us use the city chambers this morning. Can I ask everyone present to please switch off their or switch them to silent mode to not affect committee's work this morning. Check them, if you've not done so. Item 1. The committee is invited to agree to consider its work programme in private next week. Do Members agree? Thank you. Item 2 is two separate evidence sessions on the Auditor General for Scotland's report entitled y 15-16 audit o NHS Tayside financial sustainability. We took evidence on this report on the 3 November from the Auditor General. Given the serious financial issues raised, we decided to meet in Dundee so that people living in Tayside and using NHS Tayside services were able to hear directly from their local health board about how it is trying to address these challenges. Our first evidence session this morning is around table with patients groups and trade unions, where we will hear first hand their experiences of NHS Tayside. We have three themes, each of which we will spend about 15 to 20 minutes discussing. I am now going to ask all members to introduce themselves briefly and state who they represent, including the witnesses. Going clockwise, I am Jenny Marra and I am convener of this committee. I am Sonia Cotum, I am director of Payne Association Scotland. I am Gail Ross, I am the member of the Scottish Parliament for Caithness, Sutherland and Ross. I am Richard White, I am a regional officer for the United Union. I am Ross Thompson, I am the member of the Scottish Parliament for North East Scotland. Good morning, I am Mary Ballantyne, I am the chairman of Angus Cardiac Group. I like nearly MSP for Ayrdrian Shots. Bob McLeishan, RCN officer. Morning, I am Morning, I am MSP for Central Scotland. Good morning, I am Morning, I am the senior director for the Family Sports Service in Tayside for Parmesan. Colin Beattie, MSP for Midlothian North and Musselwna. Rayner Marshall, I am the joint branch safety of Tayside healthcare, branch for unison. I am Liam Kerr, MSP for the north-east region and deputy convener. Brian Hawking, committee member of the deaf links. Thank you very much indeed. The first of our three themes is performance. Can you give us an idea of what NHS Tayside means to the group you represent and your group's experience of their services? Who would like to kick this off? I will not rush at once. Bob McLeishan, RCN officer. Bob McLeishan, RCN officer. I think the key issue for performance were nurses, because primarily it is nurses that we represent in partnership. We support other unions with other members of staff. But quality of care is important to nursing profession. I would suggest that most nurses, if not all nurses, leave home in the morning to deliver the best quality of care that they can. However, staff increasingly over the past few years have found that they are not able to deliver the standard or level of care that they are trained to do or would want to do for their patients. That is not to say that they are not delivering safe care, that they are not delivering the care to the level that they would like to or indeed they are trained to do. A number of issues with that is to do with the current status in relation to recruitment of nurses. That is not just unique to NHS Tayside, it is a national issue. Recruitment, vacancies, dependency on agencies and bank staff are having an impact on the working environment for nurses. That means that their priorities are not always facing priorities for the patients and are taken away from the direct patient care. That is something that is having an impact on staff morale. That has been an increase in the issue for staff. The morale issue has become less and less. As I said, this is not just unique to NHS Tayside, but we really need to look at how we make this group of staff feel valued, because at the moment they do not, they are increasing their morale, because at the end of the day, we need the staff to look after ourselves for future planning. It is a big issue, it is not unique to Tayside, but it is an issue, but in Tayside is the recruitment. I think that one of the issues, the second issue is about agency, is that NHS Tayside, like other boards are saying, we want to reduce the amount of premium agency usage. But there is a lack of a robust process that is going to replace what those premium agencies are covering at the moment within the clinical areas. So it is a big challenge, but it is a big stress for the nursing family in relation to the stresses increasing, stresses increasing. People are leaving, not often because they can leave nursing through natural retirement, but people who maybe previously had ambitions to stay on within their nursing employment beyond their retirement age are choosing to leave now when they can, and they are not coming back to help out through bank or agency, we are bank nursing, and we are losing that experience at quite an alarming rate. Bob, can I ask you, do you have members who were on an NHS contract but have now left to work for agencies and are coming back into the NHS through agency? Absolutely, there are certainly over the past two years there has been a huge increase in staff, particularly those that can maybe come up to retirement who have been fortunate enough that they can retire 55, 60, who previously might have then engaged with NHS Tayside in a short-term contract or a reduced hours contract who subsequently have used the opportunity to move on to some of the premium agencies and then are coming back to work through the premium agencies as opposed to coming back to work for NHS Tayside. How about younger nurses? There are some younger nurses as well who, for various reasons, they are early on in their career, but they are seeing a nursing agency as an opportunity to have flexibility, whether that is just flexibility for their own lifestyle, or if it is a family friendly type issue, if they have children in that, they see that there is a lot more flexibility that is afforded from an agency and or bank situation as opposed to having a contract with the NHS. Is that easy for them to do? It has been because, like everywhere else, agencies, NHS boards, they have all been vying for the same staff that are out there, not registered nurses. There is a huge decrease in registered nurses. There is not enough, as I am sure we all know. Everybody is vying for the same recruitment of nurses once a year when there is a graduation of registered nurses. It is a competitive market, but the terms and conditions for some of the premium agencies far exceed those within the NHS. Those terms and conditions are better in the NHS than in the NHS. Can you expand on that? Obviously, remuneration has been won, certainly with some of the premium agencies. Some nurses can be earning significantly more than what the entry level for our registered nurse would be under agenda for change, which is the terms and conditions that we are governed under. Also, the feedback that we are getting from people within some of the premium agencies, and maybe not so much, I cannot comment on some of the less premium agencies, but certainly premium agencies is a training development, is very robust as well. So, they appear to be investing as well as taking the skills within the agency, but they seem to be investing quite heavily in the training development. That in itself is being benefit for the nurses, for the patients, but actually for their attention as well, because they are not struggling to recruit where other areas are because of these factors. Thank you very much, Bob. Maureen, did you want to speak? Yes. Just on the performance, I am here today to represent people with profoundly multiple learning disabilities and their family carers. I have to say, since 2010, NHS T-Side in 2010, implemented an improvement plan for people with learning disabilities within the acute hospital sector. And since that plan has been implemented, I have to say it's been just one of the best things that have improved life for people with profoundly multiple learning disabilities and their family carers. So, from that point of view within the acute hospital sector for our group, it's been really, really worthwhile. My worry is that it's dependent on a few people who were at the top of NHS T-Side, and I would like to make sure that it was fully embedded so that it continued to change, because for us at NHS T-Side, we feel are committed to the education of their staff for the future. Although it's Dundee University, we were involved this year for the first time in family carer being used to help train about 300 nursing students, and we are involved in medical students training programme every year and have been for the last five years. So I feel that that is really, really positive. So for me and the group I represent within the acute hospital, there's been massive change since 2010. And I mean, I know that because it's as simple as my phone doesn't ring anymore for serious issues. So from that point of view, my group has been such an improvement, and I wouldn't like to see that lost. I would like that to continue to grow. But what I would like to see is NHS T-Side making more use of the help that the voluntary sector can give them in the training of existing staff within the hospital. We have done that to a certain extent with technology, and they do try really hard, and we're working hard with them to pilot digital passports within the acute hospital sector. But every step of the way is hampered for them as well by their systems and getting around their systems and confidentiality. So if there were some way of removing all the restrictions that would help NHS T-Side to be even more innovative than I feel that they already are, then that would be amazing. So for the future, that would be really good. So for my group within the acute hospital sector, yes. But within the community, there are still problems, especially with technology moves so fast. And I have a lot of families now who can communicate through the use of eye gaze technology, but because the strategy for learning disability sits under mental health, equipment is the last thing to go. So when there's any funding, it's not there for equipment. So these children and young adults are not really getting what they should get. So for me, there's a bit about performance for the future that I would like to see NHS T-Side have. So we look at that and how that can be improved just to make sure everybody is having equal access. So, and I know there is eye gaze technology within the schools, so it's not that the technology isn't there. It's more about the way that it is sort of delivered if you know what I mean. Like children get about 10 minutes on the eye gaze and that isn't really long enough. So for me, a wee bit about innovative, creative thinking about how that can be looked at overall within NHS T-Side. Okay, thank you very much. Thank you. So you feel that NHS T-Side are making good use of your expertise, but that could be even better perhaps in the future. Thank you. Mary. Is it possible I'd like to add a little bit to what Maureen has said and the point that Bob is making about the quality of care that's delivered and the input that some of the groups can make. I represent Angus Cardiac Group. We're probably one of the most active patient-led groups, not just in T-Side and Fife, but across Scotland. We have a 400 membership and the majority of us all have heart disease and access primary care and secondary care at different times in the health journey. We actually know and we're really pleased with a lot of the care that we receive in T-Side Health Board and T-Side and Fife. And we do try to work hard in partnership with them. In primary care in particular, there are a number of frustrations around accessing GPs and various things like that. There's nothing different there for us, but one of the big, I suppose, the plea from our group to this meeting is involve us more in the what do we need to do to try and improve things. We know what the frustrations are and we're happy to speak about them. We know that you don't have a magic wand and you can't fix things immediately, but without a doubt we need to have some help for access. In secondary care, when we are acutely ill, access is immediate and the care that we receive is impeccable. And T-Side have delivered exceptionally on that. And just last week in a different meeting, a consultant without any prompting made the comment that if you need something at that moment in time in T-Side, you will get it. And for a cardiac patient, that is absolutely the message that we need to hear because there's the golden hour, if you like, from when you start to become ill to when you need to be fixed. So it's great to hear that we can have that. But in primary care, if we phone the GP to say that we feel unwell, it can take the entire day before the GP can return a call to you to explore your symptoms. Now that conflict is actually very difficult and we would like to somehow be involved in trying to resolve that if we can. And I think it comes back to the point that we are the people with the illness, the disease, we can offer something to help and some ideas to come together to fix it. But at that critical moment, when we're asked the question, what brings you here today and what do you want to happen? Which I believe are the questions that are now being taught to the nurses and the doctors. I can assure you in the heat of the moment there are two questions we don't want to hear. It's evident why we're there and it should be fairly evident what we need to happen at that moment in time. And it's feedback like that that we want to work with the groups to improve the situation for everyone. Mary, can I ask for your patients? Have you had any issues with treatment time? Treatment time? Waiting time is a frustration and if you look at the situation in primary care first and foremost, so if you make a phone call to your practice and you say that you're ill in that day, it could take the entire working day for someone to come back to you. So that's just that very short snapshot of the day. However, let's just imagine at the end of that day a decision is taken that you need to see someone in secondary care and that's then where this very long wait can come in. We know that the lead times to see the consultants or the specialist nurses or whoever it is in secondary care can be 12, sometimes 18, sometimes 24 weeks. We know that, but unfortunately, when you have a chronic condition, that 18-week period is not just the deterioration in your chronic health condition. You're also possibly acutely unwell at that point in time as well. So the waiting times are a huge frustration. They are getting a bit longer and the feedback from the older patients in our group, Angus cardiac group, our average age is probably about 75 or 80. I think I'm faring quite well, representing them as a youngster, but seriously for the older patients that frustration is terrifying because now unfortunately when they talk to me they say things like 18 weeks from now I might be dead and buried, it's a lifetime. And somehow if we could shorten that in any way or signpost to someone else who could see you during the waiting time I think would be really helpful rather than that period of no one sees you and no one talks to you. So the waiting times are getting longer but we need to find a way of inputting during that time and then the waiting would be easier. We know it's probably impossible. So it wouldn't be by a consultant but maybe by a specialist nurse or it's whoever is the expert needed at that point in time. In the olden days it used to be just the consultant but now there are so many other people in the multidisciplinary team who could be accessed during that long waiting time who might be able to just make that time more bearable and easier for people. It's not going to cure the situation but without a doubt when you're dealing with people who have chronic, long term they are not curable conditions they just need input of some kind that will make it bearable during that period. Thank you Mary, thanks that's very useful. I'm going to bring in Raymond Marshall from Unison but I first want to say if we can kind of move to the second theme obviously Raymond say what you want to say but if we can touch on the second theme which is savings have you noticed any strains in NHS Tayside recently? How has it impacted your experience with the group you represent? And what do the board's current financial difficulties mean for the group you represent? Raymond Marshall from Unison. Thank you so much. I think I'm just wanting to mention about the other staff that sit within NHS Tayside so though I've not mentioned our staff as well the admin staff and the support staff that sit within NHS Tayside I think they're feeling a frustration as well because they're trying to deliver a good service to the population at Tayside and they're feeling that constraint on them as well because they're an easy target or they seem to be an easy target to say like well here's the staff within Tayside and everyone's like oh and I don't like the word backroom staff because they're not backroom staff I mean they're delivering a service and it wasn't for them a lot of the services wouldn't run so I think that they're feeling that they're an easy target and there's a reduction there I mean if I was to go on to the savings and mention something on that as well Please So I mean I just think that there is an increased financial strain on NHS Tayside and it's been there for a number of years now and it does impact directly on our staff that they're being asked to do additional duties take on additional work they're asked to move into areas that they're not familiar with which Bob touched on earlier on for the nursing staff as well and it's a massive pressure on their work-life balance as well this is what I think we're concerned about the pace of some of the financial elements that Tayside are trying to push forward and one of our main concerns is around the pace about instructions that come from government around terms of conditions so for instance the enhancement student leave we're still sitting today with all staff at the Tayside not being paid that what they're due in relation to the enhancement student leave only just last week we were approached to look at that through the group that was sitting and they're asking us to now change the way that we approached that to enable them to achieve that by March this year and that goes back to something that the organisation the trade unions had suggested back in 2012 and was dismissed so you have members who haven't yet received their correct enhancement during leave payments is that right? The majority of staff in Tayside have not received their full payment I think most of the staff have received a part payment but they've not received at all and what we've been asked now is to change how we apply that and go back to what was a suggestion from the trade unions back in 2012 which was dismissed we were just looking at all that time that's been wasted and looking at that and I think there's other small they seem to go for big ticket items like staffing so we had a reduction 220 whole-time equivalents within Tayside and that produced the biggest cost saving for Tayside but it's not our current, it's not because we've then had to take on 200 or we'll have employed or they haven't employed 200 newly qualified practitioners so that cost gets offset against that some small ticket items that go forward as well we're concerned with because they just seem to be implemented without any discussions but the example of that is where they switched off the purchase of stationery like paper and staff were actually hiding paper because they didn't want to leave it in the printer because someone else might print off I mean it's these kind of things that really really frustrate staff and I don't think that helps push forward a message about how we've been engaged and I think all the concerns is that through partnership working as well we feel that sometimes we're being ignored or taken out of the loop and the decisions are getting made by directors and then the last trade unions to come in and try and take forward what they're trying to implement so that would question for us through partnership working and the staff governance as well so the trade unions are committed to trying to help and support through partnership working to take these things forward be with our members and involve our members in those decisions What do you mean by staff governance? Well we have the staff governance standards basically which means that you must be well if they involve staff at the start not make a decision then just say right this is what's going to happen it's about engaging with staff and involving them in the decision making process Do you feel there is a good relationship between managers, decision makers and staff? At the moment no and has that been better in the past? It's been better in the past and we are trying to work through it we've had other people coming in to support to help support around that but at the moment it's not as good as what has been in the past and what could be done to make it better? I think commitment partnership is based on trust as well I think that we need to really look, we do need to build that trust because if you're getting decisions made without your involvement then that sort of goes against the trust element of it Thank you Raymond, thank you I'm keen to let everyone speak and then I'll come back to you Bob Richard, would you like to speak at this point? Yeah My involvement with NHS Tayside is a regional offer officers pretty recent my colleague who retired after dealing with NHS Tayside for 30 years would probably say different things than what I would say here today but the only thing I can draw in comparison is the 7 years I've spent dealing with NHS Highland In NHS Highland I don't think I ever litigated I never had a ballot for industrial action with the exception of the public sector's pensions dispute which was UK wide sadly that's not the case in NHS Tayside I have litigated there was a 16 week porters dispute which was before my time but that was a very significant dispute there have been other consultative ballots about management attitudes towards their staff in terms of dignity at work and I feel that something is wrong in terms of the internal culture that requires strong leadership and a stronger partnership working to address that I think there are difficulties at the middle management level and I think Bob and Raymond have both touched on somehow how that translates to our members working in the front line given one of the most valuable public services that anybody can give there is a stretch on people to work beyond the terms of their job remit that causes frustration and there's a deep suspicion about the way gradings were done historically which led to the porters dispute so we've got a difficulty for sure with morale and hearts and minds and I think the financial pressures that are coming on make that very very serious I also deal with many other employers I have seen what the financial impacts your steric have had on local government and how the changes in services are made that don't actually improve the level of service delivered to the public it's a reducing cake it has an impact where you lose, there's a brain drain where your expertise and your committed people leave and I think Bob touched on that with relation to some nurses drifting into agency work because their hearts and minds are lost and it's an easier option to pick and choose your shifts and I think there's a serious concern for the future if we don't package it all together and work jointly and strongly together to change the culture and to deal with things moving forward Richard, could you address the financial difficulties of the boards specifically and any specific impact on your members? I think when you... Dundee's a relatively small city and I know we go beyond Dundee but in terms of Dundee, nine wells is a big hospital with most of the employees there people work in the NHS, people work in the council in Dundee city council we've come through 4% budget cuts and everybody is in a very miserable state and waiting to see what the announcements from today in Edinburgh will be with fear and trepidation about another 4% when you look at 5% over 5 years, 175 million pounds of cuts that is quite an astonishing thing to be looking at for people and I think that's where the concern comes from if they know what 4% in one year did to Dundee city council last year what is 5% 5 years in the role mean for NHS days? That's a concern Does Unite have ideas about how they can help the board achieve efficiency savings and maintain a standard of service? We've seen the work streams, we are involved as our sister unions in the work streams One comment would be that prescription prescribing stuff has been a target for a financial saving for a considerable number of years and it seems to go up and I don't think that's just NHS Tayside but I think NHS Tayside's a bit outlier on that it does seem that there could be something done about that but I'm unsure as to how it's not being achieved today the other issue is about agency of course but the problems when we're all don't help when you have an exit door, a revolving door where people coming back in as agency that doesn't help unless you address the internal issue you're still going to get a difficulty and having posts filled, people staying in these posts can matter to work in long term and you'll have to rely on agency so you have to kind of fix everything at once I think where I got us to that Thank you very much I'd like, Bob, did you want to come in? I was going to cover the only thing I was going to add was in relation to staff governance that Raymond had mentioned staff governance has principles both for employers and for employees and certainly, you know, I strongly believe I strongly believe that the staff governance principles are good principles, they're common sense principles and if they're applied they're quite effective principles but certainly from members that we've had contact with over the past two years the feeling is that the only governance that there is around to staff governance is the member's responsibility and there appears to be a lack of seriousness given to the organisation's responsibility under staff governance and I think if that was redressed that could help cos it's about involving people I don't think anybody's silly out there they know that there's financial constraints there's got to be savings but a lot of the savings are dictated from top down whereas I'm a strong believer some of the savings can be identified by our members that are on the ground floor but there's not that engagement with them and say well have they got any ideas how we could be more efficient still provide a good service but save waste and I feel that's something that needs to be redressed and has been lost Thank you Brian Sorry, this is my name is Brian Hogan I'm with DeafLinks and I'm representing deaf people in the Tayside area this is a tiny snapshot compared with the millions of parents that we've been speaking about it's to do with signed language interpreting and the services that are provided by the NHS and their local interpreting agency and in the past deaf people have been seriously neglected deaf people have had hospital stays for two weeks and now once was there an interpreter present to explain to them what was going on they didn't know what the operation was and they didn't give consent because they didn't know what was being said to them Over the years we've improved that situation so that the numbers of deaf people in hospital and GP's appointments have having access to an interpreter has really improved and as a result of that the cost to the NHS of providing that service has gone up now we've recently reached a situation where this interpreting contract is due to be renewed that has been postponed because the value of the contract has gone into another bracket and requires a lot more work now my obvious first concern is with the cutbacks what's going to happen to that but on the other hand we feel that there could be efficiencies made with the interpreting service they could work a lot better than they are at the moment and I feel that that is another way where maybe small savings could be made and if those small savings were made elsewhere throughout the NHS then possibly that could be a way of trying to save some money so it's like you're saying that in the services you use you can see for your members efficiencies that could be made without compromising service so would you be looking for greater engagement from the board and NHS Tayside in having those discussions with you yes I think that's happening to an extent at the moment there are quarterly meetings and people from the NHS come to the deaf hub which is where deaf people meet in Dundee and they have discussions with us and they ask us questions and we give the answers some things take a long time to happen but I think that's the case with any large organisation but I think they are genuinely listening at the moment that level of engagement four times a year sounds good okay Sonia Cotton from the Pain Association I'd just like to echo completely what Brian said there as well as other people around the table here and I think when we talk about cost savings and we look at that down the line it's not just about the withdrawal of services and the reduction of them it's about looking at how we change how we work and the way to do that particularly with the integration of health and social care is to really embrace the partnership working Pain Association do have a service level agreement with NHS Tayside to provide services for chronic pain patients we are currently operating under a three-year service level agreement obviously after that it will need to be revised and of course when it comes to revising that in 2018 we recognise that we'll be dealing with different people due to the integration the problem with that is the new personalities that we don't yet know about who we are going to have to deal with you know we need to be making those inroads we need to be speaking about services we need to be sat round the table saying what is it that service users need and we're only going to be able to do that if we're invited to sit round that table and have those discussions rather than somebody on the outset like ourselves coming in and saying well this is what we can do here's the evaluation here's the outcomes and the values and now you make a decision that that has to be that that discussion and a couple of years ago when the Scottish Government were providing funding to every health board to improve chronic pain services the disappointment for us was NHS Tayside were the only boards that we weren't involved in the discussions with you know as sort of service user representation which was a bit of a disappointment you know considering all the other discussions that we've had but certainly we do need more of that that discussion round the table to move on so you don't have the same level of interaction and engagement with NHS Tayside in terms of listening to your members as say deaflings do no okay you know we have a good relationship in terms of you know we'll provide sort of all the reporting material but that's where it stops it's not a two-way conversation and that needs to happen because there's lots of you know opportunities out there whereby we we were set up on the Sky Gateway referral platform to help GPs to be able to refer direct to our services so again it keeps in patients potential out of this revolving door syndrome of representing and avoiding potential unnecessary referrals to secondary care but we've not yet had any GPs from Tayside utilise that and Sonia what is the level of clinical care like for your members all the feedback that we've had I have to say from from the members that use our groups that they've been sort of completely satisfied they do feel that they've had you know being in the right place at the right time and there's never been sort of any issues about the length of weights etc but the number of people that are coming to us saying I just wish we'd heard about you because we've not been you know for all the times that we've been in the system whether it be sort of within the chronic pain service or within the GP I just wish we'd heard about you because it's not been mentioned so so it's an issue of clinicians and the NHS signposting patients to you so you can come together as a group yes I've heard similar from Maggie Centre and other organisations as well yes and in the meantime you know the patients are being denied that service that can that can help them okay is there anything else you'd like to add okay can I move on briefly to the third theme which is should what should NHS Tayside's health services look like in the future what services do you think we will need and are there any we won't need if witnesses would like to add anything finally to kind of future services please feel free to do so if you feel you've said what you want to say that's fine as well but if you can indicate to me if you'd like to speak that would be great Maureen I would like to see the health service move forward and agree with Sonia I think that the voluntary sector is is underused in and we're always used to thinking creatively with very little money we have to do that we've always done that historically and I just think the way that the carer reference group in the improvement plan in NHS Tayside works in the acute sector I think that could work in the integrated boards and I would like to see it in the integrated boards I would like to see it support co-production working in partnership with family carers as equal partners in care because family carers of people with profound disabilities in fact family carers in general are used to living on very little money they have to be creative so you have people out there who use the services and the carer reference group within the improvement plan in NHS Tayside is effective it's very effective it's very open it's very honest and likewise NHS Tayside are very open and honest back so I would like to see that model replicated for people with profound disabilities in the primary care sector as well not just the acute and in integrated joint boards yes Mary Ballantine in terms of chronic care and self-management which is the great discussion in you know in the health arena at the moment Angus cardiac group would like to work closely in partnership with our health board not just the immediate health board but with others to try and shape how we move forward we need to be part of the discussions proactively a little bit of what Sonia was saying resonates with us you need to be in it from the beginning rather than trying to deal with the fate of complete and that's something that I think we can continue to contribute a little bit around the savings too we do a lot of fundraising we try to provide a lot of equipment back into the NHS and we're quite happy to continue to do that to try and support our partners is how we see them but equally we need to see a little bit of that reciprocated if we are working hard to try and put something into the NHS in terms of equipment and support we would like to think that we can also impact on some of the ancillary staff who we depend on so much for making appointments portering us around you know the nurses and the doctors have to deal with us when we're sick so we know that we need to be respectful to them but sitting here today listening to some of the challenges that they're facing it seems to me no wonder that there's some friction at the coalface when the sick person is trying to liaise with the caregivers and the ancillary team they're trying to support them so moving forward if we could be involved in anything that would support that or improve that moving forward we would love to be we've been involved in nurse training and doctors training and so on in terms of trying to work in partnership but I'm just wondering if we need to be engaged with others the more support other support staff in the NHS that we could perhaps help or do something that would improve that situation for them we're very good at self managing our conditions maybe we can help with a little bit of the hearts and minds of the ancillary and the other support teams in terms of it is worth your while to go the extra mile so maybe we could do something there thank you I think that's I think that's very useful certainly to get on the record as well all that all that advice Raymond Marshall unison I just want to touch on the the future of services and I think that the the integration agenda is important in that and absolutely I think that the just to say that the trade unions are involved in the the party side the three IJBs that sit across they said I think the part of some of the concerns for us is around the the join-up and the concern that because there is different the three different IJBs that ourselves is going to be delivered differently in different areas and that is because of the the approaches by the three different IJBs seem to be different and how they're taking it forward and I think that the health part has to be strong in that to ensure that it is delivered the same but there is but at the moment the way that it's been structured and set up is different across Tayside so that's a concern I think that is that going to impact on how the services through health are delivered as well so I mean fully support the delivery of care as close to a patient's home as possible but is that going to be the same and I think it's a good direction to go and I think staff are very supportive in particular areas but my concern is that is it joined up across the three areas within Tayside and are we going to be delivered different services across Tayside? Do you mean standards of service being the same because it's my understanding that integrated joint boards are set up to to balance you know local accountability and they're being done slightly differently in different areas so the three areas in Tayside but are you concerned about the standard of service? I would take to say the standard because I think from my member's point of view they are delivering a good standard of care it's how it's delivered and I think there'd be a concern if you may get what I just think that you may get one service in a different way in one area than they're doing in another but I think help us to be stronger in that to ensure because they have the common health is the common denominator across the three IJBs and we need to be sure that we're we're we're sure that that's happening for the population of Tayside. Thank you. Bob McLash and RCN. Very quickly. Obviously I think it's touched on by yourself. Predominantly a lot of services and expectations of service users is that there will be doctors or be medical staff that will be leading on some of these services and I think to move forward we've got to look at enhancements of nursing services enhancements of their AHP colleagues as well that may be a nurse HP led services that will fill some of the gaps and you know provide so I would believe the same level of service to the patients but again we'd have an impact on the costs for NHS Tayside as well. Great. Thank you. Would anyone else like to say yes? Initial contribution because from what we're hearing is there appears to be a generally satisfactory a general degree of satisfaction at the level of health provision by Tayside and the issue seems to be about resource management within the NHS Tayside and clearly we know from the figures about the increased use of agency and that's been a major contributing factor to the deficit accumulation over recent years. We know the problem you outlined the problem very articulately Bob. What is the solution? I mean my understanding is a former health secretary is that the cost of agency nursing and they're making a distinction between agency nursing and bank nursing because they are two different things but the agency takes about 180 percent of the cost of a nurse. The agency takes a fair chunk of that obviously the nurse gets a bit more than he or she would get in NHS Tayside. I set up an initiative it doesn't seem to have gone anywhere as usual sometimes in the health service making things happen where the agency function would be brought inside the national health service and any profit would be recycled inside the national health service. Angus ridiculous that these private profiteers are profiting from the stresses and strains that we're facing in health and you know it's easy money to say the least. So what is the RCN solution to the problem? You know somebody once said that Mrs Stature... Alex sorry can you sit nearer your microphone? Yes somebody once said that Mrs Stature liked people to bring in not just the problem with the solution so what's the solution Bob? I don't have the definitive solution. I certainly can't eat nurses because if I did I wouldn't be sitting here because it would be just in somewhere nice and sunny spending my money. No there isn't one solution but I think we've got to look at this you know if we can just chip away at the problem and I think one of the the big issues that we've had and I've certainly had discussions with Lesley McLean, the chief executive just recently about how do we move forward about sort of narrowing that gap particularly about a question that was asked before people leaving going to the agency as opposed to maybe wanting to come and take a short-term contract or short-hour contract with NHS TSA. We do agree about bringing the agency function inside to the national health service and not using these companies, profit making companies. I can't comment on that I think what we have... Go on comment go on. If we've got a workforce with an NHS TSA to have service NHS TSA and delivered care to patients for a number of years there's a huge experience there you know invaluable experience experience that's built over a long period of time. If these people are then going and working elsewhere if they're working for an agency they don't necessarily have to come and work for the NHS TSA side they could be working anywhere in Scotland. The vast bulk of the work these agencies get is from NHS Scotland they're making vast profits from NHS Scotland and contributing to the problem and there's no added value because NHS Scotland could manage that agency just as well if not better and if we were managing our own resource surely that would be far better for everybody it would be part of the the answer would it not? I think part of the answer is to look after the staff that we've got that are coming up to retirement look into the reasons as to why staff are leaving you know not just for retirement staff are leaving the NHS or NHS TSA trying to address what these issues are increase things like morale look at incentives for people to come back in 10hs TSA for example flexible working you know I know it's not just unique to TSA but with constraints with recruitment with the vacancies with the lack of nurses for example that are out there everybody's fine for the same pool of graduates every year and so we need to we're not bringing in enough trainees to be in this. No we're not I was just coming to that we're not bringing enough trainees through and that was about a workforce plan it's done probably about 10 years ago plus that the determination is we would need less nurses however I think that's been proven over the past two to three years those figures weren't accurate because it didn't take into account the amount of people that were retiring in the age profile or the complexity of the page. But I think you know there's ways we need to look to see right how do we retain the people we've got how do we make the people within NHS TSA the staff feel valued because there are a number of people who are leaving and the last two to three years within the NHS they're coming to us for advice not to take any formal but for advice say I don't feel my last two or three years were valued within my employer now something's changed within that and I don't think there's a pinpoint exactly what's changed that's how people are feeling so therefore when 55 still very young they can take their pension then they're looking to go to another employer for example the agency to continue to deliver care and it's about redressing that and I think if we spend there's as I say I don't know of one size fits all but it's about valuing the staff we've got making those staff feel valued right up to the end of their career and hopefully then there will be some benefits for NHS TSA but actually for the patient groups within the NHS TSA we will retain that experience in some shape or form at the moment that doesn't appear to be happening. Thank you. For the record Alex I agree with your your suggestion I think we've created a market in nursing where there's actually no need to be one. Can I thank witnesses very much indeed for your time this morning I know that giving evidence to a committee on such an important topic can be daunting but your contributions have been extremely valuable both for us as members and I'm sure for the public gallery we'll put this report into its proper context for us as well I'm now going to suspend the committee for five minutes to allow a change over of witnesses thank you. We now move to our next evidence session on NHS TSA side can I encourage members and witnesses to keep their contributions as short and concise as possible so we can get through all the issues and I will intervene if necessary to move things along I'd like to welcome to the meeting this morning Leslie McClay chief executive professor John Connell chair of the board Lindsay Bedford director of finance and Tony Gaskin chief internal auditor all of NHS TSA side I also welcome Lindsay Patterson and Gillian Cullen both of Pricewaterhouse Coopers who are appointed by Audit Scotland to act as the external auditors for NHS TSA side I invite Professor Connell chair of the board to make a brief opening statement before I open up to questions from members. Thank you convener and if I could thank the committee for the opportunity to make this short statement now and I appreciate there are a number of issues that the committee will wish to explore that arise from the section 22 report from the auditor general and I can assure you that I and my colleagues want to answer these questions that you have in a transparent and constructive manner for the record I became chair of NHS TSA side a little over one year ago so midway through the period of the section 22 report and as a clinician with around 40 years of experience in the NHS I would like to assure the committee at the start of my personal commitment to make sure that the board will sustain high quality safe and effective health services for our patients their families and our communities across the region that is vital in the last 18 months a major review has been undertaken to understand why TSA side NHS board is in its current financial position and this has allowed us to develop plans to address this and a manner described in our transformation programme time is limited and rather than spend too much on that I will keep this statement short and allow the committee the opportunity to explore the issues that it has but I should state that in developing our understanding of the current position and in building our plans which I think are credible for financial stability we have worked very closely with the Scottish Government and I would like to acknowledge that support that we've had we've also worked very closely with health and social care partnerships local authority colleagues and third sector organisations to build a sustainable and affordable set of services for our community vitally we are developing our plans in partnership and our fully committed to partnership working with staff organisations I think the board should acknowledge that prior to our partnership review which was jointly commissioned by our director of HR and by our employee director there were difficulties experienced in partnership working and relations with trade unions that is now improving work has progressed over the last 18 months and I can say that with some confidence as I do attend all of our area partnership forum meetings these are co-chaired by our employee director and by our chief executive that positive work has been recognised by the minister of mental health who attended our annual review earlier this year who commented on the improved partnership working that was noted and as recently as last week we had a formal assurance to our staff governance committee that there was engagement and positive development of partnership working but I'm happy as are my colleagues to address questions that you might have in that regard and finally we have a very close relationship with the University of Dundee in an academic health sciences partnership which allows us to address issues of training and retention of recruitment of clinical staff particularly nursing staff, AHP and medical staff and offers clear opportunities for all of our staff to drive innovation into health service delivery so in summary chair committee we would acknowledge that running a deficit is not acceptable and must be addressed you have my personal commitment as chairman that the board has an unremitting focus on return to financial stability our five-year transformation program is actively addressing our financial position in a credible and structured way and it is led by our clinicians and is being developed in partnership with our trade unions I think we have good evidence that this approach is already working we have traction with improved financial metrics again which we are happy to demonstrate to you and finally safe high quality and effective clinical care and treatment built on positive staff experience is what we have always delivered to the people of Tayside and that will not change thank you thank you very much professor Connell wouldn't invite gail ross to open questioning Professor Connell for your opening statement it was very helpful as you said we had evidence from the auditor general to this committee on the 3 November and I refer back to the evidence session and the official report on particular page 29 and you did touch on it in your opening statement and the auditor general said the NHS Tayside is in discussion with the Scottish Government about its financial position can you update us on these discussions please yes I'll start off giving you brief context and then pass over to chief executive Leslie McClay but we have regular meetings and discussions with the Scottish Government particularly with the finance director Christine McLaughlin and John Connick in director of performance and as recently as yesterday Leslie McClay, Lindsay Belford and I had meetings with those two people to discuss our financial plans for the future in doing that we have presented to them our plans for the current financial year which they have approved and our plans for the next five years which include over that period of time full repayment of any outstanding brokerage over a five-year period and they have agreed that this is a credible plan which they are happy to support but I will pass over to my colleague Leslie McClay to give further information on that. Thank you chairman just to further add to that the part of the detailed conversation we've been having the Scottish Government is in relation to getting the board back into financial balance this year in particular the view was that we needed to work hard around our building our five-year plan and therefore the discussions in terms of the actual payback are going to commence from 2017-18 beyond but we are confident with the work that we've done to date that within the five year this being year one of our five-year plan that we will be back in financial balance at the end of year five. Okay thank you for that just to follow on from that convener if I may. Also from the last evidence session the auditor general said in her report that the repayment plan was part of the conditions for brokerage but in this case it appears that a payment plan was not realistic why did that ever come to pass if now you have a payment plan in place why was the first one not realistic? So I think there were a number of factors the work that we've been doing in particular over the last 18 months has allowed us to have a deep analysis around the service models that we deliver to the population of Tyslite. We have a model where we have a high inpatient facilities we have 26 hospital sites and in fact we actually deliver care from over 440 locations. In terms of the models of care we've also had a historical focus around inpatient models so as much as we've been and are continuing to develop a community in our primary care new service models and I think we heard some of those earlier this morning we've still been retaining a high number of inpatient beds some of which are very small units and also low occupancy. So I think our work in the last 18 months in particular has given us a far greater understanding of why the cost pressures are being experienced by the board and therefore the view was that this wasn't something that we in order to make the change we want the change to be done with our clinicians leading it we want our public involved and engaged and I think we fully recognised this wasn't something we were going to turn around within the first 12 months. So five years may feel like a long time and I fully understand that point of view but it's really important we get this right it's important that our clinicians lead the change with us and it's important what we do is a sustainable change for the population of Tyslite and hence the reason that government have agreed with us that this should be done over a five-year period. Okay, in the report from the auditor general which was October it said the board is projecting a potential deficit of 11.65 million for 2016-17 but in your minute of the board meeting of the 1st of December in the financial report it said that this could be 18 to 20 million pound shortfall at the end of the year and despite best efforts things were still not improving there was an ongoing overspend month on month and there had to be an acceleration to make the necessary savings and the board went on then to note the current position and support the actions being taken to contain spend. This would seem to me that we have gone in two months from a serious position to what would seem to be a very serious position. Are these actions being accelerated as it was recommended in the financial report and is this a final estimation for the year end or is there a possibility that things might get even worse? Okay. I'll perhaps start that and then pass over to my two colleagues but I think you're right to say the board always wishes to give very careful scrutiny to financial projections. The board is aware of the need to hit a target of 11.67 million by the end of this financial year and is aware of a need to have an accelerated programme to deliver that. That programme is in place and if you would like further detail I can pass that over to Lindsay Bedford our financial director but we are confident having met Scottish Government yesterday that our planning assumptions should see us hit that target by the end of the financial year but Mr Bedford may wish to give you detail of our accelerated plans. Thank you. So the board meeting at the end of October we took to the board a range of forecast outturn and also a further actions paper. The further actions centred around the benefit that the board is going to receive from employing in excess of 200 newly qualified practitioners which will alleviate the level of non-contract agency spend that the board has been incurring in the in the first half of the year of a significant impact in the remaining months of the year and also the also touched on within the audit of general support as a position on prescribing. So we have a further range of of actions and accelerated programme that will deliver a benefit in this year but more importantly will deliver a significant recurring benefit going into 2017-18. Thank you. Colin Beattie. Thank you very much. My first question is really for the external auditors. On the second of December 2015 Pricewaterhouse gave evidence that a substantial portion of the deficit was comprised of pension fund deficits and increased national insurance costs. I can understand the national insurance costs but I've not seen this reference to pension fund deficits having to be funded by the board. It's not referenced in any of the other documents I've got here. It's not referenced by Audit Scotland specifically as a cause of the deficit. It's not in your own management reports. Can you tell me firstly was that evidence that was given correct and secondly how do you account for pension fund deficits? In terms of the evidence given around pension fund deficits I'm afraid I don't have that information to hand so I'm afraid I can't answer that question. Can the internal auditor answer that question? The only thing I can think of and this would be speculation is that the level of pension fund deficits but we're not here to speculate. This is a pretty basic thing. I mean we're talking about millions of pounds of deficit. I want to know how it's accounted for. I didn't like that slide so I don't know what it's made. Can they perhaps come back to the committee with the... I think Finance Director Lindsay Bedford wants to come in. Yes I can answer this. It doesn't relate to pension fund deficit. It reflects the increase in superannuation employers contribution that all boards had to increase their contributions by in the year 2014-15 so it's across Scotland all boards. But the evidence that was given on the 2nd of December clearly separated out increased national insurance costs and the pension fund deficits as a result of the revaluation of the pension so either that evidence was correct or not and how are you accounting for pension fund deficits? Lindsay Bedford. The boards don't... The boards do account for any change through the increase in the employer's contributions. The superannuation increased in 2014-15 and the national insurance increase came through in 2015-16 so it's going both years. We're talking about something totally different here. I understand about the national insurance contributions. I understand about the increase in them. What I'm trying to get to the bottom is was the evidence given by Price Waterhouse on the 2nd of December correct? If I can perhaps add my understanding would be that health boards do not directly fund pension funds, they're part of the SPPA and therefore the pension fund costs are met by superannuation contributions which as our finance director pointed out rose and that's not the same thing as having a pension deficit and I suspect there may be a misstatement by PwC. Lindsay Paterson. Yes it would have been my colleague that gave that evidence and certainly... It was Kenny Wilson. Yes and certainly as far as pension fund deficits quite rightly they're not on the balance sheet of an NHS organisation. I would need to clarify that evidence that my colleague gave and come back to you. I'd appreciate if you could on that. If you could write to the committee Ms Paterson with that information that'd be very helpful. Colin Beattie. The other thing is looking at all the evidence that we've seen on this. As an audit committee we look obviously historically we look backwards. Is there not every evidence over a period of years of management incompetence and fiscal irresponsibility as far as as far as NHS dayside is concerned? We're sitting in a situation over the next five years you've got to find the better part of £200 million. That doesn't seem like good planning from years back. Again if I can start that off and then pass probably to Leslie McLeay. I mean I think first that Mr Beattie has pointed out that this situation did not arise overnight. It has arisen as a result of I think a substantial number of years of operational models that did not recognise the true financial situation that NHS dayside was in. As our chief executive pointed out the model operated in dayside has been one that has been over-reliant on inpatient beds running an excessive number of sites over what was necessary to deliver healthcare for the population needs in the 21st century and the health board in earlier years perhaps running up to 2012 balanced his books on the back of asset sales and other maneuvers so that it appeared to be in financial balance when in fact it was living I believe out with its means. That has now been recognised so I believe that there is competence in terms of having transparency over the accounting understanding the reasons why there has been an unsustainable position and putting in place credible plans to address it. But Professor Connell you say that has now been recognised. How long have you been in this job? I've been in the chair since October 2015. Okay and Leslie McClay how long have you worked for NHS dayside? Five and a half years. Okay as chief operating officer? I was two and a half years as chief operating officer and then I was appointed in December 13 as chief executive. And Lindsay Bedford how long have you been with NHS dayside? I've been with dayside 33 years. So well aware of issues in the past. Colin Beattie. Can I just refer to NHS Dayside's annual report Price Waterhouse which was actually dated June 2016 although it's the year to 31st March where it actually questions the sustainability and uncertainty about the financial situations. Now that's only weeks ago and now you're sitting in front of us saying everything's going to be fine you're going to find £200 million over the next five years. You know it's hard to see that evidence and I've seen all the stuff you've sent us on financial sustainability your five-year plan it's not that strong is it? I would argue that has been developed in conjunction with the Scottish Government it has evolved over the last year and I believe that it is robust and credible. I would put it to you that in the last, in this financial year, we are looking to achieve savings of £46.7 million and I believe we'll deliver that. That in terms of NHS Dayside is an unprecedented saving to achieve and the balance of savings between recurrent and non-recurrent savings is moving in the direction which I think is appropriate towards recurrent savings so I believe our future plans are credible. Given the level of savings that you have to achieve what impact do you anticipate on the patient's experience? You'll recall that I gave a commitment to my opening statement that NHS Dayside is entirely committed to sustaining safe and secure services for patients across our region. I do not anticipate there being impact on the current level of services. Our service performance has not been affected thus far by our financial position. There was a task force about 15 years ago I understand which produced a series of recommendations on how to avoid getting into this situation. It sounds as though rather a lot of the senior management team were part of the team tasked with not getting us into this situation. Is that correct? I'm afraid 15 years ago is somewhat before my time in Tayside at that stage I was working in Glasgow and I think our chief executive also was not in Tayside at that stage. But Mr Bedford was? Mr Bedford would be a junior member of the finance team at that time. But is there a question mark, Mr Professor Connell, around the people or this situation that has resulted it would rather appear that the senior management team have been in post and presided over it? Is that fair? I think it's fair to say that the model that was operated in Tayside was appropriate for the time in question. Tayside at the stage was operating on a different allocation of central funding through the NRAC formula. It was spending money I believe appropriately on the type of care that was appropriate. What it did not do was recognise the change in circumstance with the change towards a form of care that was more based on the community and less on inpatient science. That is something that has happened since 2012 and also did not come to terms with the fact that it had relatively speaking had a fall in its NRAC financial allocation. Those were true factors that I believe were not foreseen. I have three questions, which I will just fire to keep them very brief. First of all, there are expected to be efficiencies in areas including drugs and prescribing. The prescription costs I understand to be the third highest in the country. My questions are why are prescription costs so high within NHS Tayside? Why was this initiative only started at the beginning of October? Why is it taking so long to start? How are those efficiencies going to be achieved in drugs and prescribing and what impact does that have on service delivery? I will start with Pastor Lindsay, Lesley McClay, for full detail. The initiative has only started in October and NHS Tayside has an active medicines management programme going back ever since I have been chair. The specific initiatives that are focusing on some aspects of prescribing have begun in October. We have been actively managing medicines management ever since I have been chair before that time. In terms of fire or costs high in comparison to the rest of Scotland, that is a complex argument. It conceals a number of factors, including the fact that in some areas Tayside is better at identifying patients with complex chronic illnesses who require prescriptions. I will give you one example of that. We treat more patients with the condition atrial ffibrillation in Tayside than any other health board in Scotland for head of population due to very good general practice performance. That incurs a cost. The benefit of that is that we see a much lower rate of stroke than Tayside than we do in the rest of Scotland, so we can balance a prescribing cost that we incur now with a long-term benefit in terms of stroke incidents. That, I would put, is something that patients actually appreciate, is not having the risk of stroke, so it is a direct patient benefit. If you undertake efficiencies, you are going to stop delivering on that, aren't you? No. What we will do is focus on areas where we have evidence of waste and variation, so we can sustain the high-performing areas of prescribing and focus on the areas that we believe are amenable to a cost constrained and not pass that to my chief executive. There are a number of areas that we have looked at. We believe that there are changes we can make, supported obviously by our clinical colleagues. In particular, we have, for example, a pathway where we have a typical type of pain-relieving drug that has been identified and is being used quite excessively in terms of the high volumes of that drug. Through work with our primary care practitioners, there are alternatives to that type of drug, so progabalin is one of them, which is a pain-relieving drug. There is a high usage of that in Tayside, and it is a very costly drug. Some of the work that we have been doing in particular is working with our secondary and primary care physicians, because it is important that they work together, and identifying in terms of formulae what would be other drugs that could be used that would have the same quality impact in terms of the patient but are not as expensive. Those conversations have been going on for a number of months in particular in this year, and we are now actively promoting the changes in those pathways. So when will they conclude and how much will be said? We have a detailed plan of initiatives that we will have in place by the end of March, and that over the next four months. Turning to agency staff, reliance on agency staff is up by 39% in the last year. Why has NHS Tayside got such a high reliance on agency staff? Why hasn't anything been done before? And how long before it gets sorted out? First of all, I can update the committee that NHS Tayside has a 30% reduction today in terms of the number of non-contract agency nurses it was using at this time last year. So there has been significant work in the board. I think we heard from our colleagues earlier this morning around concerns and certainly from our perspective it's absolutely a key objective of the board is to reduce either down to zero or down with a very risk-assessed plan in terms of when you would actually use a non-contract nurse. We have been doing a huge amount of work around our recruitment and I think my colleague earlier said that we were really successful this year and we've recruited over 200 newly qualified nurse practitioners and they are now all fully within the system. We are going to continue to look at how we reduce that spend. We have invested in an e-rosting solution so we did that two years ago and we've been working in partnership with our colleagues, trade union colleagues, with our clinicians and we're now in the process of fully rolling out that e-rosting solution. By the end of December that'll be fully rolled out across all of Ninewells wards and PRI. It's already in Ninewells and we're in the closing stages within PRI hospital. Implementing that solution has allowed us to give much more detailed analysis on how we're deploying our nurses and there is undoubtedly areas where we can be much more efficient around the deployment. So examples of that would be around annual leave, around time out management. It's really important, we heard earlier, it's so important to us that staff get their time off but it's actually about how they plan to do that throughout the year. So the work we've done around e-rosting is giving us far more detail. It allows us to be able to take that helicopter view. We've also introduced this year four times a day we have huddles where all our nursing staff and other support colleagues come together at four times both in Ninewells and PRI looking at what are the staffing levels in the ward, are there in terms of the acuity of the patient, do we need to up those levels and I also can advise the committee that NHS Tayside fully implements the national nursing workforce tools and that clearly has increased the level of nursing resource that we are placing in our ward. Thank you. My final area of interest, I'm led to believe that there is a performance related extra payment that senior management can get. Are you able to comment on that if there is some kind of performance related pay against what benchmark is that measured and what performance is being rewarded? I guess I should perhaps start with that and then pass over to my colleague to give you final detail but senior management staff within the NHS are paid outside the agenda for change arrangements and are paid in a different centrally managed, ministerially directed pay scale. All of these staff are subject to evaluation on an annual basis and any approval of performance related pay, which is what you're describing, is given by the National Performance Management Committee. Annually all staff are appraised against a whole series of objectives which include delivery of clinical services, management of resource, management of staff working under their direction and management of our contribution to the objectives of NHS Tayside. Based on that performance they will be awarded an uplift in their pay which is reviewed and approved by the ministerial committee centrally. This is not finally approved by NHS Tayside. I can assure you that in the year in question 66 staff received a payment incurring a total cost to NHS Tayside of £87,000. I think you were going to pass over to you. Sorry, sorry, sorry, sorry, you covered most of that. If you don't have anything to add that's okay. Yeah, unless there's anything in addition that we haven't covered I'm more than happy to answer that. So just to confirm then 66 staff, this is senior management, have received extra payments over and above their salary for performance and what are the benchmarks? Can you give me any examples of what the senior management delivered to NHS Tayside in order to receive this uplift? So within the within that group there are different levels of grading. Within that 66 there was a high proportion of those had an acceptable, fully acceptable performance. So that would be that they delivered on their objectives. Each of the senior managers had core objectives and then they had specific ones that were relevant to their specialty. So the core objectives clearly would include deliverables around clinical care, around clearly financial governance workforce and then in particular there would be specific ones. So within this cohort you will have a health colleagues, you will have HR colleagues and then there will be agreed objectives in their particular area that then would be added to make a total of eight objectives and in terms of the decision around where they land there is a scoring mechanism that is graded for every single objective and therefore there's an accumulative score that would then determine whether that individual would land in a fully acceptable or not acceptable or superior or outstanding in terms of performance. Can I ask, did you and Mr Bedford receive a performance related uplift? In the 2015-16 year I was given a fully acceptable performance. Right, and just a quick question to the external auditors. What's your view on the performance related payments, if any? From our perspective in terms of the performance related payments they followed due process in terms of of how they were determined but we don't audit the actual awarding of those pay performance ratings themselves. Mr Bedford did you receive a performance related uplift? I did, and so was the chief executive, I was awarded fully accept. It seems to me that we're rewarding people for doing their jobs, I mean fully acceptable to me means that you've done your job, it doesn't mean that say you've done something additional that necessarily merits any sort of a bonus or additional payment and especially at the moment when we're looking at a situation where, and I'll say it again, we seem to be in a situation where there's been clear evidence of management and competence over a long period and fiscal responsibility, we're rewarding people for doing their jobs, doesn't that send an odd message? That's pretty tough, firstly I would remind Mr Beattie that the performance is not entirely based on financial metrics but in many staff it's in terms of managing issues such as eHealth, HR, clinical delivery etc and therefore I think it's very reasonable to assess staff across a range of metrics. But is it not sending the wrong message while NHS Tayside is in the present situation? Well you may comment that but we are using a system that is used across all health boards. Staff in senior management positions are not part of agenda for change and all health boards are obliged to assess senior managers using this system which if their performance is deemed acceptable, and I believe that there is a robust system for assessment of that, there is an automatic payment made which is approved at ministerial level. But given all the overruns on costs here, people have got more money available to achieve these targets and to reach acceptability, surely if you were comparing like for like across the NHS you'd be looking at other health boards that were in a tight financial situation that were managing it and that were still delivering the care. Okay, there are annual data produced which compare staff performance across all health boards. Now I can't look at other health boards by name because they're given a if you like an anonymised number but what I can tell you is that the evaluation of staff in Tayside is not in any way above average and indeed is probably slightly below the national average for assessment of staff managerial performance over the year in question. So I believe there has been a recognition that staff have delivered an acceptable performance whether there are challenges in what they have to achieve. I still find it difficult to get my head around people getting a bonus for acceptable performance and certainly that would not happen in the private sector. To get a bonus you have to actually achieve something, exceed your targets, exceed what you're expected to do in order to qualify. Thank you. Alex Neil Thank you convener. Can I go back to the figures on the deficit and the so-called brokerage which is really a debt to the Scottish Government. First of all can I just clarify am I right in saying that your estimated savings for the current financial year 1617 is just over 46 million pounds is that right? That's correct. And am I right in saying you're also projecting at the moment a deficit for this year of just over 11.6 million pounds? Yes. That's right. Now in the auditor general's report earlier this year still dealing with the current financial year. First of all it's said the projection was total savings as a percentage of baseline resource funding was 8.4 percent so does that 46 million still represent 8.64 percent so what's the percentage now? 46.7 is 6.7 percent. So the savings have been down by about 25 percent since the auditor general's report? No so when NHS Tayside was putting its financial plan in place for 2016-17 in order to break even so financially balance the books the board was looking to save or required to save in the region of 58 million pounds which are correct in terms of that being 8.7 percent. At that time there was planning that was happening across all the boards in Scotland which was providing an opportunity for sums of money from national initiatives to be included within the board's financial plan and we built that in so at that point we were building in our own work that we believed we could successfully deliver in year which was coming in at 46 million and then there was additional sum on top of that that we would draw down from our contribution to deliver of national initiatives which one would be likes of shared services however as we were working nationally and regionally we recognised the risk in relation to the delivery of the national initiatives just due to the timeline that some of them would take to deliver and therefore it was a board decision right at the beginning of this financial year that our ability to deliver 58 on our own we believed we would put ourselves completely at risk and clearly the equality and our clinical care that we provide is paramount to us and therefore right from the beginning I submitted a local delivery plan with a financial target of 46.7. We believed that was a target that was it would be a stretch target for the board given previous years in terms of what we delivered but the work that we'd done we believed that we could deliver on that and therefore right from the beginning with Scottish Government they were clear and they signed off our local delivery plan that said we would deliver the 46.7. I understand the reasons but the Auditor General's report was published just in October this is the early part of December and for the reasons you explained there's already a 25% reduction over the last two months in the estimated savings this year for the board which will is relevant to my questions about the next five years but just before I leave this point and the Auditor General's report of the 58.8 million sorry 58.58 million pounds of savings which you estimated earlier which is now down to 46 even then the Auditor General said that 60% of those savings were non-recurring 10.2% of the savings were unidentified and 12.1% were high risk so if you combine those 84% nearly 85% were either non-recurring unidentified or high risk so based on the 46 million pounds 4% now is non-recurring 4% now is unidentified and which percentage is still high risk I'll pass that to our finance director Lindsay Bedford but if I can maybe just clarify again I think I said in response to an earlier question the board had recognised that previous in previous years it's had inappropriate reliance on non-recurring savings and that in this financial year we are seeing a better metric in terms of that and in future years we anticipate shifting the balance of savings so that in the final years of our five year programme our non-recurring savings will be a much smaller proportion of our total savings but I'll pass that to you. Just to put this in perspective chair your non-recurring is 60% maybe revised on the 46 million figure which is the new one that compares to an average of all the boards of half that 30% your unidentified is slightly lower and your high risk is slightly lower but your non-recurring and given that this is a five year plan there have to be surely recurring savings you quite rightly said that previously NHS Tayside over relied on asset sales which are literally one-offs and it looks as though although you've now understood the lesson that to date you haven't actually been successful in doing anything about it. Will you accept your point that non-recurring savings is not an appropriate way to run a business or an NHS board and that has been recognised in this year that is already being changed and will continue to be changed in future years but Mr Bedford will give you the precise figures. Thank you so the paper again we took to the board in October identified the progress against the existing workstreams so that identified that the board had secured 40 million of savings of which was an equal split between recurring and non-recurring so that was demonstrating progress. So 50% is still non-recurring? 50% non-recurring and again the board approved the further actions that were required that would secure fully the 46.7 million and there will be an element of that that will also be of a recurring nature so we expect to be certainly in excess of the 46% so excess of the 40% recurring that we identified within the financial framework. So looking at the next five years that you say you've agreed yesterday with the senior team, senior official team in the Scottish Government, I want to explore this figure. Am I right in saying that over the next five years as well as if you were breaking even you would have still about £200 million to repay the Scottish Government is that right? I hope not £200 million but our final brokerage figure will be we believe around £36 million but we would anticipate over the five-year period fully repaying that as well as achieving our savings the total over the five-year saving of required to achieve that will be somewhere between five and six percent. So the reason I think the £200 million figure to win over the next five years if you were to break even you would need to make total savings of how much over that five-year period to break even over the five years. And to repay the brokerage? Well I want the separate figures how many how much savings would you need to much saving would you need to make and to pay the brokerage to break even and pay back your debt. So total over the five-year period £214 million. So it's right it's £214 million pounds which obviously averages something like £403 million pounds a year or there about in savings right? And you're going to reduce the non-recurrence element of that substantially right? So to what level are you going to reduce the non-recurrence element? Current financial framework identifies it will move to 60% recurring and 40% non-recurring over the lifetime. So 60% so 40% non-recurring will still be asset sales then basically? No or one-off. Mr Bedford can give you fun examples of non-recurring. I hope you agreed yesterday you know can you tell us what have you agreed yesterday for each of the five years what you're going to achieve in each of those five years what have you agreed with the Scottish Government? So across the each year like next year what savings have you to make next year? So in 1718 the assessment is 44 million. And is that based on breaking even then? That will deliver a shortfall, a small shortfall in single figures of 45 million. 45 million so the total is 50 million basically? To break even? Yes to break even yes. You need to make savings next year of 50 million? To break even. What about the next year after that? So we've factored in repayments of brokerage in the following three years with a standard efficiency savings target of £40 million across those three years. And then doing so in delivering a £40 million efficiency saving then as well as delivering a financial break even that will also repay the outstanding brokerage to the Scottish Government. And we're expected to believe that you'll achieve that based on your track record but we're expected to believe you'll achieve that. That's the discussion that we've had with the Scottish Government? That's the agreement you said? That's the discussion, that's the agreement. So where are you going to make these savings? Where are you going to make £50 million of savings next year? I hope we agreed with the Scottish Government where are those savings coming from? If I can perhaps pick this up initially and then perhaps ask Leslie to comment but what we've achieved this year is to try to get ourselves back into financial balance or to move towards financial balance that has given us time to look at changes in clinical service delivery which we believe will allow us to achieve credible savings in the future. Much of that will involve moving our clinical service delivery in line with the national clinical strategy and the document from the chief medical officer realistic medicine moving services closer to the community wrestle up less reliance on inpatient stay reducing costly issues such as delayed discharges which add to our bill and are not good for patients. Professor Connell sorry with respect we know what the challenges are but I think Mr Neil is asking how the 50 million savings next year specifically are going to be achieved. Can I just say you know we are talking to health board that's changed its figures dramatically and the savings have reduced your savings in year this year over the last two or three months? No we have from 58 million to 46 million well you told the auditor general and you told me your original estimate this year was 58 million of savings you then realised that the national savings couldn't really be relied upon and you then reduced the figure since the auditor general's report to 46 million. With respect Mr Neil we submitted our LDP to Scottish Government at the beginning of this financial year and that had a target of 46.7 million pounds. So why is the auditor general in October saying it's still 58 million? Because presumably the auditor general got the figures from yourselves or from your auditors. Anyway the fundamental point is this when are we going to see the detailed plan identifying line item by line items where you're going to get 50 million pounds of savings next year and for each of those years adding up to 214 million pounds worth of savings over the next five years and have you agreed the detail of that plan with the Scottish Government because I don't see how they could agree to anything until they see exactly where the savings are coming from. So where are those over that five year period have you got a list of each of the savings costed by line item to add up to 214 million pounds? We have a five year transformation programme that gives high level costings. High level costings what does that mean? Well in terms of forecasting it means you put your finger in the air and estimate because that's what it looks like sitting here. So we have a five year transformation plan and every year we are building a one year delivery plan to give the absolute detail on how that will be delivered. So when the beginning of this year we'd have a very detailed plan of everything that we would deliver costed down to the detail for 1617. We will have exactly the same for 1718 and 1819 right through to 2021. So we have the five year overall plan with key financial figures within it but in terms of running the organisation, taking on board any changes in terms of demand, any different ways of working then that final detail will be published in our one year operational plan. So we will publish for the end of March 2017 for the next 12 months and that is the way that we've been building this plan. Well I would say that somebody who was heavily involved in business planning for the last 40 years that's a wholly inadequate approach. I mean I realise and one of the things that needs to be changed is this year to year hand to mouth budgeting of the health service across Scotland and that's not your fault that's the fault of the system it needs to change but given the situation that T side health board is in I would suggest you need not a high level finger in the air estimate what you need is a detailed five year business plan that shows us clearly how you're going to pay off your debt and break even without a dramatic reduction in the range of quality of services and I don't I mean you just said you don't have that you'll have it soon hopefully for next year 50 million is a huge challenge to achieve given that we know that rising demand the complexity of the demand we've just heard this morning about the challenges on nursing staffing we've heard from yourselves I mean I'm told there's quite a number of consultancy vacancies in a whole range of other issues as well that need to be addressed which impact on that so can I suggest and I would suggest exactly the same to the senior management in NHS Scotland they need to answer to parliament because we'll be calling them as well they need to tell us how can they agree to something that's so thumb in the air we need a proper plan item by item where's the money going to be saved because quite frankly we wouldn't believe that it's going to happen until we see that and my own view is I think we're going to end up with a bailout being needed by the Scottish Government to save services in Tayside and how the fund that would need to be looked at and they don't have the money to fund it at the moment but quite frankly until we see a data if you're running a business you don't be a thumb in the air saying you know over the next five years we hope that we're going to save 50 million a 214 million pounds 214 million pounds requires a detailed plan so can I I think the committee should be asking Tayside by a certain period maybe the end of January to give us a five-year detailed itemised plan on where that 214 million pound is going to come from. Leslie MacLeod you did say that you're reproducing a detailed plan for the first year when is that due to be produced so we're working on that for 17-18 okay and when will it be public when will it be ready as I said to Mr Neil it'll be the end of March okay and can you send it to the committee once it's ready be more than happy to do that thank you we have an indication of the four years after that because I realize the closer in you are next year you'll be able to give more details than what you will be for years two to five but I do think and I think the public and T site and the taxpayers acknowledge that need to have not just a wing and a prayer and motherhood and apple pie we need a detailed plan. Thank you Mr Neil Colin Beattie can I bring him very briefly to clarify a point. It's really for the external auditors in their report on NHS Tayside a few weeks ago they stated that there is uncertainty over the financial sustainability of the board and you also questioned the NHS Tayside as a going concern do you still stand by that yes or no? In our report we just set out why we have to consider going concern for all of our organisations before we issue an audit opinion and given the financial challenges which the board was facing we set out our reason and rationale for considering it. Your conclusion was that because it's a public concern it will be bailed out basically it wouldn't be allowed to go down. As a going concern yes or no the uncertainty over the financial instability of the board the question over as a going concern as a business do you stand by what you stated in that report a few weeks ago? Yes I do. So I would interpret that as as a going concern it is not viable and that there are questions over the financial sustainability of the board which the board is going to have to address. I mean as we've set out in our report there are clearly significant financial challenges which the board will have to address and as we've heard today there are a number of plans in place in order to try to deliver those. I think the point you've clearly made here is that from a financial point of view the NHS side is simply not sustainable without very radical change. Yes and I think that is supported by what management has said here today. In the evidence we've heard the savings now sit down to 214 million I think is the figure that Alec Mule managed to tease out and Professor Connell in your opening remarks and in some of the questions today you've sought to reassure the committee and the public today that the patient experience won't diminish that that you can manage your way through these savings but NHS TSAI currently is only meeting five out of fifteen national targets so can you say if performance is currently good enough and with the financial challenges ahead how will that performance improve? Thank you for that. You are right that targets that are set by government are challenging for all health boards. NHS TSAI's performance in relation to the targets in the great majority is either in the upper quartile or certainly in the middle of the pack so I do not believe that our financial performance has impacted on our delivery of targets. If I look at the targets in detail we are presently best in Scotland on A and E for our target achievement, best in Scotland over our child and adolescent mental health appointments. We do have some problems around treatment time guarantees as do all health boards. What about cancer? Cancer target again the key metric there is a 62 day for urgent referral there we are sitting pretty well on the Scottish average at present. We have two particular cancers that do cause us concern, urological cancers where we have a single consultant surgeon at present who can do laparoscopic prostatectomy we have been trying extremely hard to recruit a second urologist but there is a national UK wide shortage of consultant urological surgeons other health boards have similar problems. Solution there is was to work with other health boards in a regional solution. Colorectal cancer is another area where again there have been difficulties in identifying specialists because of a national shortage so I do not believe that is a financial issue that is a difficulty in finding specialists who can fill roles. I want to pick up on the RCN evidence I think we heard from Bob McGlashan earlier today and spoke very well about the culture within the NHS and some of the pressures there but looking at the written submission from the RCN I understand that they feel the culture within NHS Tase has tended to be top down and divisive and this is a result of staff being under enormous pressure to find budget efficiencies but even stronger than that RCN is saying that management has been bullying towards members of staff and that they feel that there has been a breakdown between management and staff working in partnership. What do you say to that Professor Cornwall? Firstly I would turn to what I said at the start but I and my colleagues across the organisation are fully committed to partnership working. I think the board acknowledges that there were significant problems in earlier years but I believe that these are now improving and indeed Paul Gray, the chief executive of NHS Scotland made a specific comment around your review that he detected a substantial improvement in our partnership relationships since his previous review can be at a very high level and that covers a number of outside bodies. These are individual members of staff who are frightened to raise grievances and are speaking in accordance to the RCN about the fear that they have on a daily basis. In terms of culture my view and that of my colleagues is that we would not tolerate a culture of bullying or adverse staff experience and we are actively working with colleagues including staff partners to make sure that we do have a culture that is open and transparent and encourages staff to deliver the very best they can for the organisation. Over the last year we have had a large amount of effort going into staff engagement. I personally along with the chief executive medical director and director of nursing have been involved in a large number of meet or value NHS staff meetings with large numbers of staff right across the organisation. I think I have personally been to 12 of these in the last year when I have met staff in a variety of circumstances including communities and in our inpatient facilities. On all of these I have been impressed by the commitment of our staff, the genuine value they see in working for the NHS and I have not had reflected back to me at that stage major concerns about staff bullying and harassment. I do not think anyone doubts the commitment of the staff but the RCN are telling the committee in this written evidence that staff feel bullied. There is a culture of bullying. What do you say to that particular point? If there was evidence of that we would not tolerate it but I will pass to it. So what will you do having been made aware of it today? Yes. The first thing I would say is that I was extremely disappointed to read that. As a nurse by background I fully understand the work and the importance of staff feeling safe, that they can come to work to do the job as Bob McGlashan said that they go up every day to do. So from my perspective then clearly there is further work to be done and we will take immediate action so that was certainly the first time that had been brought to my attention and I give a personal commitment that myself and my colleagues will be sitting down with RCN colleagues to understand this in more detail and also give you the commitment if there is any evidence of any feeling of fear or intimidation by any of our staff we will take immediate action in relation to that. Thank you, that's appreciated. Can I just pick up the issue of brokerage? We've heard from the Auditor General that if the Scottish Government wanted to it could wave the brokerage and wipe the slate clean. Is that something the board has asked the Scottish Government to consider? Why not? Because we recognise the financial pressures across all public sector organisations and I think there are some factors on two sides that we've described earlier that are making it more challenging for us but it's not about us not having enough allocation of moneys proportionately to every other health board and public sector organisation and we are confident that there is money that we are having to either invest around like our aging estate you know we have a large number of hospital sites that are over 30 years that are really costly and we are really progressing our community and home based models so there will be a time where we will not require these inpatient facilities that will release a lot of revenue in terms of our maintenance costs our backlog maintenance and we believe that through the service redesign work we will be able to redistribute the money to support the financial pressures that we're currently experiencing so overall of course it's challenging we recognise that but we are no different than any other board and we have a we have a big challenge in front of us but we are absolutely committed to deliver so has the board debated the possibility that you might have to ask for the brokerage to be waived in the future never no okay in terms of property i'm glad you raised that because at the last session picked up on the the large number of properties that um you're hoping to expose some savings from i think it adds up to something called six million pounds but you're not having a lot of success in the marketing of these properties 13 have been marketed for over one year and three for more than four years you've mentioned you've got other properties that are aging and could be disposed of but you're not having any success trying to dispose of the ones that are currently on your books could you give us an update on that so i mean if i may i'll pass my finance director here could you sorry could you make concise as possible that would be much appreciated okay you know um by the end of march we are looking to dispose of up to 14 of the properties i guess importantly the sites that have been surplus to requirements for the longest period will be will be offered books by by the end of March will you achieve market value for those properties will receive open market value for those sites and and any property that has been disposed of has to be approved by by the board and in coming to the board we also bring the professional professional advisors valuational whether we are getting value from money from the sale of that property so have you rejected any offers on the basis that you're not getting best value out of the offers in the last financial year we did the board did decline an offer just one offer we only had it it was only two or three properties that the board was looking to dispose off all last financial year that physically came to the board for approval i guess importantly also the the sites that will be disposed of this year will generate recurring revenue savings of approximately £400,000 and also importantly it will alleviate potential backlog maintenance costs of up to 1.8 million so at the properties that you've seen offered for what money they valued at what was the value of the properties for the the properties that will be disposed of this year there are a valuation part that was included within the external orders report of close to four and a half million we expect to receive receipts of close to two and a half million pounds just to find out i'd asked if an offer had been rejected on the basis that it didn't achieve market value so what was the property valued at and what was the offer that you received the offer that we received last financial year was was close to half a million the the market the the assessment that we had in for that site was close to one and a half thank you rose thompson thank you very much convener in the evidence session this morning we heard about staff morale in particularly how low that is to quote bob Mcglashen he said staff morale is getting less and less staff do not feel valued there is a big stress for the nursing family to quote Raymond Marshall admin staff have been an easy target staff are feeling frustrated and constrained and that the relationship between managers and staff is not good and in fact has gotten worse from previously before and that there is now no trust so with staff morale and tatters is that not a direct result of the failure of management to address issues run about vacancies run about bullying as want to call in this highlighted which is there's clear evidence of within the submissions and your ability to communicate with your staff i'll again start the discussion i think first day if we have evidence of bullying or major staff grievance we want to hear about it my experience in meeting staff is that that does not accord with the statements made by RCN or unison the staff sir rca making up no i don't think they are but i think it is not as widespread as perhaps indicated to the committee but i would pass to the as i reiterated i was extremely disappointed to hear to hear that you know i have regular dialogue with the RCN as does my nursing director and i absolutely give the commitment that if there is any situation in terms of any bullying or harassment that we will take immediate action on that is our track record rose thoms perhaps proves the point that staff always feel they cannot communicate with management which always is looked at anyway following on from what we've also heard this morning we were told that there has been no engagement with staff and given that the audit report identifies you need to make workforce savings what engagement will you ensure is in place to discuss with staff your transformation program for the workforce and because would you not agree that if you do not look after your foot soldiers if you cannot command the confidence of your staff and command their trust then you're simply going to set yourself up to fail with this firstly if i would perhaps i wouldn't describe our staff as foot soldiers i think they're valued partners and delivering health care to the population of Tayside absolutely and you're not valuing them at the moment they are valued in terms of transformation program firstly i would point out that the employee director who chairs our area partnership forum sits on our transformation program board all the transformation program detail is discussed at our area partnership forum which i attend every on every occasion i have the minutes available if you wish to see them which document detailed discussions of all the transformation program plans and the work streams so staff are engaged in that and you've heard confirmation from the staff themselves that they're involved in the various work streams so i think i would contest the fact that we do not have that dialogue in place through our area partnership forum which is attended by all of our staff side unions and our managerial staff thank you just to say um thank you very much for that um it would be good if the committee as has been highlighted if there are minutes of any meetings i think given the evidence we heard this morning about no engagement lack of engagement and staff feeling frustrated with it i think we need to see the evidence of it so if the committee could be running with it i think very happy to provide you with all of those minutes i think that might be useful professor connell because if there is transparency around there obviously there's two sides to every story and that that might shed a little light can i ask you a little bit about prescribing because auditor general identified prescribing as a major problem in nhs t side for finances in her report last year but she also identified the same issue the year before in october 2015 for the previous year now i was at your annual review presentation in september as you know and at that presentation you showed a picture of chief executive and the chair launching an initiative on prescribing just the week before i think in september can you tell me why it's been so long from the auditor general you know we've known prescribing's been an issue for a long time why it took till this september to launch that initiative so first of all we were absolutely right we did launch a prescribing campaign around waste management but that was only one of six that i believe that we have undertaken in this calendar year so we are doing a whole range of prescribing initiatives out with the media we've got one just now out around the kind of stock up we know just now for example that over the winter period people stock up on excess medicines i think across the board somewhere in the region of about six eight how much was it an extra million pounds so when you say people when you say people stock up on extra medicines you mean you know there's all people in terms of communication that goes out to the general public at the winter time just reminding them and of course it's really important that the general public or patients have enough medicines to manage over the holiday period but there is evidence that there is and this is national evidence that the people actually stock up quite excessively but surely the prescribers and your doctors should make sure that they have enough medicines to get them through you know ample amounts but not stock piles of them yeah i mean we we're just looking at terms of the cost we will see a spike over the december month as my finance director saying that we'd cost somewhere in the region about a million pounds but you don't see a reduction in terms of people either stocking up and then using less drugs people i unfair from what you're saying correct me if i'm wrong that there's actually they have more drugs than they need is that right i think there is some evidence of that why are why are nhs staff allowing that to happen if you're tightening up on prescribing but if i can comment that is in fact a scotland wide problem and there have been initiatives launched in the last month by a chief medical officer and by the director of quality to try to address this i think it's a complex issue because in many instances patients can submit repeat prescriptions directly to community pharmacists so it bypasses nhs staff and of course the community staff pharmacist may not feel they have the empowerment to query whether a patient genuinely needs an additional prescription i mean i know this stock plan is happening i've seen it myself in dundee with you know stock piles of prescribed paracetamol which we know is extremely expensive stocking up in in people's houses but we you say it's a problem across scotland i do appreciate that but your own board papers say concern was again expressed that prescribing had been an issue for over two years there was not a sense that this was in any way further forward and there should be an understanding by now of why prescribing was an outlier that's your own board papers and the auditor general said this is a specific problem in nhs t side so why are people still being able to stock pile medicines stock pile medicines only one element of it it's clearly not it's not the sole area i think our chairman earlier talked about some of the quality prescribing that's going on in nhs t side that actually ultimately reduces the number of strokes which we have evidence of the number of liver transplants etc so there's clearly that element where we are using drugs that are high cost drugs but actually have better outcomes for the individual patient and i alluded earlier that there definitely are areas in t side either through formulae non-compliance so people going off formulae so using more expensive drugs or previous choices by our clinicians that are expensive where there are good quality alternatives and those are the things that we are addressing at the moment i think this year in particular we will see a reduction in our secondary care prescribing costs our primary care prescribing costs are still a particular challenge we have done some work this year where we have identified the 10 gp practices that have the highest cost now that's an exploratory conversation because there'll be multiple reasons prescribing costs and we are our community pharmacist and our pharmacy team are working with those gp practices to help to look at where their costs are and look at what the alternatives are so there doesn't feel like there's a quick fix in this but we are certainly addressing it do you feel that you have the cooperation and confidence of clinicians to actually get a grip on this quickly prescribing issue yes i believe the commitment is there and both in secondary and primary care i think you're working with you know 60 plus gp practices in particular they're extremely busy we're all aware of that and there is not a lack of will indeed okay it does lead me to question why it's taken so long to to kind of make any progress you see any progress on this to date yes you do do you have evidence of that yes our hospital prescribing costs have shown a fall on this current financial year which is gratifying in terms of our second or primary care prescribing costs last week i attended a prescribing pharmacy huddle which again was this focusing very much on some of the issues that leslie mclay identified high cost of pain prescribing there's another simple example where our general petitioners use one drug recubus statin which is a commonly prescribed statin drug which is now probably the most expensive in class as opposed to the cheapest in class that is a reason for historic reasons at one stage it was the cheapest in class but i guess as with all drugs manufacturers change prices we need to now change our prescribing to deflect that thank you professor cornell agency nursing we saw audit scotland reported a 39 rise last year in agency nursing costs which i think was one of the highest in scotland and then you've told us this morning and it's been reported that this year there's been a 30 percent reduction now given the amount of nurses that nhs two sides employs these are huge fluctuations again audit scotland reported not this year but last year the agency nurse costs were a problem so in that financial year they were allowed to rise by 39 percent why was that first of all if we are using non-contract agency that is to ensure that we deliver safe care that that's that absolutely the the first comment i would make i think i've alluded to the fact that we have a number of hospital sites across nhs two sides we've got the largest number of hospital in in patient facilities we believe in any other board and a lot of them are small community hospitals and therefore even if it's a low occupancy there's still a required level of registered nurses required on a 24 hour basis and these are driving our cost i appreciate that nhs two sides has a large property portfolio and you know rural areas and we have a lot of facilities that need to be staff but what we heard from the rcn this morning was that staff are actually turning their backs on nhs contracts and going across to agency because the terms of conditions are better is this not actually an issue of workforce planning within because we've allowed we have a national health service in scotland but somehow we've created a market in uh in in nursing that should never i appreciate this is not just an issue for tayside but it is a specific issue for tayside with this 39 increase is it not an issue of workforce planning and management planning to have prevented that i'm not sure we could have prevented it but i but i agree workforce planning is really important absolutely why hasn't that happened well if you go back to scope to uh 2012 13 even into early 14 nhs tayside was not a high user of non-contract agency but just due to a number of factors in terms of vacancy factors um i also referenced the implementation of the nursing workforce tools that we were a very early adopter as a board and that increased our whole time equivalent requirements substantially and we have continued to deliver to that safe level why more than other boards in scotland though i can't comment on the other boards all i can comment is that we in terms of the acuity of our patients the number of wars that we have on our safe staffing levels that is what we resource to it is only we have we've done a huge amount of work around our nurse bank this year we have increased the number of nurses that are on to our nurse bank so we now have gone from 800 to 1200 nurses and of course we are encouraging and looking at the flexibility that staff are wanting to ensure that our staff remain with us and don't go to the non-contract agency but specifically even before you became chief executive you were chief operating officer in charge of all these issues so surely you saw the trends and why were measures not put in place so that it was actually nhs contracted nurses that you were employing rather than resorting to agency there was a number of measures that we've continued to put in place over the last three four years we continue to do that we are dealing with a demographic situation again which is not similar only to it's not just to nhs t site there are a number of factors but we are working as hard as we can to make our organisation as attractive as possible the comments this morning from the rcn as i said clearly are disappointing we will be addressing and looking to what we can do we absolutely value our staff and we particularly our nursing staff and we need to do more but did management take responsibility for this these huge fluctuations in agency costs of course we take i mean we're the senior management and it's clearly our responsibility i think what's important is the fact is that we have we have used 30% less non-contract agency to date at the same time we had in this in that financial year of 1516 and we continue to hope we will continue to hold that position i would agree that's an improvement it's the fluctuations that worry me with exactly the same team in place i agency nurses to my understanding cost the taxpayer three times as much as a contracted nhs nurse at nurse and as a public audit committee it's our job to follow the public pound and that doesn't seem to me to be a good use of the public pound and certainly the these huge fluctuations i wanted to ask um lindsay bedford um lindsay you told us earlier you've been with nhs taeside for 33 years so you have uh been in the finance team all that time is that correct mainly to have a note at one point a different specialty but principally finance across the nhs taeside so you have long experience of the financial issues that are experienced by nhs taeside i look back at the 2001 i think audit of nhs taeside when the auditor general did a report then as well and some of the issues that come up are actually quite um similar to some of the issues today of course you'll remember the killshaw inquiry that was about illegal payments but it did lead me to wonder if you were involved at the time in the results of the killshaw inquiry why have we seen such problems with the implementation of enhancement during leave payments so as the chairman said in 2001 yes i wasn't taeside but i was a wealth of junior member of the finance staff at that time so i wasn't particularly involved in the outcomes of the discussions around the killshaw report the enhancements during leave result is a circular back in 2008 it's disappointing that having received assurances that had been implanted across taeside and fuel that the investigations subsequently occurred that hadn't been employed in fuel and that recognises i think the complexity of the circular i guess what's important is that when it was brought to our attention that we did go through a fairly detailed process of understanding what the the differences were what had been paid against what should have been paid and just clarify i mean the etl guidelines enhancement during leave guidelines were not implemented properly by nhs taeside is that correct despite the assurances received by the chief executive it turns out that they were not okay so you're saying that it was responsibility of a team below the chief executive to follow the guidelines correctly and they were not followed is that right through the through the individual line managers and down to the senior charge nurses who are responsible for putting the data into the the system then it turns out that the the circular hadn't been complied with but that recognised the complexity of the of the circular and is recognised within other boards across across scolton as well is that is there an issue of governance there mr bedford if this was not you said it was not picked up by a chief executive is that correct well the the assurance that the assurances were given to the chief executive that the circular has been complied with it's only when we did that detailed investigation it turns out that recognised the complexity of the circular that the payments hadn't hadn't been made in full when you were on annual leave mr mclay mr bedford said we were as far as we were aware when obviously going back a number of years but the assurance had been sought by the previous chief executive and myself and as far as we were led to believe that we were fully compliant when the detailed work was undertaken there was found to be some errors in some areas and and that then led to the situation that we've since addressed to the auditors have anything to say on this point about edl payments and guidance not being followed over a period of time is this something you picked up tony gaskin now we've the issue first emerged in 2013 and as that was picked up we were asked to look at the process that the board was using to address that it wasn't something that we would have normally picked up through our audit work now when in that particular year there were 200 circulars came out we don't follow every single one what we do is if there is a control weakness identified we pick it up what we do do is look at the system that is used so for every circular that is received by an hsd side there is an instruction goes out and at the point where a response is received from managers and it's the responsive managers to implement that you know the board has exercised its duty. Mr McLeod do you think this should have been picked up at an earlier point because it's now become a key a key issue for the Auditor General in the financial situation that NHS Tayside finds itself in now? I mean it's it's clearly disappointing to find a situation like that occurring but there was no evidence that we were led to believe that there was any errors happening it is a complex situation in terms of people determining what enhancements some would have during annual leave I think what's important to say is that we now are in a position from the 1st of April where we will have an electronic system for our individual staff and the e-rostering solution that I referenced earlier will also help because it will mean all our rosters are actually recorded electronically but previously they were paper based. Should there been a more robust situation in place Lindsay Bedford said that you saw assurances from other teams? Should there been better governance and a better system in place to actually give you the confidence that this system was being properly applied? I think we now we will we now have improved systems in I think that's clearly important and we're addressing the situation but at that time as I said there was no evidence there had been benchmarking work undertaken by the previous finance director looking at enhancements during leave that did not indicate that there was anything untoward in terms of our situation in Tayside so there were a number of checks and balances looked at however there clearly was and we did some further work around that to make ourselves absolutely assured and that's when we found the errors. Improvements have been made but it's just recently reported in the press that actually NHS Tayside is expected not just to run an 11.65 million deficit this year but for that actually to increase to 18 million so it's difficult for the committee to accept that all these improvements are happening when you're projecting actually an even larger deficit than Audit Scotland projected just two months ago. I would just reiterate to the committee in terms of our earlier statement from both myself and the chairman that we have detailed plans that forecast that we will deliver on the 46.7 million pounds. Audit Scotland have drawn a big question mark over your ability to actually deliver these savings over a five-year period. From our perspective on the work that we've done we believe there is efficiency in the savings that we can make without impacting on the quality or patient experience and that's what we intend to do. Let me go back to the past. The 2001 report from Audit Scotland also identified a problem in NHS Tayside that there was a heavy reliance on non-recurring savings. Now we know that this is again a problem at NHS Tayside so Lindsay Bedford with all your experience and the finance team why is this reliance on non-recurring savings being allowed to to happen again? I guess over the over the years it's actually has fluctuated going back the last four years it has been around about the 47 50% mark but over the last couple of years in particular that level of recurring savings has fallen and in part that just reflects the challenges that we faced. I think what I recognise as part of the financial framework going forward this financial year is that we need to look at things differently and that's when the implementation of the the workstream programme came to fruition so rather than looking at individual groups and their budget efficiencies then it was it was looked at more on a on a corporate level and driving through the features and in very contained contained workstreams so it put a different focus on it and also as the chief executive and chairman have mentioned we talked about valuing your NHS sessions so that kind of takes the the conversations down to the individual staff members and the public around what if they had to implement efficiencies then what efficiencies would they see being made that would deliver efficiencies but also continue the same level of quality service. But surely that's your job as a management team to identify those efficiencies and make those recommendations. And indeed that that was the purpose of the the initiation of the the the transformation programme in the workstream programme so the the implementation of the workstreams overseen by the transformation programme board of which a number of directors and non-executive directors are members. Kenny Wilson the internal auditor when he gave evidence to our committee last month said that there was a high risk of job losses as a result of this financial situation in NHS type in NHS T side. Lysimucly, why should hard working staff bear the brunt of long-term financial mismanagement? So your first comment in terms of job losses there is no forecast of job losses in NHS T side by any of the plans that we're making. We are using the opportunity of our natural retitution rate and look and through that there are some areas where we believe that we can redesign our services and actually and that will reduce the overall headcount but this is not about job losses absolutely not. So can you guarantee the committee that in the plan that you produce in March and send to the committee there will be no cuts to services or to job losses that you will actually be able to find these huge savings from efficiencies within the system that we've already discussed? So what I can say is in particular to our workforce there are opportunities particularly in some of our admin and management areas where we can redesign and do things differently so that overall could reduce the headcount but that headcount will be reduced through natural attrition by other people retiring or people are leaving. There is no intention whatsoever there never has been nor will be in terms of cutting jobs so there are different ways of doing it and we will use and we've got good examples of where technology is supporting us to do things differently that previously were done manually so that will ultimately take down the headcount reduction. In terms of cuts to services we're not cutting services but there are opportunities where we can deliver them differently and the board will use that opportunity but if we do that we will do that they will be clinically led so our clinicians our nurses our doctors our HPs are helping us redesign them and we'll be doing that in partnership both with our trade union partners our staff and the public. Okay thank you can I go back to the issue of bonus payments miss McCleill you confirmed that you had received a bonus payment for a fully acceptable performance is that correct? Yes that's correct and is that in the region of one to three percent? For 15-16 it was 2.3% and Lindsay Bedford 2.3% and would your rating fully acceptable as well? Given given the state of finances at NHS Tayside do you think these awards were medited? In terms of my own award yes I do I think they were we clearly I'm fully aware of the financial challenges that NHS Tayside has I believe my performance was awarded on the work that I was doing as the leader of the organisation and the work about building sustainable plans that were going to bring the board back into balance that is what I believe reflected my performance. Even though Audit Scotland have drawn a question mark over whether you can actually meet these savings? I understand why they're questioning that I think there's a whole load of questions around a number a number of boards in terms of their financial position but but from our perspective I think the board is in a far stronger position than it has ever been in around having the five-year plan the five-year financial plan the detailed work we've done around our workforce profile and the work we're doing with our integrated boards and our other regional partners to change the service models and continue to meet the demands of the patients in Tayside I think it's a far stronger position the board has previously been in. Mr Bedford's given your role as finance director in your long experience at NHS Tayside do you same question to you do you feel that that award was merited and deserved? So I've been in post since formless since June 2016 the the assessment that was done on me for last financial year as as I already said it doesn't incorporate just finance incorporates another seven objectives on top of that the chief executive made the the assessment on my performance and it went to the remuneration committee. But your financial director the board projects sorry Audit Scotland projects 11.65 million deffs at this year the board itself projects an 18 million pounds deficit you've gone to the scottish government for loans to break even for the last four years looks likely that might happen again next year Mr Neil pointed out that's five-year savings of 214 million pounds is that a sustainable financial situation for NHS Tayside? I think the plan that we've discussed with the scottish government as we've touched on earlier is seeking to to repay that full financial brokerage over the the remaining light of the five-year programme. But in your opinion is NHS Tayside in a financially sustainable situation? I think with the work going on with individual work streams and the clinical strategies that will evolve over the next 12 to 18 months then yes I do. But you feel that your performance merited that award? I said my assessment was done by the chief executive. Ms McLeod do you feel you have the confidence of staff to take forward the reforms that are needed to sort this situation out? Yes I do I absolutely do and I will make comment again around the comments that we've made this morning that clearly were brought to my attention only through receiving the written submissions on Monday extremely disappointed and I give a personal commitment that we will sit down with those individuals to understand the issues that they've raised with you and a commitment that we will look to address them. Professor Connell? Yes I pointed out at the committee right at the start I've been chair since October 15 and I believe that Leslie McLeod does carry the confidence of the staff. She has the confidence of the board as does the finance director. The finance director I see has pointed out was appointed only three months ago so I believe that there is confidence that we have a chief executive, a finance director who have identified correctly the issues that need to be addressed and that I think is a major achievement has have created a credible plan to address the situation and have worked closely with Scottish government and other regional partners to build a plan for the future which does not put at risk delivery of safe healthcare for the population. Mr Thank you. Mr Bedford do you feel you have the skills and confidence to get NHS Tayside out of this financial situation? The information that I provide is based on the plans for the individual work streams so all I'm reflecting is the financial implications so the work of the individual work streams will feed into any financial plan so it's the credibility of the work done within the work streams that I will reflect within the financial plan. Sorry I was asking you personally as finance director do you feel you have the skills and confidence to get NHS Tayside out of this situation? And again I guess I reflect on the work of the individual work streams that will feed into whatever I progress but I do believe I have the skills and confidence to deliver on the financial sustainability of NHS Tayside. Me too. Okay. Thank you all very much indeed for your evidence this morning. We will consider the evidence at a future meeting and decide what other further action to take and I also thank the members of the public for attending and listening this morning. I now close this meeting of the Audit Committee.