 Dwi'n gweithio ar gyfer y 15th ynglyn â'r Gweithneidol Ymwneud Cymru eich 2018, rwy'n gweithio i'n bryd i'r ddechrau bod yn cyd-gweithio'r gwyllwyr o'r rhaid o'r cymdeithasol, ac oedd i'n gweithio'r cyfwyr o'r ddweithio'r gweithwyr, ac mae'n gweithio'r gweithwyr o'r ddweithwyr o'r gweithwyr o'r gweithwyr o'r gweithwyr o'r ddweithwyr o'r gweithwyr o'r gweithwyr o'r gweithwyr o'r gweithwyr o'r is an evidence session with representatives of NHS Greater Glasgow and Clyde as part of our programme of taking evidence from NHS boards. I welcome to the committee John Brown, CBE, the chairman, Jane Grant, chief executive, Mark White, director of finance, Dr Jennifer Armstrong, the medical director, Jonathan Best, interim chief officer for acute services, and David Williams, chief officer of Glasgow health and social care partnership. Welcome to you all and can I invite John Brown to make an opening statement? Thank you for this opportunity to share the work of Greater Glasgow and Clyde. As a convener, I have already done the introductions for my colleagues. I just would like to pause just before I start and put on record how privileged I feel to have such a strong senior leadership team. Greater Glasgow and Clyde is the largest of the Scottish health board. In fact, it is the largest healthcare organisation in the UK. To have such a strong leadership team makes all the difference to the role of the chair and the role of the board. Obviously, being such a big organisation, we submit documents to any committee to explain our business to a considerable amount of information to try to get across. Hopefully, those documents will give me some insight into how the board has responded to the challenges that are faced by all the healthcare providers across the UK. The documents have mainly described the current situation, but as this committee is very well aware, the changing demographics, the ageing population, combined with a lot of other factors, including, for example, the shortage of some specialist skills in the clinical world, means that all health boards have to change if we continue to deliver the high-quality services that we aspire to. I hope that you do not mind me using some notes. I will try to keep it fairly short. I was interested when I looked at some of the other presentations that other boards have made to the committee, just how short some of my colleagues have managed to make it. Unfortunately, because of the size and the complexity of Greater Glasgow and Clyde, mine might just be a bit longer than you normally have, but I have some notes to try to keep me on track. Before moving forward and looking at our plans to transform health and social care to meet the increasing demands that are on the system, it is probably just a couple of minutes, if you do not mind, to describe who we are and what we do and put it into that context. Population, we serve at 1.1 million people. It is across six local authorities, which is one of the reasons why, of course, there was so much briefing paper coming forward. We employ around 39,000 people. We are the biggest employer in Scotland, and we are located across 10 hospitals, 61 health centres, with around 115 care homes currently, 237 GP practices. Given where we are positioned geographically, 87 of them are in the top 100 most deprived areas, so we have 87 depend practices. I am sure that you will be familiar with that concept. Big organisation, a very big budget, and over £3 billion annually of the taxpayers' money that we are responsible for. As I said, that makes us the largest healthcare organisation in the UK, and we represent almost 25 per cent of NHS Scotland. A large demand on the system, a large number of patients, service users, their families and their carers are looking to us to support them. We have almost half a million visits a year to our A&E departments, which is high and disproportionately high, if you think about the size of the population. We have over 200,000 scheduled in-patient appointments and 1.1 million out-patient appointments in a year. Five million people in Greater Glasgow and Clyde go to their GPs every year, and we deliver over 15,000 babies. We have 24 million prescriptions in our part of Scotland. The Greater Glasgow and Clyde is not just about the geographical patch covered by six local authorities. We also provide specialist services for either all of Scotland or for the population in the west of Scotland, so we have things such as the national spinal injuries unit, the paediatric intensive care unit, and the national bases. We also have the Beats and Western Scotland cancer centre. We have significant training boards, so we do more than simply deliver the services. We continue to grow the capability and capacity for NHS Scotland. We have around 1,300 doctors at any point in time in training across the board, and we support 800 medical students. There is a lot of good work done with Greater Glasgow and Clyde in the universities. We do a lot of clinical research. We work very closely with Glasgow University, Strathclyde University, and we also work with the private sector, and we deliver over 900 clinical research studies in a year. We are at the forefront of R&D. At the forefront, I would like to think of the work to deliver the health and social care delivery plan. Our priorities are four key aims—better health, better care, better value and a better workforce. You will have seen the triple aims, and a number of organisations and papers would describe them as better care, better value and better health. We have put better health first on our list because of the priority that we think it needs to be given to prevention, to improving the population's overall health for the future, and we have added better workforce because we clearly recognise that making Greater Glasgow and Clyde a good place to work—in fact, a great place to work—will help us to recruit and train the best-quality staff. That is who we are and what we do, but the real question is what needs to change and what we are going to do differently. We want to move from treatment to prevention, so there is a real emphasis within Glasgow and Clyde on public health. Clearly, we want to maintain and where possible improve safety and performance and equality of care. One of our big challenges that faces all health boards in trying to move to a new system of integrated health and social care is how we move resources out of acute care to primary and community care. Of course, like everyone else in the public sector, it helps no different. We have to live within our budget allocations. I am pleased to say that this year, once again, we delivered a balanced budget that, given the size of the budget and the complexity of the system, is at no mean feat. I credit to my colleagues in the senior leadership team, and our expectations will do likewise this year. Living within your means is never easy in the public sector. I have been 45 years in the public sector, and that challenge has always been there in every year. I think that it gets harder. For us to stay in financial balance, I think that it is realistic for the taxpayer to expect us firstly to be as efficient as we can with the resources that we have. We have done a lot to reduce our costs, reduce waste and improve productivity in the current system, but that is an on-going process. In the current year, we are looking to save around £40 to £50 million out of being more efficient. We think that that is doable. We have a good track record in that regard. Last year, our efficiencies overall were just over £60 million—£40 million of that coming out of the acute services. In addition to being more efficient in the current services, we are also looking for how we can do things differently and how we can deliver the new system. We have invested a lot of time and energy in thinking into our transformation programme, which we call Moving Forward Together. It is called that to emphasise inclusive nature of it. It is being designed by our clinicians. Our involvement of our staff is very important to us to get the design right, but the involvement of our patients or service users is equally as important as is the involvement of their representatives, which is why today I think it is a good opportunity for us to talk a wee bit about what we are doing looking forward. The approach, as you would expect, is based on an analysis of the population's existing and future needs. It is very much research-driven. It brings into the play of the latest thinking around best practice in health service delivery, not just in Scotland but across the UK and wider. It conforms and supports the direction set by the health and social care delivery plan. Dr Jennifer Armstrong, our medical director, is the person who we have asked to lead on the redesign of the service. She has been working with her colleagues across the different specialities and the different clinical groupings to look at what is the best way to deliver it in the future. I am sure that Jennifer will be happy to talk more about that. We are not just looking at what we do from a Glasgow and Clyde perspective. In line with health and social care delivery planning, we are also looking at what we can do to support national changes and what we can do to support regional changes. Of course, they have been the biggest resource in NHS Scotland. We have a big part to play in it. All of my senior team have been involved in national and regional planning work. It is a good example of how we are taking that forward. Of course, nationally, we are looking at developing a major trauma centre for the west. We are looking at adopting a more regional approach to cancer services and introducing a west of Scotland renal transplant service. While we are working with our colleagues to develop a population-based approach, it is best to describe it to deliver on those services. Of course, there are pros and cons of that. It means that some set of services will be centralised into centres of excellence, which will make them physically less accessible in the sense that they are perhaps less local but have a better quality service and are looking to provide better outcomes. That is an issue for us in how we engage with the public and we get the public on board with what the benefits of making those changes are at the earliest possible stage, how we engage with the public at the earliest possible stage in the design of the services so that they can meet their needs, as well as make the service delivery that more efficient and effective. It is getting that balance right. That is what we have to do. Of course, when we look forward, we cannot take our eye off the ball of the hearing now. We have to recognise that we need to do more in our current services. There is a lot of energy that goes into trying to improve current performance. We need to do more, as the papers have shown you, in relation to elective work. An example of one of our areas of performance that we are doing a lot of trying to get up is the number of patients who are waiting longer than we would like before starting their cancer treatment. The 62-day target—we are familiar with that terminology—is one of the areas that we put a lot of effort into. Of course, on schedule care, we have done a lot of work over the last year to improve on schedule care. We have stabilised our performance at the front of the hospitals, but it still needs to improve. Again, our chief executive and chief operating officer are more than happy to talk about any particular issue around their current performance. I am very pleased to have David Williams with us. David is one of the six chief officers for the health and social care partnerships. David has the largest one. He is the chief officer in Glasgow City. David will be happy to talk through any issues around health and social care partnerships, the setting up of the IJBs and so on. He will cover all six, not just to Glasgow one. Of course, having six local authorities, having six health and social care partners, six integration joint boards brings challenges, as well as opportunities for us. We have put a lot of energy since the IJBs and the IJBs came into being to ensure that the work of the IJBs and the IJBs, the health board of council, are all consistent. They are all heading in the same direction that they are integrated. For the integration joint boards in particular, they support the delivery of the health and social care delivery plan and the aims and objectives. The integrated approach that we have obviously presents a governance challenge. It is an integrated organisation with more governance boards than we had before. We have reviewed and revised our approach to governance and have brought together the full system at the sub-committee level within the boards. I can talk more about that. I think that you have laid out quite a number of the challenges that we are going to want to explore with you this morning. You talked about the need for change and one of the mechanisms for achieving change clearly is the annual accountability review. Those set out in the short term over 12-month periods what it is that you need to do in order to improve performance. I would perhaps start with some questions on those. Can I ask Alec Cole-Hamilton to ask a couple of questions? In particular, I would like to take our focus to waiting times and particularly the 12-week guarantee, which has been exceeded for both in-patient appointments and out-patient appointments for the number of people waiting more than that 12-week is doubled in the last year in both cases. This committee understands that one of the principal reasons for that delay or waiting time delay in any health board is about demand vastly outstripping supply. We accept that, but one of the biggest interruptions in supply is delayed discharge. Yet you are the best-performing health board in the country in terms of reducing bed blocking and delayed discharge. That does not seem to scan for me. Can you explain to me what is causing that delay in treatment for all those people if it is not delayed discharge? I think that you are right in identifying that the challenge is how we match our resources with the demand and the different demands that there are on the resources across the piece. I will invite Jane Grant to talk a bit more in detail about the work that she and her team have been doing to try to baseline what our capacity is and how we can actually improve and increase that capacity to better meet the demand and how we can target our resources to the particularly high priority areas that are within the treatment time guarantee space. I will give you some oversight and maybe Jonathan, who is dealing with it on a day-to-day basis, could give you some insight. One of the challenges, as the chairman has said, is that we need to balance the elective work with the unscheduled care demand. That has been a challenge for us, as you can see from the figures. We have spent some time this year looking at our baseline capacity in terms of looking at the number of clinics that we have got, what the clinic templates are, what the actual demand profile is, and they are different for each specialty. In some areas, there has been a significant gap because we have on a non-recurring basis been covering that gap for a number of years. The challenge is to get to a recurring balance for that. It has taken us a little while to get to the absolute detail of how many theatre sessions there are, how many clinics there are, when they start, when they finish and what that looks like. We are now well down that road and we have made significant progress in establishing that baseline capacity that we have. You refer to delayed discharges, but it is not all about beds. There are some areas clearly where it is about beds and we have work to do there, but the delayed discharge work and David and others might pick up on that. However, we have done a lot of work with the six partnerships and the board to deal with that, and as you see, our performance in that is good. However, the capacity gap in patients in day cases is much more than just the beds. It is about the resource that we have, the theatre sessions that we have, the manpower that we have and the workforce that we have. We have to look at what workforce we have and what physical capacity we have as well. Our focus has been on making sure that we have an efficient service and that we are actually being able to prove that the productivity and efficiency within the baseline that we have got is correct. We are also looking at redesigning some pathways and doing things in a different way, as well as the traditional additionality. We believe that that tripartite approach will get us in a much better position during this year. I do not know, Jonathan, if there is anything that you want to add to that. Thanks, Jane. A couple of things to add to that. You are absolutely right. We have stepped back and looked at a written branch review of the capacity that we have just now and how we can fit that capacity to the demand that is being referred into our hospitals. We have taken each specialty, we have taken how many clinics we have over a year, we have done it consultant by consultant, and we have looked at our ability to maximise the use of the clinic slots and clinic sessions. We are also looking at ways to redesign. One of the exciting opportunities is the modern outpatients programme, which you will be familiar with. We have a number of streams of work going on in that. One of them is to mention patient focus booking, which is giving the majority of patients a choice of when they come to hospital and what time. That opt-in process through our referral management centres has certainly proven popular and it avoids wastage of appointments and allows us to maximise what we provide to the patients. In terms of how you manage those patients waiting longer than 12 weeks, the health boards that seem to do best around that are the ones that capture, at a granular level, the reasons why people are waiting longer than the 12-week guarantee. They set them up in a register and then they talk about what they are going to do to mitigate those problems or interruptions in the future. Do you do anything like that? We look at the waiting lists on a regular basis. We look at the urgent slots and make sure that patients who require urgent care are dealt with first. We are looking again at the cancer slots to make sure that we have enough capacity to do that. Our boards access policy talks about clinical priority and then in a date order. One of the challenges that we have across Glasgow in Clyde is that we are a very big organisation. We have a number of places where people can attend for an orthopedic appointment or so on and sometimes that demanded capacity in the sector does not balance. However, we have to be cognisant of the fact that people in Clyde perhaps do not want to travel to the royal family. We have a bit of work to do about trying to smooth that pathway and make sure that patients have some choice but that they have access quickly to services in their local area when they need to do that. That is some of the work that we are doing just now. That example that I was going to give is for a more wider example. As you know, the chairman has mentioned that we provide services for the region but also for some national services. We also support, for example, the Western Isles. We have a recent pilot project that started through telehealth and video conferencing. I was over at the Royal Infirmary in Glasgow and one of its orthopedic surgeons is now holding his whole-day clinic via a video link to the Western Isles. In the Western Isles, there will be a physiotherapist or a specialist with each of the patients, so it is a whole-day clinic. Therefore, all of the patients do not need to travel down to Glasgow. From that particular list of about 20 to 30 patients, I think that seven were listed for surgery, which is a very good and efficient way of running the service. We need to do a lot more of that, so we are not only managing the lists but we are managing how people come to see us and how we anticipate their needs. Final follow-up question briefly, if I may convene it. I think that the other thing that I would be keen to hear about is expectation management. There is an MSP for Edinburgh Western. I get a steady stream of constituents through my door with letters from the health board that say, yes, you have been scheduled for surgery or treatment of one kind or another. You can expect by law to be seen within 12 weeks, but sometimes exceptional pressures mean that that slips. Only to find that they get another letter a few weeks later saying, actually, it is not 12 weeks, it is nine months, you are going to have to wait. I think that there is something terribly cruel about that expectation management. I have taken that up with NHS Lothian before. How do you manage expectation in terms of when you know that you are likely to miss the 12-week treatment guarantee? You are absolutely right. The patient management system that we have generates letters automatically and makes sure that the correct date is given to the patients. In Glasgow, over the past year, we have changed our correspondence with patients to be much more upfront and open about when the dates will be. We provide advice lines and phone numbers so that they can speak to someone, so they can speak to not just a receptionist but one of the specialist nursing staff, or indeed a doctor if they need to discuss their condition. That is beginning to bear a bit of fruit, but it does not detract from the fact that it is a longer wait for some patients. The cabinet secretary set you some specific targets for this current year. She said that the waiting time standards for outpatients and inpatients should be no worse than they were last year. She said that the four-hour accident and emergency wait at Queen Elizabeth hospital should be achieved in at least 92 per cent of the cases. You missed all of those targets, partners have gone the opposite direction. Was she unreasonable in setting those requirements? I think that, as we have explained, the elective position has been difficult. There is no doubt about that. The whole of Scotland has found it difficult. We have spent, as I say, some time trying to get the baseline capacity to build that, because if we just keep on doing more and more additionality, then actually we will never crack. We have spent some time this year trying to actually establish what capacity we do have. We recognise there is a lot to do. We recognise that there are a number of initiatives that we have talked about already to try and deal with that. We have looked at the operational plan for this year and signed up to returning to the March 17 position, with the exception of outpatients where we are going to try and do over two years, because it is very significant. In addition to that, we will have to balance that with the ED targets. We are making sustained progress with that, albeit that the increasing demand coming through the emergency flow is proving to be somewhat challenging for us. We have work to do through our unchedul steering group across the board, which includes partnerships to try and change and alter those demand profiles. The complexity of that picture across the size of Greater Glasgow and Clyde is not to be underestimated, but we have work to do and we recognise that. Do accountable degrees drive performance at all for the board? Yes, they do. The feedback that we have had is a one-level helpful to see that the things that came back from the County of the Bullets review are the things that we are paying attention to and that we recognise our challenges for the board. We were working on them anyway, but it is very much about being countable in the public domain for those areas where we do need to do better. We absolutely recognise that and we are working really hard to do that. So what happens if we take this year as an example of what happens when you are set targets as part of that accountable review for the following 12 months and that you then do not meet those targets? What is the consequence of that? So what we have done this year going forward is to set more detailed trajectories so we can clearly see where we should be on a monthly and quarterly basis. We spent more of our time last year trying to establish the base capacity and some of the base issues. This year we are quite clear about the trajectories that we have to do so that we can see whether we are ahead or behind and whether the actions are absolutely delivering what it is that we set out to do. In some areas that is easier to be said than done because sometimes the cause and effect is not exactly a direct impact, but we have set out clearly the actions and the trajectories in a more detailed way. That will give us in the board the ability to be able to see very early in the year if things are going awry much more swiftly this year. And finally on this, does the direct involvement of ministers in the accountability review make a difference to the outputs and indeed to the responses from the board? Yes, certainly we work closely with the Scottish Government all the time and certainly having the minister there does focus the mind on the key priorities. I have also been involved in non-ministerial reviews as well in other boards and actually the focus there is quite important as well on the same key issues but certainly having the minister in the room certainly focuses the mind of the team and everyone. Okay, thank you very much. We've touched on the latest charts, but I know that Arsdenham will want to follow up on that. Good morning. I did ask about supplementary about 10 minutes ago. I wanted to pick up on what Alex Cole-Hamilton was saying in regard to obviously people come along and they can't get their operation, the time differences and cancelled, etc. Obviously you're looking at new policies in that respect. Do you advise those people that they can actually go on another hospital waiting list? Do you advise that to folk? Is that part of the information you give certainly? I know I do, and I will phone up other areas to see if there's a vacancy for a patient to go there. Do you advise on that? We do advise on that and we also have at the consultation a conversation with patients because in many instances patients may want to stay in their locality, some choose to wait, some don't. For example, many folks in Greenock would prefer to go to the local hospital. However, we offer across our range of hospitals in Greater Glasgow and Clyde because we do have, for example, orthopedic departments in most hospitals. Again, the key issue is that the clinical priorities are seen first and then, as Jane has alluded to, we see people in date order, but we do have that conversation with patients. Just one slight, one other one. I noticed the peaks and the troughs and the outpatients and, obviously, waiting lists as well. Can you tell us when there's a flu epidemic because that's one of the peaks in the report that we have here? Obviously it affects your targets. How does that apply to your targets? If there's a flu epidemic, obviously the beds are full, admissions can't come in. Is it taking into account that there's such a thing as a flu epidemic or that type of thing? Clearly this year we've had one or two short times where we've had really substantial additional demand and we have had to cancel some patients during those periods to ensure that we had enough capacity to deal both in terms of beds but also in terms of workforce to make sure that we're dealing with those patients appropriately. However, they have been short-lived and they have been small and we are working hard to mitigate that and to make sure that we're getting back those patients who were inconvenienced during that period have been reappointed as soon as possible. We're working hard to do that, but undoubtedly there have been one or two challenges this winter for short periods. Good morning to the panel. I just wanted to ask you about the delayed discharges and clearly you've made some really good progress on that. Other boards are struggling with this issue themselves, so I was wondering if you could share with the committee particular actions that you've taken of allowed success in reducing delayed discharge, particularly where it might be of use perhaps to another board that might be struggling with this issue. I'll just say some brief words and then maybe David Pickup. We have tried to address this in Glasgow and Clyde as a whole system issue between the acute and partnerships because we do believe it as a whole system issue. It's not one part of the domain and if we don't have efficient processes for identification of patients early when they're in hospital then that will lead to delays. In addition, if we don't have a good dialogue with our partnership colleagues then they won't be anticipating what patient profile they have got to deal with. David and colleagues, we have worked closely with the corporate directors as well within the board to make sure that there is some coherence across the whole of the health board area, but David will pick up on one or two of the examples that he's been involved in. Whilst the performance is good in Glasgow, we're never complacent and it requires an incredible amount of hard work to keep on top of the performance and the demand that is within the system on a continuous basis. There is, as Jane has highlighted, a real joined up working between the acute system and partnership workers and managers. That engages and involves provider organisations from the independent sector particularly who will be providing care placements and care homes and care at home provision to ensure that there is a smoothness in the system. However, that granular detail of knowing patients is key to that in relation to looking at how we can keep on top of the progress through hospital of patients. That requires hard work and people are committed to achieving the best performance that we possibly can do. We have six partnerships within Greater Glasgow and Clyde that are invested in a number of provisions that are assisting all of that. In Glasgow City, for instance, and one or two of the other partnerships in telemedicine care beds, we are specifically designed to look at a reabling process and approach to look at how we can assist and support patients to go home, rather than to necessarily, particularly for the over age, the 65 age group and the older populations within that, assuming or coming to the conclusion that I'm just heading to a residential care bed or a nursing care bed, because most people tell us that they want to be at home. In order to deliver on that, we have changed our thinking about how we have moved away from assessing people in a hospital bed for their long-term care needs. I think that that's really important that we have the early referrals so that we can get social work staff in to meet with families and individuals and begin to assess at a low level whether that person can go home with or without home care support or whether they can go and need to go into intermediate care, because the assessment process is a bit more convoluted and complex and needs are a bit more complex. We set targets for delivery and achievement in terms of provision of intermediate care. We've set targets of, for instance, trying to see if we can complete the rehabilitation and rehabilitation within the intermediate care beds to a minimum of 30 days or thereabouts. We can strive to get approximately 30 per cent of people who go into intermediate care beds home, recognising that those individuals have got complex needs. We've got a performance regime in place to deliver on that. I think that that's been really important. In summary, hard work joined up working between acute and partnerships and the independent and voluntary sector if they're involved in that, because they are part of that process. Genuine partnership working is the essence of the integration agenda, if you like, around how we transform health and social care delivery. Where we're able to invest in new models of provision, then we should be able to do that. That requires some challenge in the system, which is more difficult for some of the other areas across Scotland. Smaller partnerships, for instance, if they wish to invest in intermediate care beds, may only require three or four beds to make a big difference, but registering those three or four beds within a care home that's a long-term permanent home for the other residents within that care home can be a challenge. The response has to be variable. I think that the key to how the system impacts positively for a big complex health board, like Greater Glasgow and Clyde, is that the six chief officers work in tandem and we strive to achieve consistency across the piece so that it doesn't conflict and impact negatively in the system. Alison Johnstone Obviously, representing Lothian, it's not without his challenges when it comes to delayed discharge. Is it easier to get hold of property because it's more affordable to deliver the care home setting? Why are you finding it easier to get staff? I just wonder how well the best practice, because you clearly are having greater success than many health boards, as Ash Denham pointed out. Is the practice being shared, or is it simply that one size will never fit all and what you're doing in your neck of the woods can't be replicated in others, or do you think that there are some lessons that can be learned? I absolutely think that there are lessons that can be learned, but in saying that, I absolutely don't believe that there's a one-size-fits-all for all partnerships across Scotland. As I've said, intermediate care provision, for instance, won't be applicable in some areas of scale because there are other more appropriate responses. I think that in Glasgow City in particular and more broadly in the six partnerships across Greater Glasgow and Clyde, there's a bigger population with which to draw from in terms of recruitment, so there are less challenges there. I think that there are issues around the availability of care home provision, so if we went back not that far and there's still the case in Glasgow City in particular, we had an over provision of care home facilities and that probably reflected to a certain extent the land values in the west of the country, in particular the city where property could be developed and built relatively more affordably than perhaps some parts of other parts of the country. I think that there was a real assumption by developers at one stage not that long ago that that route out of hospital was de facto straight to residential and nursing care business and that the councils locally would pick up the tab before that because there were fewer and relatively fewer self-funding patients in that cohort, so there was a ready business that was already developing, if you like, and I think that that's one of the reasons why we moved to and changed the assumption that we would do the assessment from a hospital bed and strive to deliver on the shifting of the balance of care and supporting more people to continue to be at home and recognising that some people can actually recover. I think that there is something around about the availability of the workforce as well, and as I say, in Glasgow City and Greater Glasgow and Clyde more generally, there is something around about the wage levels, which are different from the east, so the cost of living is more expensive in the east and parts of the north east, in particular where there are some issues, and I think that that is the reason why the Government has attempted to address that agenda with the Scottish living wage issue, for instance, and trying to ensure that there is a more appropriate level of remuneration for the workforce. I mean, you've pointed out, I suppose, that there are some conditions that are particularly favourable then in delivering social care, but when I think about the casework that I've been involved in myself, I had a case where a patient was kept in a hospital for several months just because adaptations couldn't be made to his home, he'd lived in a tenement to which he couldn't return, so there was a long wait, this was in Edinburgh, to provide accommodation, so it sounds as if that kind of thing would be less of an issue, but I'd be grateful, I'd like to hear your views on that, but also your campaign around power of attorney seems to have had a big impact as well, because we're aware certainly that some cases where people are kept in the wrong place for a very long time have to do with that legal issue, so be grateful if you could, you know, that's not infrastructure, that's about public education, if you can touch on that too. Well, certainly in terms of the first point, we are by no means perfect, we have those issues from time to time, and very clearly that some particular issues we have in Glasgow City, for instance, particular housing stock, which can create a challenge for many people, the tenemental accommodation that makes up a significant proportion of the housing stock in the city, and it's not easy, for instance, to put in place in a close, a communal close, a stair lift. So there are real issues there that does impact, and that's why we don't have a zero delayed discharge figured from time to time, and why we do also have within the acute system some fairly lengthy delays, particularly in the under 65 age group, where there's more likely to be a physical disability, and therefore the need for adaptation as a consequence of that. In terms of the pair of attorney campaign, there is something that we used, some of the initially change fund money that was available from the government four or five years ago to do a very local campaign jointly with the health board within the partnership, and that has been a well-received campaign, and the issue there was quite deliberately to recognise that there are certain numbers of patients who can get delayed unhelpfully for them in terms of their recovery journey for the lack of a decision being able to be made for them because they have no capacity themselves, and the pair of attorney is clearly a relatively quick and speedy process without necessarily then having to wait for the welfare guardianship routes to be taken because that is very lengthy and protracted, and it's seen as a preventative and early intervention kind of approach that actually applies to all of us. It's not just older people, and that's the message between and behind the power of attorney campaign. I should say that it's something that chief officers across the country have recognised, and as a collective body we have agreed in a matter of weeks ago to progress a national power of attorney campaign on behalf of Health and Social Care Scotland, which is the national collective of chief officers, and each partnership is going to be contributing financially to the development of a national campaign, which should positively impact across Scotland. Glasgow City Health and Social Care partnership is leading that process for the other partnerships, and we are working at this point in time to develop the procurement framework by which that power of attorney in a national campaign can be delivered. You are working, obviously, across six local authority areas. When it comes to deleting discharge, are there peaks and troughs? Are there areas that have greater challenges than others? It's a peaks and troughs business, essentially. There can be, for a variety of reasons, and Jonathan has alluded to that in terms of the levels of demand that go up and down. If demand goes up in terms of the front door of the hospital, then necessarily that at some point will flow through to the discharge process and the numbers of individuals in that. Geographically, within those local authorities? Geographically, part of the response that Jane provided in relation to whole system working is that we tried to keep on top of that. The nurse director for the health board has a co-ordinating responsibility for ensuring that we are all keeping abreast of and mindful of our responsibilities to have that at the forefront of our attention. We are in the granular realm of knowing patients and looking at things on a case-by-case basis, regardless of which of the six partnerships. That covers all six partnerships, and we are absolutely clear about the need for that. Thank you very much. The Scottish Government has set a general target for the latest charge of zero, given that your performance is relatively strong, but you still have 4,300 bed days lost in the current year. Is there any prospect of achieving that zero at any foreseeable point? We are working, as David has said, to minimise that. The number is coming down in the last few months. The occupied bed days has reduced further. We need to pay attention to all the things that he has described and all the mental health delays. We are also working with others, because we have delayed discharge of patients from other health boards in terms of Lanarkshire and Dershire. We are working with all of them collectively in the same way as David has described for Glasgow and Clyde. We will continue to make progress and give the attention that it needs, because patients need to be treated in the optimal situation for them. We will do our absolute best to continue to reduce towards that zero figure. There was mention made earlier of the 62-day cancer weight, and Emma Harper would like to open questioning on that. Thank you, convener. Good morning, everybody. I am interested in cancer weighting times. I know that Greater Glasgow is working with Lanarkshire, Dershire and Arran in Forth Fally as part of the regional cancer network. I think that there are discussions in place about networks such as Dumfries and Galloway, for instance, currently as part of the east network, but Stranraer does not consider themselves east of south of Scotland. That might produce further challenges. I am interested to know what are the reasons for contributing to the worsening performance for cancer weighting times. I know that it is important that, when people are diagnosed, they get their treatment within 31 days, or, if there is a suspicion, they get their further care within 61 days. What are the key factors that cause delays in cancer weighting times? I will pick up the high level and then Jonathan could give you some of the details. You are right, we work within a regional context for most of this, and there is on-going debate at a regional level about what are the optimal pathways for patients, whether within the current west configuration, or, as you say, within Dumfries and Galloway and other areas. We are doing very reasonably well in the 31-day target, and we have more or less hit that generally all the time. One or two areas we have not, but generally we do well in that target. In terms of 62 days, one of the key things is that we have to be absolutely clear about the pathway for patients, because you have to make sure that you are identifying those patients and tracking them properly at the beginning. You have to make sure that the time to first out patient appointment is optimal. You have to then make sure that the test, if they need tests, then those are optimal, and if they need surgery or whatever is going on to that. If you do not do it in that trapped way with consistent targets breaking up the pathway, then when you come to 61 days and you find that actually there is surgery, you have a very small amount of time. We are trying to chunk that back into making sure that if people are behind in their pathway, then we are on to that pretty early in their pathway rather than waiting until there is a cumulative impact. In each specialty there are different issues, and so there is not one thing. I will let Jonathan give you maybe some of the details on some of the pathways, but we have reinforced that cancer tracking process to make sure that we have got that chunked into appropriate parts of the pathway to make sure that, as I say, we are not always chasing our tail to make sure that those patients are in, but Jonathan may give you some of the details and some of the pathways that are causing us some particular drawl. Thank you, and you are absolutely right. Some of the big volume cancer modalities are causing us the most challenge in terms of lung, breast, colorectal and upper GI. A number of reasons for that. Firstly, there is a workforce issue in some of those areas. We have been trying to recruit in particular to our consultant radiologist cohort, and we have for some time had a number of vacancies there, which is a real difficulty for us in terms of the diagnostic part of the cancer journey. I am delighted to say that we have got nine new consultants starting over the summer. Many of those who have been trainees have been with us and are staying with us and have achieved their first consultant role, which is good news. Secondly, we have just appointed and just started a new breast radiologist in the Clyde area, which is one of our most challenged areas. Workforces are proving an issue, and we are working hard to recruit and retain. As James alluded to, getting the volume of patients into that first outpatient appointment slot within 14 days is a key target that we are working on. Also, at the other end of the spectrum, what has happened now is that some of the cancer pathways have become very complicated with multiple stages. For example, in colorectal, we used to see patients going through two or three stages with diagnosis now with much better diagnostic imaging equipment and more detailed testing such as PET CT. We are seeing multiple stages, which sometimes make it harder to achieve that 62-day target. However, you will be aware that there was a national consensus conference around all the cancer centres at the beginning of May that was held. All of the pathways are now subject to a review. We are taking all of the best practice from each of the boards in Scotland through each of the three regional cancer networks and looking at how we improve the cancer pathways to try to get back to the 95 per cent for the 62-day target. I notice that in one of your papers, urology was one of the challenges. Is that because of vacancies in the urology area? Yes, we have had a number of challenges within urology. Some of them are vacancies and we have been recruiting to the new robotic service for prostatectomy in Glasgow. We finally got our four consultants in place, which is a step forward. However, some of the subspecialty areas such as reconstruction within urology are very hard to recruit and we are outscanning trying to persuade folks to come and work with us in Scotland, because it is a key area in terms of achieving the targets. I know that our age of population with multiple comorbidities is obviously going to be a challenge and the increase in population is being squeezed at one end in multi-disciplines breast lung urology. That means that your pathway processes are going to be affected as well, just looking at population and age of population. That is why we need to constantly review our capacity and make sure that the actual slots and the clinic templates, for instance, are reflecting the current demand. We are looking at that all the time to make sure that we are actively able to deal with that demand profile. It does change and we have got to make sure that we are fleet of foot in making sure that that does happen. However, the key to this is trying to keep down the waiting times for those patients who are in the urgent, as Jonathan said, capacity at the front of the pathway in terms of outpatients, and then making sure that diagnostic capacity is tailored to those patients and that we have a proper tracking mechanism. We need to flex the capacity and we do that when we have to. That might be an opportunity to pick up on your point about the changing demand on the system. It might be an opportunity to ask Jennifer Armstrong to talk a little about the way forward for cancer services and the cancer pathway and the changes that we are looking to make around that, bringing in perhaps some of the region of work. Jennifer? Yes. On your question, there is a lot of detailed work that goes into cancer planning. We work very closely with ISD to look at all the tumour groups, and we have been doing that as part of a moving forward together programme. We do it fairly accurately through to about 2025-2030, so we know how many cancers we expect. We looked worldwide about the best practice, the new treatments coming on board, the new radiotherapy techniques, and we have eight tumour groups. That has a cross-system approach. That is what we have employed in all of that, from GP's to oncologists. They will then look at what is happening with breast cancer treatments. We then do radiotherapy planning, and we do that, and the whole of Scotland does that. Things like the number of linear accelerators and the Bigel Lynac machines are part of a capital planning project that we do with Scottish Government. We then say, what is happening? Are we able to devolve, for example, chemotherapy delivery to more local units, depending on if it is going to be intravenous or oral? We know that about 40% increase is going to be required between now and about 2023. Therefore, we have a regional plan looking at chemotherapy, developing the cancer units and looking at the cancer centre as well as a whole-system approach. At the other end, what is interesting in the public health debate that became available in 2008-9, was that there were a lot of things that we could do ourselves to lower our risk of cancer. We know that obesity is a driver for many cancers. It is actually doing it across the whole system about smoking rates going down and what we think will happen. At the moment, we are moving forward together. The programme is an actual projection of the increases. We are looking at redesigning the way that we deliver that, but there will be a step-changing capacity required as we begin to see numbers rise. Is there an opportunity for radiotherapy to be delivered more locally or will that be in core centres, such as central belt centres? It is interesting to hear about telehealth. It might work for orthopedic surgeons but not necessarily for chemotherapy because that has to be delivered face-to-face because you need intravenous management for that. In terms of the radiotherapy, there was an interesting debate back in about—I used to work in Scottish Government—that was part of the better cancer care. We have a satellite centre in Lanarkshire with three line accelerators there as well as 12 at the Beatson. The thing with radiotherapy is that you have to be extremely precise about how you do it. We have five different stages of checking. You have the fields right, check the patient. It is a very complex treatment to do. There is a balance between us devolving it too much and the quality control has got to be absolute. We have about 700 treatments a day in the Beatson and every single one of them is carefully planned by a consultant, is carefully delivered and it is a very complex treatment. With Lanarkshire, we saw a big volume of cancer around that area. The Lanarkshire satellite is working well. It is delivered by staff who are trained and part of a bigger system at the Beatson, but it is delivering more local radiotherapy. That is part of the debate that we are having at the moment. If you watched the Beatson programme, you will have seen a lot of the new machines that we have brought in that are delivering more targeted radiotherapy to prevent the side effects. You saw that with the prostate. There is a lot of debate going on at the moment, and that is part of our moving forward together programme, keeping the quality control, looking at the population growth and then looking at your service model delivery. That is what we are doing. One of the other requirements in the accountability review most recently was to keep the Government informed of significant improvement in local health improvement activity. I wonder if David Stewart would like to ask some questions in that area. Thank you, convener. Good morning, panel, and thanks very much for coming along today. I am very interested in public health, and through Spice's good work, I look very carefully at the male life expectancy in Glasgow, which has obviously been well documented. You are still lagging behind the other major Scottish cities, albeit that the rate of increase is very similar. Effectively, it is an historic lag. Is that your top public health objective? Perhaps I will ask Jane Grant to run through some issues around that. Thank you. We pay a huge amount of attention to health improvement and life expectancy, in trying to close that gap. We have a lot of programmes on-going, and David and Jennifer could pick up on some of the details. We are working hard with smoking cessation and obesity, trying to improve overall life of our patients, because it is not just about the health issues. It is a much wider issue than just health itself. We have a lot of work going on both within the board and within partnerships, which are co-ordinated through some of the board activities. Maybe, David, you could speak on some of that, and then maybe Jennifer. Certainly. I guess that some of the particular aspects that we are focusing on are things such as smoking cessation and alcohol brief intervention—not exclusively on that, because I think there is. The role that health and social care partnerships across the board area are having and are taking in collaboration with not just the health board but also local councils in terms of activity and active participation in community planning partnership arrangements around that. There are also issues about good physical health and good mental health in all of that. On smoking cessation programmes, for instance, there are a quarter to two figures for this year, or for 2017-18, which suggests that we are marginally below target in terms of the number of quits at 12 weeks, but we are substantially a good bit further on from the same period last year, which we are encouraged by. That is down to improved performance in pharmacy and community services working together in relation to programmes of intervention. There is joint working with Smokefree Pharmacy. We have done some particularly good work in POSL around the connectivity between pharmacy and community services, and we want to roll that out to other poorer areas of force areas in the city, the deprived areas in the city. Outside of that, we have, for instance, an incentivisation scheme in partnership between the health and social care partnership and the Strathkelven credit union, which is a roundabout financial reward for people in the 15 per cent more deprived areas. There is a range of actions that are being taken in relation to addressing that particular issue. Canary is particularly the vengeance study for the Glasgow Centre for Population Health, and you are probably very well acquainted with that. What I found fascinating was that they were comparing contrasting cities with the same social economic difficulties. Clearly, you cannot be naive about that. There is clearly a major factor in your patch that causes this. However, when they compared Liverpool and Manchester, they argued that the excess mortality could not be put down to any social index within Glasgow. There is some ongoing research on that. Have you contributed to that study? What is your observation on that study? That is really quite interesting in terms of social deprivation. I will invite David and I to sit on the Glasgow Centre for Population Health Board, to chair that particular board. You make a very valid point about the issue in Glasgow being historical and the work that the Centre for Population Health did last year to bring together its 15 years worth of research over a long period into why Glasgow does not compare favourably with other cities that it would do. As you know, I have not read the report yet, that a lot of it is down to decisions that were made a number of years ago around planning, around the distribution of the population in the west of Scotland when the new towns were set up, and also decisions that were made around investments in Glasgow and where the investment was, which differed perhaps from how Liverpool and Manchester as local authorities might have made their investments. We are in a position where we are paying the price for earlier decisions, but I just want to reassure you that public health is a top priority for this sport. I touched on that when we looked at the triple aims and made them quadruple aims, we actually moved public health better health to the top of the list. As a board, we are driving that. We have this year introduced a public health sub-committee of the board for the first time. That sub-committee allows the non-executives to help working with the public health director on our team to set the direction. It also helps us to hold to account the colleagues in the HSCPs who deliver a lot of their public health initiatives and the colleagues in the board that do it. However, we are now on the Public Health Committee membership from the Scottish Government, so we have been quite influential, I think, with setting the agenda for public health across Scotland. We also have membership from the chief executive of the centre for population health and, as you know, the centre for population health pulls together Glasgow City Council, Glasgow University and the health boards. We have academia, local authority and the health board all there together. However, we have also started doing a work with Glasgow Life, because obviously public health is more than simply smoking, alcohol, drugs, obesity. There is lifestyle and there is support for Glasgow City Council. We have been working closely with Clyde Gateway. We are very interested in looking at what Clyde Gateway has done on the east end of Glasgow post the common wealth games and the regeneration there, where the housing has improved and the employment rate has gone up. However, health has not caught up yet and we are trying to get ahead of the game and trying to understand a bit around that. I am conscious of the other minister, Mr Gimby. Finally, you have mentioned public health initiatives that have made a big difference. Historically, the smoke-free zones were very important. The smoking ban has made a huge difference. Last year, we did quite a lot of work around low-emission zones, and we took some evidence from Glasgow and another committee. I am very conscious that health inequality really hits Glasgow. It tends to be the poor disadvantage and the elderly who are hit by NOX in a particular matter. Glasgow is obviously going to be leading on the pilot. How important will that be to change public health outcomes? Can you see your life expectancy graph go up to meet the Scottish average once we have the low-emission zone running for a few years? We certainly would expect to life expectancy graph to go up as each next generation comes along and is living in a healthier environment because of smoke-free emissions but also with the education around better lifestyles. I do not know, David, if you want to add anything from perspective of the population of the HSCP. From the perspective of the HSCP and just to add to the chair's comments around our relationship with the Centre for Population Health Studies, we actually had a development session for the Glasgow City of IJB just towards the end of last month. The entirety of that session was devoted substantially to public health. As a commitment that the IJB wishes to make to it being the top priority of the IJB going forward. Much of the learning that the Centre for Population Health Studies has been working on is now very much at the forefront of the IJB members. We will be tasked as officers to come back with ways of improving the life expectancy issues for men. I think that the low-emission zones agenda will be significant in that respect, but it will be one part of a jigsaw and a panoply of interventions to address that. It will not necessarily get us to the Scottish average, but it will be an important part to that. If I could explore this a little bit further, I would prevent the health agenda of something that I am particularly interested in within. My life expectancy averages, and those are averages. If we look behind that in Glasgow, there is a huge disparity in quite a tight community. I think that, correct me if I'm wrong, it is 16 or 17 years life expectancy within that. What I have heard this morning is about how we are tackling people who have already fallen into ill health through smoking, obesity or MSK, or type 2 diabetes. What should you be doing around preventing people from getting into that situation? I think that we would recognise that that is not just a health board initiative that is required here. There is obviously education that is required in planning and so on. What work are you doing in that area to try to prevent people from following those patterns? I will ask Jennifer to pick up on the first part of that, and then maybe David, if that is all right. I think that I know that you have taken evidence before around ACEs, the adverse childhood events, and there has been quite a bit of work looking at how we might apply that within Glasgow and Clyde. With the adverse childhood events, we know that if you score a score of 4 out of 10 and above, your chances of dying by violence, of suicide or just about everything goes up dramatically. There is a real focus on trying to make sure that children have a better experience in Glasgow. Those patterns are set through generations and you see generations playing out. You are alluded to the study around the Manchester. I think that there was a lot of excess mortality around violence and drug addiction within that. It was not uniform across the patch. You will have seen that with multi-agency work in trying to reduce violence and trying to reduce gangs. There has been quite a lot of success in that. I think that there is a key around making sure that we provide as good an environment to bring up children as possible. The next bit is really around looking at the key causes. The big challenge for society in the NHS is how do you keep people healthy? If you like co-produce, I do not like that word particularly, but how do you have that about trying to have people taking exercise? We have tried to do a lot of that promoting exercise. We are also interested to see with the new alcohol legislation because a lot of that with the minimum pricing will be a lot of what we are trying to do is shift the alcohol curve over to the level. We will have everybody drinking at a lower level, but particularly in some of the deprived areas, some of the very strong alcoholic with high units, which were low cost. We are hoping that the alcohol legislation will help us to reduce there. There is a whole range of different targeted age groups. The other thing that I would say is that a lot of the work that we are doing is moving forward together because we have asked a lot of the community to give us the information that we can manage our own conditions. Once we get an early chronic condition, we need to provide a lot more information that people can manage the conditions for themselves. You will see that coming to the fore more. You have been doing a lot of work in the children's aspect. We might not see that for 20 years, but we have to focus on those particular areas. A couple of things on what we are doing in the city particularly. The community planning partnership is key to that. The two priority themes for the partnership in relation to the local outcome improvement plan are early years and transport. There is a connection between the two. The health board, the health and social care partnership, are core members and co-partners in the community planning partnership arrangements. The councils have recently published a commission into mental wellbeing in the city that looks at early intervention and prevention agenda around the areas of trying to prevent people from feeling unwell mentally and how that can spiral into other more concerning aspects of behaviour and presentation. There is a real connected whole system approach in terms of looking at what we can do more preventatively in relation to that, which the city government is committed to taking forward. I think that just to finish on what Jennifer has been indicating in relation to the early years agenda—this is something that applies not just across the city but across the whole health board area—is the centrality of getting it right for every child agenda and the clear connections with education for children on how we make those connections. It is not, as you rightly said, just a health board issue. I have a brief follow-on from that. You alluded to that, Mr Brown, around how planning plays into that. For example, we know that, in the lower percentiles, there is a higher propensity for fast food and alcohol outlets. Has any work been done around that long-term planning on how that can change? I think that that is where the connection in the centre for population health is very helpful, because that brings together the council, the health board and the academic research that provides that evidence. It will be more an issue for the council in making its decisions around where it allows those outlets to flourish, shall we say? Last question in this area is from Sandra White. I think that most of the questions that I was going to ask have been asked, but I am glad that you recognise the fact that it has been many, many years in that respect. Planning people thrown out to housing schemes is absolutely nothing there. A sense of loneliness and deprivation is one of them. I am pleased that you mentioned education. I wonder how much work you are doing in schools, because when you are going about, I am in Glasgow, I live in a city, I represent the city, I want to be able to live longer, as does everybody else too, in a better quality of life for people, but when you go in the outlying areas, it seems to be of lack of aspiration. It seems to affect people and the positivity is not there. Is there any work that the health boards do in schools through education, primary and secondary schools in regards to improving your health? It is not just what you say about health, it is much more holistic. We had evidence of that from the Cabinet Secretary a couple of weeks ago that all portfolios in this Parliament must work together to improve the health. What input does the health board have in schools, not necessarily yourselves going into schools but the GICBs or anything like that? Do they have an input in schools that they speak to teachers? My colleague education director in Glasgow City Council Maureen MacKennan would be very clear about the importance of children's wellbeing and the importance of our health improvement colleagues in the partnership being engaged in supporting schools to make sure that their programme of activity and engagement with children is as healthy and active based as it possibly can be. We have connections and engagement with schools not just within the city but across the partnerships in the board area. Now we have time to address the issues of finance and process and start with Ivan McKee. Thanks, convener. Good morning. It's good to see you again and welcome to the health committee. There are a couple areas that I want to touch on. First of all, I want to touch on the financial aspects and then move on to some of the efficiencies and process improvements that sit behind how your driving improvements are. Let's start at the beginning. In terms of budget for this year, what is the health board's total budget and how does that compare with last year's budget? Thanks for that. I'm going to hand over to Mark, who will give you the detail that underlies it, but our budget, as I started off to say, is £3.1 billion a year, which is made up of provision for a range of services. It does get increased a year on year, and Mark will give you a bit more detail on that. The budget that we have for 2018-19 is obviously that we have received £31 million more income this year than we did last year. The large part of that is the 1.5 per cent of what we get from the Scottish Government as a core part of that funding. We have discussed a number of service level agreements with neighbouring boards for services that we provide, which have an inflationary increase built into them. That gets us an extra £5 million or £6 million. When we have other smaller sources of income, the national new medicines fund, we give us a couple of million pounds around that. That sums up where we get our additionality in year. On the counterside of that, we have a range of pressures that we have to manage. They are amounting this year to just under £100 million—a large part of that being £41 million, £42 million per year old pressure—a large part of people moving through the scale, plus the additional commitments in the budget to award the pay increase. As always, we have other big areas of pressure around it for prescribing. It is the biggest pressure that we have outside of Pyrrw, which, for us in years in acute alone, is around about £23 million or £24 million, and that increases in price and volume that we have to manage. On top of that, we have other usual inflation increases that you would expect to see across our supplies and sundries, which amount to around about £10 million or £12 million. Against that level of income, we have to balance that level of financial pressure and increases in all those areas that we see each year. The £31 million in cash terms, in addition to last year, is fine—thanks, that is the scene. John Bryn, you mentioned earlier on that you would achieve £60 million worth of savings. You said the previous year, so I am assuming that is 1718. You exited that year with financial balance. Moving on to this year's 1819, what is the number that you need to achieve in similar terms? You mentioned about £40 million for this year. Just caveat 1718, because we are still going through the audit process. At the moment, it is clear that we have financial balance and we have to have that approved by Audit Scotland, so I will caveat that. I do not envisage any problems there, but we have to go through that process. This year, we are looking at a roundabout for the board in general, including IGBs, which is just about £92 million. If it is just the board itself without IGBs, it is around about £85 million. That is the savings challenge that we have in the year. You have a track record of delivering that scale of savings. It is a big organisation, very complex and a lot of different things going on, which makes it very challenging but also means that there is a lot of opportunity there, if you dig away at it and find things and you have clearly demonstrated the ability to do that. I want to dig down to the next level and see what is the process improvement process that allows you to identify opportunities for savings and deliver them. I am not sure whether you are moving forward together. The programme encompasses all of that. It has a different focus. Clearly, when you move into that area, there are areas such as service redesign and so on that will give you big, chunky savings potential as they work through. However, there is also the accumulation of hundreds and thousands of small actions that are taken up and down in the organisation that will drive small savings that all add up. I am more interested in the latter of those. What is the process whereby you identify those hundreds of thousands of different small things up and down wards that then all add up to a number? What is the process whereby, if I am on the front line, if I am a nursery adult, I say, look, if we did this, it would be cheaper than that. If we did this, it would be more efficient than this. What is the process whereby that feeds in and gets considered by management and acted on? Before we move on to that, I want to be clear that the figure that Mark was quoting is the financial challenge. Not all of that is met by efficiency savings. Some of that will be met by additional funding in year. As the year goes on, you get additional funding for the winter, you get additional funding to target the waiting times initiatives and so on. I was quoting the efficiency savings figure. Mark was quoting the financial challenge. It is important that we understand the difference. Obviously, to meet that financial challenge, there are a number of things that we have to do. We have to look to what might come from national initiatives and what might come from regional initiatives, but then, as you rightly say, there is what can we do within the board itself. We have at one end of it a bottom-up staff suggestion scheme. It is called small change matters, which will not give us a lot in terms of cash, but it will help us to encourage an empowered culture and encourage us to involve the staff. It will deliver a lot of small change matters. Then, in the directorates, there are normal efficiency plans that they look to, and then there is the cross-cutting, the end-to-end system. That is the sort of different tiers in the different levels. Mark, would you like to talk us through some of those tiers? The small change matters has been something that we have tried to launch and reinvigorate over the past 18 months. As you say, the front line is where the money is spent and that is where we have to try to manage behaviours and financial control. We have really worked with our communications team to get a lot of information out to staff and by launching an electronic form on an internal staff net, we have given every member a staff the opportunity to bring forward their ideas to which we then review them and we consider them and we laze with that individual staff member to take that opportunity, the idea and turn it into a savings programme with their help. We are really ramping that up and trying to get as maximum from that as we can, both from individual members of staff and from staff forming groups themselves to bring forward ideas. We do look a lot for that and staff are inherent in that process. The second level of savings that the chairman alluded to is that we have a devolved budget process across the board and we give out a savings target to every director and every general manager that has their own budget line and that can vary anything between one to two per cent across the organisation, which is expected and they will come up with a range of schemes within that figure and they will subsequently deliver them. The one thing that we have tried to do slightly differently this year that has always been within the board but we have tried to change it a little bit is to manage a lot more centrally to get some more organisational wide initiatives, focusing much more on efficiency and getting more for the same, working a lot around their processes and are internal ways of working to try to bring that change across the organisation. We obviously deliver our acute services from five or six sites, you get a lot of variability across working practices and across performance and it is trying to get the best out of each of those and roll that out across the rest of the organisation and again that is something this year by establishing a central programme management office within the board headquarters that we are looking to support and bring new ideas to each member of staff to get more from that. As we alluded to the top layer, the top level is around about transformational change which is much more medium to longer term and we are envisaging small progress or small savings in that this year but much more focus on that in the preceding years and that has predominated around the regional working which again we have touched on but it is very much taking up a lot of our time and effort in terms of moving towards that and then moving forward to get a programme which is internal within Glasgow which again is looking at service redesign and delivering in different ways with a big focus and shift in the balance of care obviously. That is the different layers to which we are adopting this year, slight change on before but again building on the good progress and the good delivery that we have had in the past. That is clear, thank you very much. Thank you very much. The projection that was published the other day for December of last year suggested that Greater Glasgow and Clyde was facing an overspend for the year just finished of £20 million but you are telling us today that that has not transpired. Is that simply a matter of accounting or is there a substantial change in the last quarter of the financial year? It was a combination of a number of things. I think when we set out the financial plan back in June last year we had an £18.5 million projected gap and that is what we have been operating with throughout the year. When that became evident we took a number of different measures to try to bring that under control. We put a lot of processes in place around financial controls, financial grip as we called it, far greater scrutiny and monitoring around a lot of our budgetary and nondiscretion spend. Examples of that were around our premium rate agency nursing, which was a big cost for us. We managed to have that in year through better management and through better interaction with our staff and better monitoring procedures. We have also been very big on our supplies and sundry spend. Again, we have managed to take £5 million out of that, much of that coming in the latter quarter of the financial year by the time that those processes and schemes were in place. There is a range of financial control and financial grip that happened in the latter part of the financial year. Winter is obviously a huge area of pressure for us. Again, we were projecting significant financial pressure around about winter and some of that was prudent, some of that was around about the pressures that we have experienced in the past. Again, we put a lot of time and effort, a lot of detail planning into winter this year and we were able to deliver winter within the financial envelope that would set out and again that comes through in the latter quarter. As I mentioned, we had a whole range of savings schemes identified at the start of the year. Those took a lot of time, a lot of effort from staff to be able to deliver them and a number of them crystallised in the latter quarter that again helped to impact on that number. We were predicting pretty much around about £18 million, £20 million all through the year and then just as we came out of the back of Christmas and the back of winter with a bit of clarity and a bit of rebasing of some of our assessments, we were able to bring that down to around about £8 million at the end of a sort of genuinely fairly time and then back down to financial balance at the end of the year. I wanted to pick up on that point because the most recent audit of the accounts of the board pointed towards you carrying forward an unachieved saving of £29.6 million. I wondered in terms of future savings where have you looked to identify them within the board? The 29.6 million is our underlying recurring deficit coming into 2017-18 and that is an area that we are continuing to try to increase and look at. There is a range of different things that we have covered in the year. If I can give you an example of one of the big successes that we have had in 2017-18 around about our pharmacy savings and that is around about biosimilar drugs, where we have a very dedicated process of horizon scanning. We try to identify expensive branded drugs that are coming off patent or that are coming to the end of the particular purchasing deals. We put a rigorous process in place to get all our clinicians and all our pharmacists prescribing those drugs rather than the more expensive ones. Again, in the year for 2017-18, that was saved as upward of £12 million within the acute division alone. That is a big area for us. I touched on nursing. Medical locums has been another big area of spend for us. Again, in 2017-18, we have really focused on and we have managed to reduce our spend in that area by £2 million just by adopting a far more rigorous and far more detailed process of delivering those services in a different way. The big areas of prescribing staff spend are areas that we have really looked at in 2017-18 to try to drive out that level of savings that we need. I want to go to a point that John Brown mentioned in his opening remarks about A&E visits. I think that he said that half a million of the board's experience is out of a population of one and a half million. For all of us, A&E is often a good test of how people are using our health services. What sort of work are you doing around that for people to go to the appropriate professionals? What does that really say about general practice across the health board area, especially given the challenges that you outlined with deep-end GPs? Before I pass that on, it is about the point that was made about public health. Glasgow and Clyde has always been an outlier when it comes to the use of the NHS. There has always been significantly higher use of the NHS in Glasgow and it is across all the population groups. It is not particular to any one population group. In A&E, we consistently have been 11 per cent above the norm anyway. As to what we are doing about it, I will hand over to Jane. I will give you the overarching board position. As you are probably aware, we had a written branch review of some of the emergency work that had caused us a challenge the year before last. This year, we have set up an unscheduled care steering group across the board, which includes a number of the chief officers from partnerships and a number of the directors from the acute sector, as well as corporate colleagues, to make sure that we are looking at all the drivers of that activity. One of the things that we have set up was one of the board's objectives to reduce demand and reprofile in a different way. What we are trying to do is make sure that we have proper anticipated care plans in place. We are clear with GPs about what the services are. We are trying to look at patient education in terms of making sure that they are aware of the range of other alternatives. We are also looking at other initiatives at the front door, so that, when patients appear at the front door, they are clear if there are other appropriate pathways rather than through that assessment unit or admission unit that we are looking at. We are also looking to promote our minor injuries units in those areas where we can treat patients in other alternative areas where appropriate. There is a range of things going on, but maybe David or Jonathan might want to pick up on some of the other things. There is a lot of activity in that area. Thanks, Jane. We have seen a 1.7 per cent increase in attendances over the last year, ending in March of this year. I think that the important thing, as well as having the unscheduled care group at board level, is that we have now got three integrated unscheduled care groups that are based around the three main sites of Paisley, the Queen Elizabeth and the Glasgow Royal Infirmary, and David's team through all the IJBs. We now have those as joint integrated groups, so we are trying to get as much of an integrated approach about what we can do when people come to our front door. We have things like social work at the front door. We have a good example, for example, on the Queen Elizabeth of a frailty unit where we have 10 beds assigned, whereby instead of going through a lengthy process, patients can go to the frailty unit and there is a dedicated team trying to turn them round and keep them as mobile and possibly at home or in another location as possible. A range of services is there. We are also working with the Scottish Ambulance Service, because they are often the first people to get the call or to get to the scene. We are working with them about appropriate places to go. Jane mentioned her minor injury unit, so instead of turning up to a busy ED department, we are trying to get our ambulance colleagues to work with us and with patients to suggest a minor injury unit where we are treated quickly, turn round and back out. The other thing for us is how do we manage the older frailer patients coming to ED? Again, it is very important that we have that joint work with our social work and IGB colleagues to make sure that the appropriate person is going to the appropriate place. Finally, just to say, over the winter period, we did run extensive media campaigns, local radio campaigns, adverts and leaflet drops just to try to point people to the right place to go to get the most appropriate treatment, but we will continue to try and improve in that regard. I will brace up Louinter from David and then Sandra White. I would like to say from speaking to community pharmacists that they feel that they are a kind of underused resource and I think that their campaign about 1, 2, 3 before you say your GP was extremely good. Is that something that you can link in? I am unsure that you are already doing this. I may know that other boards have looked at this and I was reading just this week about an English case where people who are persistent users of A&E, I do not mean because of normal medical issues, but talking about hundreds of times going to see A&E were targeted by the health boards in England and they managed to reduce dramatically the figures there. Is that something that you have looked at? I think that it was in the economist this week, but I do not know if that is something that Dr Armstrong is able to speak on. So with community pharmacists, there was a pharmacy strategy published a few years ago by the Scottish Government prescribing for excellence. We have done quite a bit of work with community pharmacists on minor ailments service and things like that, but one of the big things that we are looking at now is what access we give them to clinical portal, which is the patient record. You need the patient's permission to do that, but it is also about the drugs that they are being prescribed. We will see community pharmacists develop in much more meaningful and constructive ways in terms of accessing patient records, but they already provide a lot of minor ailments service. In terms of being the first port of call, we have done quite a bit of work with things like optometries. If a patient is in eye condition, we are changing it to the go-to-optometries, the first port of call as well. A lot of that you will see coming out over the next few months about working to the top of your licence and shifting work away from GPs, making sure that people access the level that is appropriate to their needs, rather than pitch up to an accident. With the frequent attenders, there is some interesting work that we may do around the north of the city, which is looking at patients who come and often are patients with mental health problems who are in crisis who will use that. It is about what services do we need to put round those patients to prevent them from using A&E. There is quite a bit of work going on between A&E and GPs to say that we know those lists of patients and how we can put more preventative measures in to stop them attending. That work will play out over the coming months. A lot of the issues with A&E are when we are looking at the Moving Forward Together programme, what we said to everybody is that we had 32 clinical groups looking at it and we have engaged maybe about 600 clinicians and we had cross-system groups. We said, what do you currently do in hospitals that you can do in the community, what do you currently do in the community that you can do at home and what do you currently do at home where we can do virtually? What we are seeing is a big, is a programme shift away from that. We have got the stakeholder reference group, which has got all the charities, patients and everything on it. We have been playing out all of the developments with them over the few months. They all said very clearly to us that, if you make this big transformation in care, which we would like to do and we will describe that, we need you to educate us about where we have to go. It can be quite confusing to patients. Because A&E has a big brand, you see A&E, that is the easiest place to go. There was an interesting article in the BMJ this weekend, and it talked about patients who are a bit unsure of which pharmacist. We need to set our stall out, take patients with us, get their engagement and then be very clear that this is the appropriate to your needs, not any. At the moment, we have too many people turning up at A&E. We should really be preserving the four-hour target for acutely unwell patients who need to get seen quickly. That will be a big challenge for not just Glasgow and Clyde, but other boards as well. How do you find the information from Emma Harper? You mentioned the virtual aspects. I think that there is work happening all across Scotland where people are not being admitted to hospital because they are self-monitoring for COPD and stuff like that. I do not think that we have even scraped the bottom of the barrel for telehealth and the potential savings that can come out of that. That is the point that I am making. I want to ask about the joint boards. Before I get to that particular point, it would be very remiss of me considering that the minor injuries units have been raised, which I was going to raise there, but I hope that I can raise it just now. I am sure that the amount of work that goes on, but you mentioned before, and it has been mentioned again about refiguring, you know, basically care and what is happening, minor injury units, transparency, speaking to people. Obviously, it is an open question. I have written letters as well. It certainly was not transparent to the people in my constituency that the York Hill minor injury unit was closing. I would just like to put that forward. Will it be in Gatnavel or will it be somewhere else? That is a question that I want to ask specifically, but I figure perhaps going to the Integrity Joint Board because I am sure that you must have input into that. That was one of the issues that I wanted to ask. Basically, it is absolutely massive, right? The work that you have got to do, Mr Williams, and you mentioned in there about moving together and engaging with the public as well in regard to the joint boards, six partnerships. Do you have an input into such as the York Hill minor injuries unit? What input do the partnerships have? Do you think that all the work that is going on in one size does not fit all the practical reality of dealing with the six separate IGBs? Just how difficult it is and can you progress in this style? I do not know who wants to answer the question first. I think that there are three points there for me. The first point is about the communication of when we originally closed the minor injuries unit that was based in York Hill. I would like to apologise for the poor communications around that. I do not think that we got that right at all. I apologise to you, Sandra, for your constituencies as you first raised it with me. That is something that, as a board, we are very conscious of, that we have made mistakes in the past and that those mistakes in the past have damaged the public's confidence in us. It is something that we are looking at how we can actually be better. Jennifer mentioned the engagement group that we have set up around our work to design the new system and how we have involved patients, patients representatives, the charities, stakeholders group, as we have described that. We want to do more of that. We want to get better at that, but I just want to start and make the point that we are learning from our mistakes here. The next part is about where do the people in that part of Glasgow now go for the minor injuries? I think that, Jane, you would want to talk about that. David, I am sure, will give you an insight into how widely the health and social care partnerships and the IJBs that the Government are actually involved in the NTA system and the provision of the system. In the minor injuries unit at the moment, as you know, it was open for the winter and we extended that until 20 April to allow the Easter period to go by. In that time, there was approximately about 20 patients a day going through there and at weekends it was much less than that, perhaps less than 10. There is a relatively small amount of patients going to the minor injuries unit, albeit recognising that access is important. Those patients at the moment are principally going to the Queen Elizabeth. As part of the overall Moving Forward Together programme, we are looking at the whole profile of emergency care and our elective pathways and so on. The minor injuries unit's patients will be part of that process. As Jennifer has said, we are looking to see whether all of those patients need to come to a minor injuries unit, whether we can move them to a different place appropriately or whether they need to come there and, if so, how many and what are they coming for. That detail work is on-going as part of the Moving Forward Together banner to ensure that we have the right services for the right people. That Moving Forward Together gives us the opportunity to design services for the current population needs. Quite a lot of the services have grown up in all of the health boards over a large number of years. Therefore, this is our opportunity to look at what patients require and do something in quite a new way with new models rather than just doing more and more of the old. That is the opportunity that we are taking with Moving Forward Together. It will be a change for some people. As Jennifer and others have alluded to, we will need to take the population with us and look at that. There is a lot of work going on, but the minor injuries unit's patients as part of that process will be reviewed. David, do you want to say something about partnerships? There is no doubt about it that the integration agenda, particularly when it is a multi-partnership facility or area within Greater Glasgow and Clyde, as it is with six partnerships, is complex. Within that, there is a balance that is needed to be struck between and for the board in terms of recognising and respecting the responsibilities and duties of the integration joint board. However, at the same time, that balance is about ensuring that there is a consistency of patient care for patients across Greater Glasgow and Clyde. Beyond Greater Glasgow and Clyde, in large part, because there are, as you have heard, many patients who come into Greater Glasgow and Clyde from out with that board area. There is a need for collaboration, there is a need for joined up working. Within Greater Glasgow and Clyde, the chief officers meet formally on a monthly basis to ensure that we are working together. We are required in the legislation to co-operate with each other in a multi-partnership board area, to ensure that the responsibilities that Dr Armstrong has in relation to the clinical governance leadership are not compromised because one IJB takes a decision about going down that route and another IJB takes a different decision. Beyond that, we are beginning to get engaged as chief officers and health and social care partnerships within the west region, regional planning boards. The 15 of us have discussions about how that is evolving. As I said earlier, there is also a national health and social care Scotland network of chief officers where there is a developing and evolving approach to learning, sharing and ensuring that there is a degree of consistency. That is different from a uniform one-size-all kinds of approach. It is about recognising the difference within communities. That is the importance of locality planning within health and social care partnerships or IJB areas. In terms of making it work, there is a need for a will to make it work across all partners within the integration arrangements. That is the IJB, the council and the health board. It requires hard work. There is no question about that. That is the nature of partnership working. What you have heard through the course of this morning is that, in the key interfaces around about delayed discharges, about the unscheduled care agenda and about moving forward together, the partnerships within Greater Glasgow and Clyde are absolutely up the middle of all of that work jointly and together with the health board itself and our colleagues in the acute system. That does not mean to say it straightforward, because we are all learning about each other, but we are committed to it. The will is there. I am asking to come along to some of the meetings, but I know that priorities in different areas also cover fail-of-leaver in places such as Lanarkshire. I want to know how difficult it is to get consensus around what one priority is to another. Is it difficult with the six different IJBs? Can I give you an example of the five-year mental health strategy that we have just collectively approved across the board areas and the process that we have taken in delivering that five-year mental health strategy? It follows on from the Government's own mental health strategy and is completely consistent with that. It is expected to deliver a transformational change around how mental health services are delivered. The hard work bit is about involving and engaging in the first bit. That is a different concept to perhaps where we have been historically in terms of delivery of public services. It is about ensuring that the different parties who are party to delivering on this five-year strategy, which is a board-wide strategy, must be delivered within the six partnerships because their devolved responsibilities are about working together as part of those monthly meetings and ensuring that people are party to the development of that strategy, so that when it comes to the point of presentation for approval at, initially, Glasgow City IJB, because we host mental health responsibilities for the board area but it is something that the other five IJBs and the health board need to be party to, that there is a consensus achieved. You have got to be confident that you will have people signing up to that before you present it. I thank all the witnesses for their attendance today. It has been a very full session. We will now suspend for five minutes and then we will resume in private session. Thank you very much.