 Good morning, and welcome to what is the second meeting of the Health and Sport Committee for 2018. I would like everyone in the room to put their mobile phones on to silence so that it doesn't interfere with the proceedings this morning. We've received some apologies from members as well, so Jenny Gilruth and Brian Whittle will not be with us this morning. The first item on the agenda is the declaration of interests, because we have two new members to the committee. This is in accordance with section 3 of the code of conduct, so I would invite the new members. That is Lewis MacDonald and David Stewart to declare any interests that are relevant to the remit of this committee. David, would you like to go first? Thank you, deputy convener. Could I draw members' attention to my role as chair of Inverness, Caledon and Cecil Trust, the largest shareholder in Inverness, Caledon and Cecil Football Club? The role is unpaid. Thank you very much, and Lewis. Thank you very much. I have no relevant address to declare. Thank you to both of those new members, and welcome to David and Lewis for joining the health committee, and I hope that you'll enjoy it as much as we all do. The second item on the agenda is a choice of convener. The Parliament has agreed that only members of the Scottish Labour Party are eligible for this nomination as convener of the committee. That being the case, I would like to invite nominations for the position of convener. Deputy convener, can I move Lewis MacDonald? Thank you. Any other nominations? No. The nomination has been received, and I therefore ask the committee to agree that the nomination of Lewis MacDonald and that he be chosen as the convener of the committee are we all agreed. We are. Thank you very much. Congratulations to Lewis on his appointment, and I will now hand over the chair to Lewis so he can carry on the meeting. Thank you very much. Our proceedings in the months ahead, but particularly now, of course, to start with the third item on the agenda for today's meeting, which is an evidence session with NHS 4th Valley. Allow me to welcome to the committee Alex Lincson, the chairman of the board, Cathy Cowan, chief executive, Fiona Ramsey, the director of finance, Angela Wallace, the nurse director, Andrew Murray, the medical director, and also Shona Strachan, who is the chief officer of Cluck Manager and Sterling Health and Social Care Partnership, which works with NHS 4th Valley. I believe Alex Lincson that you wish to make an opening statement. Thanks very much, conveners, and congratulations on your appointment. First, I'd like to say that while there are many areas that the board is performing well, we fully appreciate that there are other areas where a performance is not where we'd like it to be and needs to be improved. So get that bit up front at the start. We hope that we have the opportunity to highlight some of the work underway to address the challenges we face and also share some of the many examples of good practice within our board to improve the care and experiences of our patients. It's also important to highlight the advances that have been made to improve the overall health of our local population. Although, like all NHS boards, we have areas of high deprivation, there has been significant improvements in life expectancy, along with reductions in premature deaths from heart disease and strokes, and we regularly report on the overall health of our area. We also aim to provide members of this committee with assurances that we, as a board, along with front-line staff across organisation and council partners, have a clear grip on the areas where we need to improve and are totally focused on addressing those. In addition, I am confident that we also have the right governance and internal and external scrutiny processes in place to monitor and manage our performance. That includes board seminars, which focus on specific topics and challenges in great detail, service visits, along with our main scrutiny committees, performance and resources, and clinical governance committees, which gives our non-executives the opportunity to scrutinise and question our performance and action plans. We also have a clear strategy for the next five years, shaping the future. This is our document here, shaping the future, which is closely aligned with the national health and social care delivery plan and the strategic plans of our two integrated joint boards. This strategy was shaped through extensive consultations with patients, members of the public and staff. This has been taking forward in partnership with neighbouring NHS boards, local councils and other key partners to share best practice and identify innovative and practical solutions. As a board, safety is our key priority, and despite the recent winter pressures, our staff have continued to provide high-quality care. This is borne out by the positive and supportive feedback from many of our patients over the last few weeks. I remember that just a couple received through social media in this one over the last week. I would like to thank the staff at the ICU at the Forth Valley hospital in Larbert. Sadly, my father died on Sunday, but the care he received was thoroughly professional and much appreciated. Thank you. In the second one, an unexpected visit to NHS Forth Valley A&E today with daughters who broke a bone in her hand. Fantastic service. Brilliant staff makes me proud to be a civil servant. Those are two of the many products that we have had in this year. We very much welcome this opportunity to update the committee on our work and we hope that we will be able to answer all your questions. If, however, we are not able to provide all the details you require today, we will seek to provide this information as quickly as possible. Thank you for the opportunity to make this a dress. I will just make one further point to say that Kathy Coyne is our chief exec. She has only been imposed from 30 January. Does she appear that way in your questioning? Fiona Ramsey, who is our director of finance, has been acting chief exec for the last nine months. Give some context to your group. Of course I am delighted not to be the only newbie on the block and you have 13 days advantage on this. I look forward to hearing from you as well as from your colleagues. I know that your colleagues will have a good deal to say and answer to your questions. Can I simply ask to start with about the annual review for NHS 4th valley? I noted that it took place in September of last year and was a non-ministerial review. I wonder in your experiences that a new development, is it a surprising development or have you become accustomed to reviews in which ministers do not directly take part? I have been chairman for five years now and have had five reviews. Two of them have been ministerial and three have been non-ministerial. As a board, we are quite relaxed about either, obviously it is a matter for the minister, whether it is a ministerial review, it is different when it is ministerial, it is very much controlled by the actual minister. When it is non-ministerial, we can have more of an interface with our audience but both are beneficial and in both cases our board is scrutinised. Thank you very much. I wonder if I can ask Ash Denham to follow up on some of the issues that were raised at the annual review and had come up previously. Thank you, convener. Good morning to the panel. Thank you for attending the committee this morning. I would like to get your review on levels of accountability. Obviously, as Lewis has just explained, there is an annual review process that has recently started taking place. That is followed up, if necessary, by a number of action points that need to be looked into. In 4th valley's case, the action points for the last two years have been pretty much the same. I am suggesting that there is perhaps some challenge in moving forward in those areas. How do you view the reviews? Would you say that they are considered instrumental in trying to drive performance forward? My colleagues come in with the detail. I think they are. I think that it is important for every organisation, the public sector organisation to reflect on its performance. It is part of the performance culture, it is part of holding us to account as a board. It is a valuable process. The two aspects that say progress have not moved to the hard-trick issues. Good morning. My name is Andrew Murray. I am the medical director of NHS 4 Valley. I have been here for the last almost a year. It was my first time at this specific annual review. I did find it helpful. It was a very constructive discussion. There was Government presence there, so there was opportunity for people to take notes and to then compile our feedback. With the specific point that Alec has raised and passed around our healthcare acquire infections, particularly our SABs, we as a board, as a group of senior people within the organisation, we see the figures around things like SABs and we can relate it to other types of infections. We are very much aware of where the organisation is. We see individual reports from different directorates. We know when there are any areas of concern. We also see very clearly, yesterday, I was looking at reports from all four different directorates, showing the breakdown of exactly that information of SABs. I could see that in November, we had no-one in our organisation with a hospital-acquired SAB. That is the area where the acute hospital has to have absolute high standards of cleanliness. That is where we can really influence those figures in those other SABs' headings. There are community-acquired SABs. Sorry, SABs are staforias by terimes. There are a type of blood poisoning, if you like. Our numbers, when they have been higher, and we were discussing this this week, we think that we are now coming down to what would be a baseline. It is difficult to eradicate completely because people can be predisposed to develop those infections. What we have previously seen has been community-acquired. That is very difficult for us to influence with a very direct action plan because that could be individuals with sustained trauma in the home environment. Unfortunately, it could be substance abuse related. That is a high-risk group. There are different ways to try to influence those numbers. We have done that through an ADP group to, again, specifically, target where we might see people running the risk of SAB with IV drug abuse, for instance. On the particular point of SABs, we are aware of it. We think that the numbers have improved. We certainly see areas where we have a very close control over, if you like, that we can get to the point where we are not seeing any SABs at all. It is difficult, as I said, to totally eradicate because a lot of treatments in hospital involve putting a little bit of plastic into people. Unfortunately, that predisposes a small group of people to SABs. In terms of the review, it is useful to have it flagged for me first-year in the organisation. It is important that it is given the right level of scrutiny. It is a key quality indicator for us, but we look at it regularly. As I said, yesterday we will look at it some weeks. I can look at that information four times at different groups and different committees and also see the actions that are being taken to resolve them. In terms of supporting what the chairman said in relation to a ministerial review, or whether it is an NHS board-led review, we have a significant patient and public engagement across all of our indicators. Supporting my colleague in relation to any kind of infection, this has been something that we have, as Andrew has said, dealt with at the highest level. We have had patient and public involvement even in terms of the clinical environments and working alongside doctors and nurses and physios and others, making sure that the environment is clean and supporting us on key things such as hand washing. We have really strong governance. The public sees that this is a measure of how well the health service is performing for them, although there are lots of targets that may interest them. We often see that this is the touchstone of whether a board has really got, as the chairman said, the grip on things. We have had significant improvement and, as Andrew says, we have a staff ores bacteremia, which we have months where there are none at all. Small numbers that we have are still our patients in our communities, either in the hospital or in healthcare required in our community. We treat them with the exact same vigour should we have a staff ores bacteremia in a hospital. We are looking at that incident, whether it is a member of our public who is drug-using or someone who has pricked their finger when they were pruning their shears or pruning their garden. We need that to see if there is anything that we can learn from that and then make sure across the system that we are learning and trying to prevent them. They are coming from very unusual or very individual sources, but the board still says the same amount of vigour. Our patients in public are really active around this agenda and they work really hard with us, whether it is hand washing, cleaning, clinical environments. Again, as Andrew has mentioned, around the healthcare-enquired infection or the healthcare inspectorate, boards in Scotland have not had a cleaning mentioned and that is a real touchstone for the public when they come into our environments to see clean clinical environments regardless of whether it is hospital or community. We engage with them in terms of what matters to them and infection control. Any kind of infection control is something that they have really robust conversations with us. Thank you. Obviously, the board did not achieve some of its action points for 2015-16, so I would like to ask you that as a result of not achieving those action points, what then happens? If that happened again for another year, how would you go forward from there? If you could just stick with SABs quite often to it, but in terms of SABs, I think that we have probably plateaued as much as we can do. The figure was a lot worse in a number of years. Sorry. The SAB's point is a very important one because Andrew and Angela have both addressed that in some detail. No other colleagues will want to follow it up. Ash's point is more a general point around how you deal with reviews and recommendations and what happens when you fail to meet the standard that you have been seeking. Those are carefully considered by our board. We take the scrutiny very carefully and we try and understand why we are in that position and what actions we are taking to improve the performance. On-going scrutiny is a board. None of those points that come out of the action plan from the review are news to us. We are aware of them. There are things we are already working on. They are all well within our actual site. There have never been any surprises as such. They are all areas that we are actively working on. Does the Government require anything further at that point? Obviously, we want you to keep them informed. Is there anything else that they require? There were a couple of points to add on in terms of scrutiny. Some of the areas that are in each subsequent year, one of them is finance. I would expect that it was not that there were any particular issues with our performance. We have always achieved our financial targets but with the risk that is associated with it that is why it may sit in the annual reviews and it is consistent with other board areas. In terms of follow-up, another example is that we have waiting times and access issues. The issues each year may be different. The item may be in the annual review letter but it may be a different issue that is causing that. What we then do is take that into our performance. We have weekly meetings in terms of access in terms of our ops group. That flows through to our performance and resources committee and our action plans and what steps we are taking to address them. We will then have follow-up meetings with the access team at the Scottish Government. That flows through. A tiny point of support of my colleagues. It feels that the Scottish Government is really close to those areas and wider areas because there are emerging challenges and the risk profile will change across a range of things. It feels very close. We also have a formal mid-year review of professional meetings with the chief nurse or the medical directors. Key issues concerning performance in relation to a whole range of things are also brought up in these areas and it will be the same with finance and certainly the chief executives meet monthly and there is a real rigorous process. It feels close so I think we take the responsibility as chairmen's described but it does feel as if they are very closely alongside us in terms of opening remarks. We work hard across Scotland to learn from other boards or anyone who is best in class outwith the Scottish Health Service and we have done a lot of work across that with its safety in other areas. It feels as if they are scrutinising and there is improvement support from a range of agencies to make sure that we are learning and preventing the same issues around performance. Thank you very much. Emma Harper wanted to ask some further questions around the SABS issue which you have already addressed. I will declare I am at interest because I am a registered nurse who used to actually teach nurses how to reduce staff ories back to Remus, line infections, cannula infections and all that. I am interested in the data because community acquired is obviously not related to sticking needles in people but the data does not really reflect that it just reports over all SAB rates. I am interested in whether the data needs to be delineated a bit more differently so that community acquired is separate from hospital acquired but also what are you doing as far as learning from other boards other clinical educators other nurse educators, other infection control teams because there are folk doing better although there are people who are doing worse as well. I hope that we will kick it off and my colleagues, I am sure because I think Andrew has already highlighted how close all of us are whether we are clinical or non-clinical. I think we know that nationally they are looking at the target around SABS just to try and make sure because obviously it is calculated in the amount of occupied bed days and obviously each of the systems are slightly different in relation to how their beds are supporting patients and they are looking at that target and to make sure that it is doing what it needs to do. Regardless of that we have always taken it really seriously and my colleagues have said that. We have our local data of whether they are hospital acquired and we have given you some of that or whether it is community acquired or healthcare inquired so we have on a month by month breakdown which goes to the board as well as dedicated time around clinical governance and to the front line teams to the NHS board. We have the detail of when the last SABS was within hospital and what caused it and we do a root cause analysis around that and all of our staff are developed and trained around patient safety and including techniques like root cause analysis so we are looking for how we might prevent that again. In terms of healthcare acquired and community acquired we know whether that is coming from a drug-using population or whether it is just happening in the community for various different reasons. We will know what that reason is so we are looking at it from an individual patient perspective so I think it is a board. We have got a ways to go we are wee bits of the peace in terms of other boards but we know with real clarity and we know that we are not there is no cross infection. What we have done around this is make sure that our staff and our patient in the public really feel that any kind of infection control, as I described earlier the seat is a touchstone of how well the board is performing and what we have done is we work our infection control teams with our managers and with our clinical staff across the whole breadth of the clinical community work together on this. This is not seen as a management target or a piece this is about patient care and therefore all of the training and development happens at that level and what we do have is each of the wards and departments of patients in public and the staff the last time they have had an infection some of the wards and departments in 4th Valley Royal it has been over a year and sometimes even more recently the gynaecology ward it has been nearly three years since the last time that they had had a staff aureus back to Remia so what we have got is action and support for the front line and for management and clinical leaders all the way to the board really really cited on it so the board are able to see and ask Andrew and I and the director of public health what are we doing about that and then we report back on the actions so it's a very very tight sort of line if you will from board to the front line and the actions without getting into too much detail are simply things like don't disconnect an IV unnecessarily and scrub the hub of the bio connector and make sure it dries and all of that so I'm assuming all of that is down at the co-phase detail and that there's parts of the bits of plastic or the cannula that's popped into people on various things they're part of the Scottish patient safety programme which the whole of Scotland has embraced and we can see if there's any failures which often tends to be documentation and not practice we can see that at that granular level and we can also see that per ward, per department, per directorate or across the board and we're able to drill down and see whether it was a failure of a step as you've described or it was a failure of documentation and if we find anything like that again we go in and support the staff this is about continuous improvement and we've shown pretty spectacular results in fact the recent visit from the Scottish patient safety programme who were looking for patients with cannula couldn't find them to see if we had done the bundle as you've described correctly any device and any patient unless they absolutely need it and that's what Andrew described because sometimes there's a small group of patients who are going to need incredibly invasive procedures and we need to make sure our staff are making sure there is no unintentional harm and again I think we've performed really really well that's why it's really disappointing that we've not quite got to other boards and although we're only a little away the amount of energy we've and our staff are really quite disappointed around it but we do visit and the Scottish patient safety programme supports that but we do visit other boards, anybody who's doing something different than us we will go and try and learn and put it into our own context education, training and development even in tough times that's something the board will never ever not want to address we're a board and I'm sure you'll come on to our financial issues but we are absolutely clear about keeping patients safe supporting our staff as well as balancing our books because without balancing our books we can't hear properly that's helpful to our point I mean you've given very full answers in terms of the hands on actions at the world level and a little bit about what you've done to learn from other boards but I'm not sure I have heard something that tells me what you're doing this year is different from what you were doing last year and it's more likely to deliver the targets that have been set again in the review, I wonder if there's an overview of that in this area I could say, all targets you have to be careful as Angela said it's calculated based on the bed base, we have got a relatively small bed base relative to other hospitals so our divisor is smaller most of the infections are community based there's three categories, hospital and I'm satisfied as chair that we've cracked up we have the occasional case and those are fully investigated in any lessons or learn but it's fairly minimal the other two categories, healthcare and community, most of those are community based healthcare in my view is erroneous somebody's been in had any contact with the health service and they get an infection I'm satisfied as healthcare when the infection can be nothing to do with a healthcare treatment most of its community if the calculator with total population I think the figures or comparative figures would be a lot different and that's why I make the point we are doing a lot of our problem is with drug users we're doing a lot of work with that we've done a lot of work over the years and reducing that in those cases where it does happen there's an outbreak we investigate and we do what we can but dealing with drug users is a difficult group and it is a moving group so it is difficult to say exactly what we're going to do given that this group can actually change but we still take it very seriously but we're limited what we can do that's what I'm saying I think we've calculated just now and what we are doing as a board it's difficult to see us substantially improving on our performance and I say if it was population based and I think our comparative figure would be a lot stronger than what it is when it's bed based Emma, I think there's a quick follow-up Why drug users are more difficult is it because they're finding veins in groins in places that aren't the place to decontaminate the skin in the best way or the fact that they're not doing it in the first place so can I respond to you I think we it's a very vulnerable group who don't always take all the precautions that other people would so people say diabetics who are injecting themselves would always prep the area properly with sterilisation we don't think that our IV drug abusing community that those individuals would take those steps and reusing of needles etc so the way that we try to work with that group is through, as I said, through our ADP trying to improve accessibility to clean needles ease of disposal of equipment so we recognise it but it is a difficult group because of those vulnerabilities to be able to reach out to in a consistent and meaningful way and as chair said that group will be a different group from five years ago so it's a constant process to try and engage with them but we've got some really for me relatively new we work really strongly with our addiction community we've got some really good examples through our public health services so we are really trying to make sure that that group is not is not left as vulnerable and they get the support they need we move on to one of the other areas of action points that I highlighted which was around access targets and standards in particular child and adolescent mental health services and psychological therapies I think Alex Cullant Thank you very much convener and good morning to the panel for coming to see us today I was very struck by your compliance reporting you've gone from being one of the best performing health boards in the country in a matter of months I understand that about staffing pressures but can you explain exactly what's happened because to go from 100% to below 50% in just three months seems like a considerable dive and is that entirely about staffing problems, is there light at the end of the tunnel please bottom that out for us I can perhaps pick that one up it has been almost entirely staffing issues in CAMHS it's slightly different in psychological therapies so in CAMHS we've had a range of a few staffing vacancies which are filled now and we'll be coming into post over the next couple of months it came at the same time as we had some specific sickness issues in some maternity leave given the size of the service it was around a 10-12% difference in staffing that we had at any point in time and the remaining staff have then had to pick up those people's caseload staff are coming back maternity leave comes to an end a number of the staff who have been in sick leave are coming back and we've got the vacancies filled and with all these coming into place and nothing else happening we're looking at probably a June timeframe to get us back to where we were so I think we would see it as a temporary blip but obviously that doesn't help in terms of the patients etc that's quite a fine to hear but in terms of your risk and resilience planning I mean people go on maternity leave all the time and obviously people fall ill all the time so were you content that your processes and your plans were ready for this blip and how can we learn from it so that it doesn't occur again it probably spiked it was almost like yes you would always have these issues to face but I think we probably had a number of them all coming together at the one time normally would be a little bit more spread over the year or over the system in terms of resilience I think we need to work with some of the other boards to see how we can help do that we do try so we speak to other people to see if we can get some additional capacity in to help cover for these particular instances and I think that across a range of issues not just CAMHS that's where some of the regional work fell to give us a little bit more resilience in terms of the size of our system and staffing levels that's probably where we could get some help I'm grateful for that and I think on that I'd like to explore the fact that whilst these statistics really only show us what's not being met as in the 18 week target and those young people not getting access to that services within that 18 week target what it doesn't show is the maximum worst case scenario weight that some of these young people are going to experience and that is obviously our chief concern here in that respect what additional resource can you buy in from other health boards how can we get these young people seen in a reasonable time beyond the weight they've already had to endure to pick up broadly across CAMHS and psychological therapies our weights the longest weights are not the longest that you would see across we've tried to even though we're not hitting the target our weights aren't lengthy beyond the period that you see sitting there I think we've been also working on just to give some examples particularly with in CAMHS with the parents we've set up a parents group very specifically to see what additional support you may be able to bring in and also to give a wider support to the family network we heard very clearly actually at our annual review in terms of the patient session just the impact that CAMHS living with a child with mental health issues has on the wider family so I think the parents group is a really strong support and we've had real help from the Scottish health council to help set that up in terms of getting support from the regional network I think that's a bit about resilience because everybody's facing some of these issues at any point in time and it may be when we're at 100% somebody will come to us and ask for the same thing so I think it's just about us broadly doing some of the capacity planning across that and final question if I may convener I'm keen to know also across the four tiers of CAMHS provision is this delay in treatment experience right across the board or is it particularly focused at tier 1 or tier 4 or how is the profile particularly at tier 1 because one of the areas that we are focused on is what we would call between tier 3, tier 4 and it's part of the learning from other systems is to put a focus there so that we're preventing young people having to spend any time or minimise any time they may have to have in an inpatient facility so we've been focusing quite a lot of effort there to make sure that we don't have that the way it's really in the tier 1, tier 2 Thank you convener Thank you It's striking that as well as the maternity leave and staff issues that you mentioned in reply to Alex Cole-Hamilton there's also an issue around an increase in referrals in the period under review is that a trend you're anticipating continuing, is that a spike or is it a trend? If I can just pick up in terms of child and adolescence it's not been so much of an issue there pretty much what we plan for is what we've been seeing there may be some variability across the system more where we've had real challenges and increased referral has been in psychological therapies has increased dramatically we've seen we've actually seen 13% more new patients and our returns and follow-up treatment program has an increase in 17% so it's been what we planned for where an average of 375 referrals and what's actually coming in is 484 it's varied across the system so some of what we're trying to do and again some learning from other places some support and we're looking at this at the moment into more of the primary care setting to look at why there's variability across practices which is causing some of the increase in referrals so there's some work that we're linking with Dumfries and Galloway who I think have piloted some of this so the increase in referrals is predominantly psychological therapies Thank you for letting me come back in in that vein what efforts are the health board and indeed the local authority employing to sort of prevent young people needing access to tier 1 support is there an early intervention program within 4th Valley it's one of the priorities areas in terms of children around our health improvement strategy and we've got clear links across both social care and education we've got some really good examples in the health improvement strategy of work particularly in the Falkirk area around some of the secondary school mental health and wellbeing of secondary school children you get the various stresses and strains that they go through as teenagers so there's a lot of joint work with the local authorities and it's a clear community planning priority across the area Can I just add a little bit of detail I mean we are the only health board that's offering free mental health first aid training we describe it so anyone can access that there's some very active programs within the schools around some of us as well and there's a very impressive initiative which is in 4th Valley which is called max in the middle which is again about building resilience in younger school children as well and includes mental health and all sorts of other aspects and that evaluates very highly so I think we've got a really strong program in that regard thank you very much cancer is another area where there is an issue around achieving standards I wonder if you would like to comment on that in particular on the regional arrangements and planning arrangements and how all of those impact upon meeting those targets our cancer performance in terms of achieving the 62 day target to treatment is an area of focus for us and we recognise that to come out to Chairman's opening statements where we need to improve we have seen through we look at all the data on a monthly basis and we compare health board performance and so we can see where other surrounding health boards have demonstrated better performance and so we contribute to what's called regional cancer advisory group where active members are and that's where the regional teams get together to compare as well and to see what is best practice and agree what best practice is clinical leads who meet to agree what best practice is and what the best pathway would therefore be for patients so there is a structure which allows the sharing of that best practice and clinical lead for cancer who is now actively in the next two or three months will go round every single cancer pathway and suggest improvements and we're using that regional benchmarking if you'd like to advise what ours should be we're particularly looking at Lanarkshire's performance and seeing how they've managed to achieve what they can and what we can replicate locally and we're already seeing some improvements particularly around one of our areas that we've looked at we've been able to put in a little bit more resource which is going to improve the urology pathway for men so we expect to see that side of the performance improving so overall we when you look at the cancer breakdown the cancer target breakdown there are the two parts to it 62 days which as you said is about regional and tertiary treatments and there's a 31 day part to the local health board to be able to do as slickly as possible because the key thing in all this is obviously my clinical background is in the management of people with suspected cancer and then through to their treatment so it's absolutely, it's that weight it's that uncertainty of not knowing when you've got symptoms and making sure that part of your journey is as short as possible so you get the answers you need to allow you to then engage with the clinical team so we are very aware of where we need to improve we have seen our referrals go up in cancer pathways from roughly a thousand a month to 1400 a month so we have seen quite a strain on our system but as I said we now have a new clinical lead who's going to be going through all the pathways and my expectation is on the next two or three months we will have a refresh programme there which will demonstrate best practice and bring us up to where we want to be thanks very much is it fair to say that there's a wider pattern of increased referrals from primary care into the acute sector in 4th valley I think it's very dependent on the specialties I would say I don't think it's definitely across the board but I think when we look at our overall figures I'm looking to see if she's got any data on that but the feel is that our GP colleagues know what specialist input can bring they know the tests that that can provide and there's a whole expectation thing as well not just from primary care but from the public so when we're looking at our data Fiona, do you know the most up to date picture? To say I think it does vary across the specialties some particularly obviously with demographic change I've been hit particularly where you've got things like ophthalmology, orthopedics etc there definitely have been increases particularly orthopedics in terms of trauma certainly over this year it does vary by specialty some others we're not saying that You can be in relation just going back to Andrew's point about cancer I think the government's programme around to take cancer early and really targeting groups is very observant about what they're being presented with the public are now very aware thankfully of symptoms and they're actually putting themselves forward so I think that referral pattern that we're seeing will probably increase and that's about raising awareness and it's about how we then in terms of diagnostic rule out or move people through the pathway to treat and whilst there might be an increase I think that's a really good thing quite early and make an intervention we know that if we do that the outcomes are greatly improved for our patients In terms of meeting the 62-day target where we don't meet it we don't miss it by much it's slightly a small period and it's all related to treatments and as Andrew said we're looking over pathways so it is about trying to take a few days of some of the actual treatments so that we can get all our cases within the 62 days there's not a major issue and we've always been driven by making sure people get the best treatment and carrying out the appropriate tests and the tests that we can carry out as a board have improved greatly over the years to developments medical science so we've not got a major problem to resolve but our intention is not to try and hit the actual target and hopefully the work that we're actually doing will address that Thank you very much for the number of colleagues who wanted to ask around the position with delayed discharge perhaps start with Sandra Thank you very much and good morning everyone thank you for getting in this morning with the weather so bad Mr Lincson in your opening remarks you mentioned the fact that in some areas need improved and I note delayed discharge and schedule care has risen quite a bit can you perhaps give us some explanation for that? I'll take that because delayed discharge is something that's a multi-factorial, multi-disciplinary and multi-service area I think it's fair to say that there's considerable variation in delayed discharge figures across the piece both in the mainstream of delayed discharges but also in what would be referred to as the code 9s or the more specialist areas of guardianship I think when you look at our figures we have had some deterioration it is not a consistent deterioration though when you look over the last one to two years you can see general downward to trends in most of it we do have peak periods and we do work to anticipate those peak periods both through winter planning but in general through the day-to-day planning so we're doing a great deal of work so for example we've done work certainly across clip manager and sterling on guardianships because we do have quite a high level of guardianship in our area and we have carried out reviews of all of the guardianship so we have taken advice from the mental welfare commission we've worked with Greater Glasgow health board to have some specialist input in terms of just retraining and refocusing particularly our mental health officers on the way that you would handle guardianships given that the legislation in the practice tends to move quite a bit so they were using quite a traditional method and not using 13zd which is a way of if somebody is able to either not consent themselves but there's a clear impetus and a clear statement a pre-existing statement about a desire and a clear agreement both with clinicians to alternative placements and we weren't using those as well as we should have been so we are now seeing that number declining and being managed very tightly on a day to day basis to give you some assurance really about the work that's going on we have weekly calls in place that are supported by the chief executive and that involves all of the senior members of staff including most of the panel that you see here and we review our activity any issues that have arisen any things that we really need to go in and sort very, very quickly those are supported by senior management team steering groups which again meet absolutely every single week and review and flag up on a daily basis I check our delayed dischargers and if you were talking to any of my staff they would tell you that I'm on the phone the minute I see any kind of variation or I don't like the look of something or I want to just query and we are working very, very hard to just keep up with all of that we've got multi-disciplinary daily huddles in place so social care staff, third sector providers, clinical staff etc on the ground in the hospitals every day reviewing who is delayed and discharged but also who's coming through the system and we are needing to do a little bit more work on that but I think we are getting a lot better understanding those people who are likely to be delayed as we move forward and those are the people who tend to be pretty complex so if you look now at the delayed discharge figures both in Falkirk and in Clifmaninshire and Stirling you will see that the people who are delayed are those who have a degree of complexity it's not straight forward there are family issues, there are sometimes accommodation issues there are frequently mental capacity issues or other things that are causing the delay but it certainly has worked on very, very heavily we are also working just now on our frailty pathway and that's one of the areas that we know as a board that we can do some improvement work on and around and we've got iHub involved in that who are the improvement support service in terms of commissioning both integration authorities have looked at commissioning and we have recommissioned some of the care home services some of them are currently under contract so Stirling's won't be due for renewal until later this year but we have done it in Falkirk we have commissioned jointly commissioned a new provider with a focus on discharge to assess and that has made a huge difference in terms of the Falkirk services in Clifmaninshire and Stirling we have re-barged ours as a quick step to be very clear with staff with providers that we're expecting a very quick hour to two hour response not a day to two day response and that has made a huge difference we have also initiated really a home first approach so when we're talking to families clinicians and others we're talking about people going home the focus is on going home, not remaining in hospital, not moving to other hospitals and not moving to long term care the focus other than those who absolutely need to do the focus is very much as patients I would tell you it's about going home that's what most people want to do in a supported way over the last year and a half worked much more strongly with providers we've established provider forums the strategic planning group itself also monitors there's a strategic planning group which is a multiagency group that patients, carers, service users etc are also part of also monitor our performance in and around discharges and support us with direct feedback from service user and carer experience so that there's a clear feedback loop I'll just come back in thank you very much for that the evidence that we've been given is awaiting place availability completion of care arrangements you mentioned that yourself and assessments also and there has been some criticism in regard to the fact that since the integration joint boards were established there has, I'm not saying blaming integration joint boards but basically the evidence you've given has improved with the integration joint boards and not the opposite that the increase in delayed discharge and unplanned bed dates just happened to coincide with the integration joint boards so as a panel or yourself would you say it has improved and given benefits to the situation? I think I probably should highlight for you a specific issue that we have just now we have a number of care home issues so some of the delays are relating to care home availability we were quite badly affected by the fire in the Fife care home which borders on the Concerned area and both Falkirk, Clitman and Sheram Sterling had a great number of patients in these care homes so that has had quite an icon effect because both Fife and ourselves have had to absorb the people who've been displaced through that process the other issues that we have is that we have a care home closure being flagged by one of the providers and we have a moratorium in place in one of the very very large care homes and we are working very closely with the both providers but particularly with the moratorium in place to improve those services and we are doing that with nursing staff from NHS Forth Valley and working with providers and I think that kind of gives you an indication of the improvement that you can have it's much more of a multidisciplinary approach and it's much more of a shared what are we going to do in order to make this improve, make it better and that also includes the work with the providers and the stakeholders just a small one thank you very much for that that certainly clarifies for myself and others exactly from the evidence we've given and the evidence that you've given I'm really quite pleased that you mentioned obviously the tragic situation with the care homes but also long term with care homes I presume it's bill that's closing in your area which we took evidence a couple of weeks ago at the health committee and it seems to be that maybe the pattern going forward so would you say that in your situation, the health board you find it more difficult to place people in care homes if they continue along this pattern of closing so what you've seen with building a number of others the care homes are very small they are financially quite challenging they are also challenging in terms of staffing and the people who are now resident in care homes even at residential level require very very high levels of care so it's not the way it was maybe five, six years ago where people were still, if you were reasonably you could go into a residential care home I would say there's probably very little difference between residential care now and nursing care and some of the work that we are doing and the board is just about the integration joint board is just about to consider we have some very small care homes it's about how you use those care homes to best effect so in clip manager and sterling we have used those for intermediate care beds to support rehabilitation to support people getting back up on their feet a kind of period of convalescence if you like and we have a £35 million investment in sterling care village which will include both the current residential and intermediate care facilities across the sterling area of clip manager and sterling and include some of the community hospital facilities so we are investing we are also we have a market position statement that we developed with providers and we are currently working through our commissioning strategy and there will be some tendering activity probably in the next 12 months in terms of both care homes and in terms of extra care housing and we are currently working with the local authority housing providers in terms of extra care housing and that's particularly paired to net and clip manager thank you thank you very much that's helpful Ivan did you have a question in this area as well? explore thanks convener thanks panel for coming along this morning yeah just drill a wee bit more detail on the delayed discharges there's some numbers in there that says you've had about 33,000 bed days I think in your paper you talk about the number of specific cases which I think is about 66 at the moment but it's been up or down 48 and that kind of range just to put that in context how many acute beds are we talking about in the health board? acute beds so we have only one site which is 4th valley royal hospital and when we designed the models around that we designed the models so that urgent patients and patients requiring elective were able to be seen equally so one wouldn't sort of gysump the other if you will so we talk about bed numbers and we talk about spaces of where for 23-year day surgery and things so our bed number varies slightly but it's probably just 650 and then obviously working with our health and social care partners but we also flex our accommodation during winter or any other need for community health we're talking about give or take 10% and then we're tied up in delayed discharges of one type or the other so what we're talking about for those delayed discharges are they typically 2 or 3 days or 2 or 3 months or where are we in that range do you have that data? It tends to be for the majority of delays, it's under the 4 weeks so we are performing within our partnership we're not hitting the target so I don't want you to think that I'm minimising that we are working towards that we're performing very well so we perform better than other comparator partnerships and we perform better than the Scottish average so there aren't many that are there for a long time? No, those that tend to be there are highly complex code 9s Do you know how many of those you have? Not off the top of my head at the moment but you're saying that the vast majority are moving That's good in the sense that what that says is you've got churn a lot of people coming in but those people aren't staying very long you're finding a route out for them it's not as if you've got a huge number of that 60 odds that are stuck for a long long time Across Forth Valley we have a low stay rate That's good So then moving on to the downstream part of this if you compare the costs what kind of numbers do you use for an acute bed night what kind of cost number do you have for that? A little bit and how much do you pay for a care home bed? A care home is £656 a week So we're talking about somewhere between £800 to stay in the acute hospital versus £100 a night to be in the care home There are some variations in that we have some very small care homes who are over £1,000 a week So we have some but it's not in the same Absolutely So just to get that in contact clearly the integration process was supposed to fix that problem whereby the money would flow and you would be able to realise the gains in the acute sector by spending a very very small fraction of that in the care home sector So you kind of talked earlier about care home capacity So is that the main block that stops you moving those 60 odd people out of the acute sector today? At the moment we have a temporary situation in our partnership with the auditorium in place in terms of care standards We are expecting there to be sustained improvement so we're in a period of monitoring sustained improvement at the moment and we'll review again at the end of January It won't take all of the people there are a few there are six people in our partnership who have highly complex needs who require specialist placements So they are on the delayed discharge list because they are clinically ready for discharge but they have special codes because of the level of complexity Right, so just supposing we made it where the magic was in that unlimited care home capacity in the area we are saying that practically all of those people apart from a handful could be moved out of the acute system Majority could be moved I think There are some that are waiting though you need to be careful I'm waiting for guardianships There's a legal process around the guardianship But you're telling me that's a small number in the scheme of needs No, there's a small number of highly complex cases and the majority in clipman insurance sterling are in relation to guardianships The majority that you're now seeing on our delayed discharge are guardianship situations Right, so back to the start There's a core process that's followed there I understand all of that I understand a lot the break-up of your 66 ones So I'll go back to the start of your 66 How many are complex cases and how many are guardianship or code 9 cases? So in clipman insurance the very complex are five to six cases at the moment so a very small percentage The vast bulk are guardianship for us The vast bulk are guardianship Right, and you said the majority of those you were moving through in less than four weeks the grouping that you're seeing here are the grouping that are delayed in their discharge are those who have guardianship or more complex needs No, I'm right I need to clarify here At the start we talked about there were about 60 odd people there and I said of your delayed discharge is how long are they staying Maybe I wasn't clear but what I meant was how long are they staying beyond the point at which they should move out Right, okay So the question was of the 60 odd people that are once somebody is available for discharge and they are then technically delayed discharge how long are they in that delayed discharge process for? So we will use some of the community hospital beds for some of these people too in terms of freeing up the absolute acute but they are still within and they legally require to be within an NHS system So how long are people stuck in systems for? Guardianship can take up to three months it will depend on how fast the private guardianships are particularly problematic and stilling has quite a high level of private guardianship So going back to the question I was asking if you have the magic wand, the unlimited care home capacity of those 66 how many could you move out tomorrow and how many are stuck waiting for guardianship issues I think the last time I looked at the figures which is relatively like yesterday I thought it was almost a 50-50 split So half of them could go out of those care homes so then you've got two problems you've got a problem with how do you streamline the guardianship process which is quite involved in a legal process but it could maybe be looked at at a micro level but then there's the issue around about the care home capacity now why are there not enough care homes in the system is there a cost issue there is there a false economy that says we could save £1,000 a day but we're not doing that because we're not willing to spend more than £100 a day I think that we have to think about our whole system and I know that you're looking for this point in time but one of the things about integration is about that whole pathway we know that if we can have early intervention particularly with older people we actually slow that process down older people want to be at home but they want to be at home we support and care and I think that one of the things that we're being challenged on in relation to that is that whole notion of isolation it's fine being at home but it's less of other things to spend your day with we have to think about that so as a partnership I think that we will be looking to we've started that by moving our front door in the emergency department for those people coming into our system particularly our older population our frail elderly we're actually saying to our social work colleagues who know these people can we take these people back home with an intensive package as opposed to coming into our hospital so I think that we've got work to do right across the pathway at care at home cost at care at home will be relatively less but I will look to colleagues who know the fourth valley situation so we've got a number of providers who actually come in and take those patients home looking at the figures as the new person I think that we've been doing intensive four visits but very quickly people get on their feet we put in additional support in terms of less support so to speak and that trails off but Shona, you have the figures to hand so the care at home again varies depending on who's providing it so the upper level would be somewhere between £35 to £42 and those tend to be internally provided services by the local authorities £35 to £42 per hour per one worker so some of the people who are being discharged are really costing that depending on how long they're in for so to get to a residential or a nursing home care level you would have to provide a sucker 35 hours a week in somebody's own care home so that would be the level that we use as a rule of thumb that brings you back to just about £1,000 a week kind of number because if you look at that a macro level of 33,500 delayed discharge days last year that would be £800,000 per day so that brings in a £25 to £30 million a year kind of number so that's the kind of eyes on the prize but that's clearly some kind of log jam happening here and we're trying to build on and understand that and if there's not enough people coming out of the care home market because you're scrimping saving at that end and missing the big prize I don't know if that's the issue but certainly I talked to care home people who had a very slight amount more we could open up more capacity in your kind of cutting your nose off despite your face I don't know if that's the scenario but certainly from the outside the kind of sort of looks like that I don't know if you want to comment on that We're also doing some additional work on models of neighbourhood care which is a bootsog type system and we have a pilot in one of the rural areas because sterling also has a huge rural hinterland so we're not looking at an urbanised area I understand that and there's lots of solutions to that so there are lots of solutions that we're working our way through in terms of both the front door and the frailty work and the models of care but all of them come in a fraction of the cost they all do, yes Can I just maybe comment a couple of things because I think it's already been highlighted the majority of our delays are not sitting in our acute system they're sitting in our community hospital beds and we want to change the model that we're actually using there so I don't think that that would be a much lower cost that we're talking about there I'm sorry I can't remember off the top of my head but it's much lower than because we've tried to keep the acute system clear of that the other thing to take into account it frees up that bit but it's also the bit about we've got across the system we've got to take account of the demographic change and the impact so it's not as straightforward as just to free up that bit but I mean a macro level is as simple as that I know there's a lot of work to be done on it but I think it's important not to lose focus on it at a macro level as well The last question that's been raised is that I suspect will be for Government rather than for the board to answer but we'll no doubt have the opportunity to pursue those questions one point that I'm aware of is that the numbers, the costs that you indicated for a night in hospital are perhaps higher than we've had indicated from other sources within the Scottish Health Service we may ask you further about that later when we write to you after the meeting We are not a highly cost effective system so I'm not conscious we are out with any normal parameters We'll clarify the details We'll come to the cost efficiency question in just a moment but that point will return to Miles I think you had one quick question Good morning to the panel I wanted to look specifically over the last few weeks when pressures obviously have been at their height and wondered about the number of cancelled planned operations within your health board if you had a figure for that and what was meant to be taking place I can certainly say from the third to the 15th of January we've had 19 cancellations when we compare that with last year it was 22 for that same period That's useful, thank you Of course here in terms of a point you raised earlier about the number of drug and alcohol people you have within your health board area you're looking after what I wondered the government's cut to alcohol and drug partnership funding did the health board meet that? I think it's the new person coming in that I was really impressed by the board's priority around that they actually didn't make a reduction in that priority and all boards will determine what their priorities are so from my memory we continue to put in about 5.6 million pounds into the partnership to actually support people in a very robust recovery programme so I think there's huge lessons for other boards from the work in 4th Bally I've been very struck by how impressive that is and just the staff newsletter I was reading in my way in about people who have been previous substance misusing people who have actually set up cafes and they're trying to get into worthwhile employment so for me that's a really good news story, it's really powerful and in short we haven't reduced the funding into the partnership I think we're just about to open our fourth recovery cafe so we've got three and again these are people that encourage and other people both in support and back into work and active community so we're really quite proud of that work and do you keep figures on referral times for people seeking that as well specifically do you have any data on that which you could provide I don't have it to hand all the targets we've been at 100% for meeting that and we have been for some time I'm looking at population wide some of the challenges you face and one of the things which I find quite interesting is some of the referrals into NHS Lothian for treatment and also where you lie between Edinburgh and Glasgow in terms of using additional capacity within NHS Scotland how's your experience of that especially given the figures around the 62 day white which you've recorded which is 64% do you find capacity isn't available with your health board area sitting at that level clarify the pathway you're referring to the referral urgent referral for treatment within 62 days so is that the cancer suspected that we're referring to so the way that serves your structure we all have specialists within our own complement of teams but there will be just because of the rarity of some of the presentations it will mean that we do need to work with regional teams and with tertiary teams and we have good links primarily to the west I think most of our patients are referred to colleagues within the west reaching but we have again with very specialised areas where we know we're going to get the best treatment for our patients essentially we will use those pathways which will take some patients to the east but it's not because of a lack of our resources it's just because of the specialised nature of those your submission states that some of this relates to local capacity issues so I wondered what they were then for you that probably rewinds into some of the earlier discussions about what's within our gift within that referral pathway to be able to to fix so that's why we're reviewing all the pathways reviewing all the steps in them but ultimately you've got the pathways of course from symptoms to somebody being going to test a diagnosis and it's only once you get the diagnosis that you then would know that actually you'd be referred out with the area to a specialised team what we can do within our service though is absolutely as you say is optimise that earlier part of it If I may just give an additional example around there's benefits and dis benefits but the benefits of where we geographically sit we've been able we've had particular challenges around radiology recruitment but we've been working jointly with Lanarkshire to make sure for example the breast cancer pathway has continued to be met because you need the radiologist and the consultant surgeon there at the same time and Lanarkshire have been very supportive to help us to keep that as a high priority and keep the pathway running for that Can we find the relationships given that we are this pretty bit in the middle between Edinburgh Glasgow we do find the relationships across whether it's regional networks or individual services to services the clinicians have fantastic relationships and we always find our colleagues if we've got needs for our patients sometimes having a delay our other board colleagues have got their own patients to see are incredibly supportive and understanding we do have to work really hard to make sure that in seeing our patients we don't knock the board off we have got the specialist colleagues there but again that works really well both at clinical and managerial level and if we do get challenges we will raise it within execs or the chief exec would have a conversation and to try and get the best for both sets of patients so that happens on a day to day basis because they're incredibly collegiate people do incredible things to care for our patients and that's the relationships that we have and we're all building different types of relationships with regional and some national planning some of our patients will need to be seen on a very national basis as Andrew's described okay, thank you you very much if we can now move on to the issue of efficiency savings and the financial targets that have been set for you within the review I wonder if Alison Johnstone would like to start and good morning Audit Scotland's latest report on 4th valley estimates that efficiency savings of 24 to 25 million are required for the next three years to meet your financial targets and that 10 to 12 million are at risk of not being delivered and I believe your own board indicated that 6 million pounds of savings will have to be met from non-recurrent sources I would be grateful if you could explain how you plan to achieve those targets and the impact you think those savings might have on services if I can pick up yes we have 24 million savings in the current financial year and you're quite right we have about 6 million pounds of that that we will be covering by non-recurrent means it is becoming increasingly challenging around finding additional savings I think I'll in common with most boards the additional routes have been we continue to pursue them but with diminishing returns around that the figure for next year is probably going to be slightly lower than we had originally estimated and so we're looking at the moment around about 18 million and I think that includes the 6 million that we've carried forward on it so we always plan to make sure that we've covered it is incredibly important that we have sustainable financial position and this is really the last couple of years is the first time we've hit challenges around recurrent savings areas that we are looking at are continuing to look at where we've got variability and looking at the big spend areas so you will hear and I guess in common with other areas that we look around our prescribing efficiency we did make significant improvements a few years ago in prescribing where we used to be one of the highest and we looked at other systems and what we were doing and we are now in the third lowest in terms of cost per head spend we still have some areas that we can go for there we look across in terms of energy savings and things like that we've still got some areas that we can go for but that won't address everything I think a lot that we are going to have to do and look at across the next couple of years is around the implementation of our clinical services review and our healthcare strategy to actually drive some of the costs out through that route so it will remain challenging I'd like to learn a little bit more about what those non-recurrent savings will be and you pointed out yourself last year was the first year you were unable to meet that target which speaks to the demand and the challenges that are faced given the many challenges 4th valley and other health boards are facing that it's largely possible to achieve these savings you are delivering demand-led services and that demand is increasing you've got £25 million off can you become £25 million more efficient without impacting on the services you're able to deliver and I think that that's part of the challenge for the management team we have to deliver financial balance it's a statutory requirement so we're clear we have to live within the resources we have available we're very clear about balancing performance and meeting our performance challenges as well as making sure our quality so we're very clear about the three strands around that so we keep the focus on that and it's looking about different ways that you can deliver it's looking at what you may be possible in the community around some of the outpatient services that you can use technology for that might be able to be delivered that way if that means that people don't have to come to hospital which then can free up capacity to meet some of the demand so it's looking on a much wider basis it's also looking at how we can help through and this is longer term it's not immediate around some of the prevention agenda to try and take some of the pressure of the system and that's quite difficult you heard us keeping some of the priorities we did the same around well etc to keep our priorities in the prevention agenda to make sure it was trying to help minimise some of our demands I mean this is and family nurse partnerships along with the EDP and other things we really wanted to try as well to deal with the demand and meet the savings but actually to be a bit more thoughtful about the future in terms of where our priorities were as a board I mean I think that question that tension also between prevention on the ground when it's needed is one that I think this committee has been discussing for the last couple of years Miles Briggs and I visited an access practice earlier on this week and there's a clear feeling there that many of the people we met who were in their 30s might not have been in the situation they found themselves in if there was greater emphasis put on early intervention for example do you think we're getting that balance right yet in health? I think one of the challenges that we face as a national health service is sometimes short termism and I think we have to think about so what is the long term strategy if we're really committed to prevention how do we intervene that's starting well, the links to schools I think looking at targets sometimes they're very single and I think we have to think broader than that where we actually have a picture of targets that actually make up so what is it that we're trying to achieve in terms of outcomes a link to say starting out well as a child so that we actually slow things down or we actually reduce expenditure but the other thing just going back to the original question about savings I think we had a very good debate in relation to delayed discharges and if we did things differently what could we actually reinvest so I think we've got some work to do in terms of how we actually respond and reposition the investment as we go forward it works really hard every time in some of our IJBs to have prevention at the heart of what we do and just in a very simple thing you talk quite a lot about governance today the board starts with patient experience and patient safety we look at our infection control and we always have a health improvement and prevention topic so the board is really trying with everything we do to do the demand led as well as transforming what we've described, health and social care integration but really try and keep the focus on prevention in the board particularly our non-execs are challenging us all the time to do more and more of that and we're just trying to balance those things and some of them will be very long term as you've described in the example you've given but we do have a focus on that it's just how you do that at scale which I suspect all of boards and probably for a wider discussion are really struggling in how we make that much much bigger than the good work but if I could in terms of patient safety just to give you an example so when patient safety was launched I think and clinical colleagues would keep me right about 2008 we're now reaping the benefits of that huge improvement programme where we're actually reducing through prevention in an acute sector infection and so on so there is real things that we can do but sometimes that takes a long time and it's having that commitment to the long term and having that compelling vision that actually moves us forward in a way that we can demonstrate that we're making improvements as well as adjust as we go along because we want to be as flexible as possible to get those improvements coming forward thank you I think the committee would share the aspiration to prevention and long term thinking however there is an immediate challenge to make those savings and we've heard some of the challenges facing you in a number of fields what do you envisage what do you expect the impact on services to be of the savings you're required to make in the next few months I'll refer to Fiona in terms of but we have choices to make every health board has choices in terms of discretion we spend and we do that in terms of if we slow that down what's the implication on that and we make those decisions almost every day but in terms of the fourth valley situation Fiona will have in-depth information that probably I don't have so forgive me we're trying to minimise the impact on performance I was trying to stress that we are very clear that we have the three strands in terms of performance, quality and finance we do risk assess all our savings are they deliverable or not but what the impact is on performance so we're trying to look at and we've been putting quite a lot of focus to ensure that we've got engagement with our clinical community around benchmarking et cetera and where there might be benefits again it's a bit about looking elsewhere so we're using discovery system for example to say and that's at clinical level it's not the exact round here it's the clinicians looking at their performance and also I know Andrew has been leading around our look at realistic medicine and quite how that might be able to it's not about direct cost savings it isn't a cash saving target but actually over time that gradually change and helps to manage demand and helps to manage performance again we'd look at where we're out of I'm looking to go back to prescribing so again we look at primary care prescribing and where we're out of line or we've got variability across the system so that we reduce that variability we also invested in the HEPMA system around secondary care prescribing cos the data has been there in primary care but not in secondary care to the same extent and we used a lot of the data in primary care to help drive that change so we should start to see the benefit of that that's now embedded in our system so it means that the clinicians can see very clearly across their specialty what they're spending and that can bring benefits cos it's one of our high spending areas just an example around how we use our current resources so in terms of we worked really hard to make sure that the nursing and midwifery nursing establishments are safe and effective the cabinet secretary had launched the safe staffing legislation in Forth Valley and what we've shown we may not have the highest amount of nursing numbers in Scotland for example but what we've got is safe staffing levels and our nursing staff on the wards and departments can demonstrate through the quality of care preventing falls, preventing infection as the chief executive has mentioned caring for people and matching those nursing skills if you will with direct patient outcomes and that allows me and the board are very supportive of a range of things they've not been cutting staff posts and all of those things we've really tried to as Fiona said deliver on the services where the board can see using evidence based tools and also see the care that the nurses are delivering and what matters to patients where the investment should be and again the board have protected and supported that and a range of things and the nursing can't be obviously ring fenced or excluded but actually what they are able to do is look and see what kind of care we're delivering what that cost, what does that is and what's the consequences of that and if we did need to make changes I could go to the board and describe the impact on services on such a large large important workforce as an example of using our resource as well Thank you very much The committee is also very interested in the issues of governance and I would ask David Stewart to Thank you convener and welcome to you all this morning Angela Wallace earlier mentioned the issue of governance I'm very interested in governance particularly in your own audit committee and as you will know none of your council-appointed members have attended any of the audit committee this year, why is that? No, this year but we have one elected member on the audit on the audit committee now since elections in May there has been there has been regular attendance from the elected member on that committee prior to May I wrote to all the chief executives pointing out the responsibilities on the councillors and they should take that into account when they are appointing them so I think we've changed the actual culture on that I'm glad to hear that have you specifically addressed this at formal board meetings about their non-attendance previously I've dealt with I've spoke to the councillors individually the new ones that were appointed I wrote to the chief executive council before the elections for the appointed new elected members to the actual board now the actual commitment so I think we have addressed that issue You currently only have one councillor representative on the audit committee, is that correct? That's correct, yeah So previously did that affect the level of scrutiny or debate that you had when you had a no-show at the committee? No, we have other non-elected members we have other non-executives as well, of course one councillor it's part of the non-execut But clearly the councill representative is very important because I suppose there is an argument and I'm glad it's now being resolved that who guards the guards if you don't have these people attending there's an empty seat, there's no debate I can assure you all our committees that the scrutiny is intense we are well represented we get good quality information for us to do our job of scrutiny particularly at the Policy and Resources Committee and the Clinical Governance Committee we have our own scorecards and the information goes well beyond the statutory performance indicators we look at what's important to patients or performance and make sure that we monitor that and we get regular reports What's the tennis like for other members of the audit committee since the council election? It's good. There's no problem there If there's any failures in terms of attendance or contribution what systems do you have in place to remedy that? Well then the cabinet secretary appoints a member presumably if a member wasn't attending then I would speak to a member if that didn't improve then I would probably speak to the leader of the council I had to go down that I spoke to the chief execs and I wrote to the chief execs and I spoke to the new members when they were appointed to make it quite clear what their responsibilities were other than the member that you referred to we didn't have a problem with the other elected members in the previous administration There are other committees because she said there's only one member They are represented on all our scrutiny committees and they addressed it because clearly having a well-functioning audit committee is vitely important so I'm reassured to hear that Thank you very much One of the aspects in which clearly the relationship with local government is particularly important is around integration joint boards and there's been some discussion of that today Can you tell me when this year's budgets were set for the integration joint boards and also the integration joint boards Budget was set on time it was set in March for 1 April We are on track currently to set the final position will be on 28 March for 1 April Thank you Some of the comments we've heard as a committee in general around integration joint boards is that at the world level at the hands-on level at the different cultures that local government and NHS bring together can work well but sometimes it becomes more difficult as that goes up the chain of command I wonder if there's comments from either the joint board perspective or indeed the health board perspective about how that marriage of cultures is working within the boards as a health board we're committed to making the integration actually work well with the actual local authorities there are discussions going on between health board chairs and chief execs to improve relationships at a national level and we will learn from that exercise but we're all committed to making it work we've talked about efficiencies different ways of working and we have to support more people in the community if we're going to give people a good quality life and care for them safely and that requires good interactions between the council and health we're totally committed the other area that we're committed to is community planning so we have very good relationships with the local authorities and with them there are a lot of good examples of joint working she wants to speak about the working at her level because I may be just making an observation of somebody coming in new to 4th valley obviously I started in 3rd of January but Alec and my chairman in Orkney allowed me to attend a number of meetings I was very struck with the transparency and the challenging conversations because challenge is a really good thing to actually make improvement between the organisations and at my last Falkirk integration joint board there was a number of key actions that I thought were really very promising but I suppose and reflecting in the 4th valley landscape that has been a track record of integration both at community planning level and with council colleagues the care village is just an outstanding example of that where people have actually invested because we can talk integration unless you see actually being played out in action and somebody new coming in that would be my observation I'm not worried about integration I actually think we can actually take huge steps forward to actually make the changes that we know need to be done around the care pathway to support people in their own homes I think ours is an unusual partnership in clip manager and sterling local authorities and so we have to work I think probably a little bit harder than some other areas to make sure that the variable cultures and the variable priorities that sometimes push and pull are taken account of and as Kathy has said that there is robust discussion our IGB is chaired by the leader of sterling council who is extremely committed to the board and to integration and I think that that's a good signal because it's not all true of all of the integration joint boards so they are signalling by presence and by commitment and by the robust discussions that we do have and it's a challenging atmosphere to be working in but if you can keep the dialogue going and we have managed to do that we have managed to set the budgets we have managed to have pretty challenging discussions about priorities and about stresses and strains around in the system and found a way through there's nearly always a pragmatic view of finding a way through and I meet regularly with the chief executives in order to keep that dialogue going and to make sure that we we have a rounded view and a single view of the direction of travel Just thinking about the connection to the wards which is a very important area yesterday the cabinet secretary visited NHS 4th valley and that was a discussion we had actually with the clinical team that was one of the questions I posed was as an ED team what have you seen that's a direct result of integration or have you seen anything and they were able to see that team down there that help people get home if we don't think they need to be admitted that was a direct result of the communication around integration so that for me was really interesting hearing that very visible and associated with how we were working differently when Andrew and I were with the cabinet secretary yesterday who was listening to staff about how well they've been dealing with flu and other things. I've heard an ED consultant say if I had more money to spend I would spend it in keeping people safe in their communities and my colleagues are incredible but within that zone of caring for patients sometimes the wider aspects of that but actually an ED consultant was saying we need to shift that balance we need to prevent people coming in here unless they absolutely need it and it was really really heartfelt and I'm not sure I would have heard that even two years ago it was really really really powerful and how do you as a board or as IGB how do you hear from the public that you serve IGB has an engagement strategy and has regular engagement we still have the public forums in place we've got the community planning partnership networks and there's regular contact we also have the strategic planning group that has a cross cut of all of the stakeholders including service users and carers and there's feedback there there's also individual feedback through service feedback loops that we already have in place some of those members of the patient and public are active in our patient and public panels in our inpatient services so they're bringing that experience from across 4th valley to the IGBs as well as in these other voice of what matters to people when they're receiving services so we have tried to integrate our active engagement in patient and public involvement whether that's in our service user whether that's in mental health or helping us make sure people wash their hands is really active and they're all linked to that process thank you very much my final question and I'm looking around colleagues that there are no other final questions lurking my final question is on accident and emergency performance over Christmas and New Year and you will know that the latest figures indicate 4th valley had the poorest performance over that period against the four hour standard clearly would be important to get in the record what you have to tell us about that and how you intend to address it going forward is the new person coming in before I invite Andrew just to give us some more details I think I've been really really struck my first day in 4th valley I spent in the ED department meeting staff and as a nurse by background I was really struck by the calmness and the organisation around how we were looking after patients 4th valley actually had gone out and bought extra beds so that people didn't have to wait in trolleys and I just thought that was a huge example of just the kind of commitment to good patient experience the other thing that I was really struck with was the near patient testing and it made me think about targets in the sense that 4th valley was putting care first they were putting treatment first and target second and while targets are extremely important for me with that clinical background I saw first hand clinicians social workers the whole team working hand in glove to make sure that the patient experience for those people who needed care urgently and I made it a point to actually write to patients who waited longer who had to wait that bit longer who were less urgent if I can put it like that everyone always feels they're urgent but for those patients coming in who really need attention there and then care was our priority and that was just great to see Thanks Kathy I'll expand a little bit on what Kathy alluded to there when she referred to near patient testing I think it's important to remember that in the context of the figures a lot is a four hour emergency access standard what that means is that there's actually lots of things happening within those four hours it's four hours to complete that episode of care so people are being seen, they are getting tested they are being treated and then decisions made about where they should go thereafter but yes, when we look to those figures at the beginning of December and when I say look up, this wasn't a look back we were seeing this very actively a lot of us are very involved in day to day in monitoring of how we're getting on what our assessment areas are like when we saw what was starting to unfold you're right, it was gravely concerning because we understand exactly what Kathy says that's the impact on the patient's experience which is compromised then so we needed to find out rapidly what was happening we've seen through the weeks in December just the evolving picture which culminated at the end of December and particularly distressed in figures what we've found, what we've discovered is that obviously flu is everywhere and everyone's reporting usually increased numbers I've been around winter planning for the last few years and we've planned every year for flu but this is the first time we've seen the kinds of numbers that people have come in so when people are admitted to hospital with a diagnosis of flu there's a couple of parts to that firstly that's not health usually people who have no other health issues usually there's other what we call comorbidities so people who are coming in have other illnesses and so are complex, so flu is part of that and what we've seen as a direct result of that we've seen our length of stay for people with respiratory specialties we've seen that go from last December from four days up to this December of 14 days so we've seen a huge impact from that group of patients because of the complexity so that's one factor the other factor to refer to Cary's point near patient testing so what is that, that's a diagnosis of flu within half an hour of turning up at the front door of the hospital previously, so in previous years this is a brand new development this year previous years that would require a diagnostic test to be sent to an external lab and the results would not come back for a couple of days why is that important because if you're making a decision about where someone can go so firstly it's important because a patient then knows their diagnosis and more importantly the staff is welcome to try and implement our infection control policies to minimise the spread of that flu but that's a step that we weren't we haven't been faced with before because we now know somebody's got flu A or flu B, RSV and we could look across our capacity our bed capacity and we could see that actually know this person according to our algorithms, our guidelines that person can't go there, they need to go there and there could be a delay inherent in that so once we saw that start to unfold our policies needed to be different needed to be a bit more flexible and Kathy very quickly, even in the short time she's been able to ask us to look at that again just to see about our decision making and we think we've improved on that but that was a very difficult month and a very difficult month for our patients what we've seen subsequently is that our performance has improved it's been up to it went from in the high 50s it went up into the 60 per cent in the following week it's now up into 80 per cent and in the weekend it's gone actually our performance was well over 95 per cent so it's in the high 90s so we think we've improved a lot of the system a lot of other things have happened over the weekend it's been helpful but actually we think we've learned and we've improved what we're doing Will it therefore change any aspects of your winter planning? Absolutely, I mean it's part of any winter planning we would do a debrief I mean we've had to adapt to this as we've gone so I think we've got the process in place we're reassuring that we are continually monitoring where things are working well and not so well but we will do a formal debrief as well in winter and this will need to be a key feature of what we decided to do next year absolutely The chief executive described and Andrew's alluded to and I was in the hospital on boxing day when the flu numbers were spiking and we were coming in and people were very understanding of the delay although we were trying to minimise it but what we have seen is that our staff were really really calm really really supportive we haven't had patients being assessed or lying in trolleys so there was the A&E department just to get the patients that Andrew described out of A&E into a safe ward so they were not mixing people with flu A or flu B because actually patients we know can get the three types of flu or quite vulnerable as Andrew described so it did take us slow but we started to re-establish flow and get that much quicker but the patients and the families understood we were keeping them informed they understood about the testing the testing is a gargle wash so the patients were participating in that and they were understanding why we were moving patients were coming in we were popping masks on them in our assessment areas so we could prevent any spread of any types of flu to other patients about the cleaning of our facilities and how that gives people confidence in us as a board and their environment and the cleaning services whether that was Christmas Day, Boxing Day and all the days in between including the holidays we're coming behind the staff, the nurses and doctors in terminally cleaning places so we could free up spaces for patients so we appreciate we need to do better but actually our staff and as Kathy said really really difficult situations ambulances coming up our patients were being brought into the department looking after them, not in corridors, not in trolleys and those who were waiting long they had full nursing and medical care during that time so we would like to reassure because otherwise we would be doing a disservice to our staff who were absolutely incredible which is why the cabinet secretary came out and thanked them and they really appreciated that and we have done too but that might have meant a bit more than us keep saying thank you I think looking forward so we have got a single target of 95% and I think maybe we need to reflect on the the patients coming through you know is there an opportunity for us to actually think about reducing that standard in terms of patients who are actually presenting with minor injuries and being very clear at the outset about redirection and so on in Forth Valley because I as chief executive and I know my clinical directors will share this it's making sure that we have a very safe system and I would like some measurement around the safe system and are we actually caring for patients in an appropriate manner so I certainly think as a health board we would want to reflect on that and that will actually help us decide about where we actually invest in the future in terms of is it the out of hours, is it you know there will be huge data that will come forward in terms of us actually prioritising going forward and presumably that's something you could do without waiting for and definitely absolutely and we've actually started doing that redirection but we'll learn from that intervention understood a very final supplementary from Emma Hart it's not too late to get the flu vaccine and NHS staff members and social care staff members should get the vaccine are you doing anything to encourage the staff to continue to take up the vaccine? yes are you monitoring the percentage the numbers? I think it was the 4th of January we had about 40 per cent of our staff I think just that raising awareness and the public domain people are now stepping forward I think the other thing that we're doing in Forth Valley we've actually asked our public health colleagues just this week is to actually use patients attending hospital to have the opportunity to well we can offer the vaccine whether it's out patients, whether it's at risk groups so that we're actually targeting patients coming into our services GPs are doing that but we've actually got an audience of patients that we could actually really be promoting that so we've kind of ratcheted that up and we hope that that will actually increase our figures even more thank you very much that's been very comprehensive you've had a lot of answers to give and we've welcome the fact that you've done that after we have a discussion we may have some further supplementary questions right to you with those in the next few days so thank you all very much for your attendance and I conclude the public part of the meeting we will now move into private session