Health, Social Care and Sport Committee [Draft]

Meeting date: Tuesday, May 21, 2024

Official Report 823KB pdf

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Healthcare in Remote and Rural Areas

The second item is an evidence session with the cabinet secretary and supporting officials as part of our inquiry into healthcare in remote and rural areas. I welcome Neil Gray, the Cabinet Secretary for Health and Social Care; Stephen Lea-Ross, who is the deputy director of health workforce planning and development at the Scottish Government; and Paula Speirs, who is the deputy chief operating officer of NHS Scotland.

Before we begin, I invite the deputy convener to say a few words about the committee’s visit to Skye last week as part of the inquiry.

Last week, several committee members took part in an external visit to the Isle of Skye as part of our inquiry. We were based in Portree. On behalf of the entire committee, I thank the staff of Broadford medical practice and Broadford hospital for meeting us. We are incredibly grateful to those national health service staff for taking the time to discuss the myriad issues that are impacting delivery of services across the island, as well as the unique challenges that come with recruitment and retention of staff in remote and rural areas.

We are also very grateful to those on NHS Highland’s board who, behind the scenes, helped to plan the agenda for the visit and ensured that things ran smoothly, and for the committee clerks’ work in supporting the visit.

I also offer our thanks to the Skye and Lochalsh Mental Health Association for allowing us to use its facilities for a set of evening engagements. The committee members were keen to hear from service users and local stakeholders, and we are really grateful to the significant number of people who came along to meet us and engage with us, often travelling long distances in the evening to do so.

The points that were raised during the visit will certainly be taken into consideration alongside the evidence that is received throughout the inquiry, and it will be invaluable in helping to inform the recommendations in the committee’s concluding report.

Thank you very much, deputy convener.

We move straight to questions. Cabinet secretary, I want to focus initially on the national centre for remote and rural health and care that was launched last October. When the then Cabinet Secretary for NHS Recovery, Health and Social Care wrote to the committee, he said:

“I have been clear that the Centre must focus on deliverables and impact”.

To what extent in the development of the centre has the focus been not only on strategy development but on actions, delivery and that impact?

First, I am pleased to hear that the committee was in Skye last week. Initially, there was a suggestion that I might have joined you there for that evidence session, but I am very pleased to be here this morning and grateful for the opportunity to discuss what is a very important issue for me, having been born and brought up in Orkney.

Like other colleagues around the table, I understand well the importance of delivering health and social care services in rural and island communities, and I also recognise the challenges therein. I am very much looking forward to seeing more of the work that comes through from the committee, and I am very grateful for the work that you are doing.

I will bring in colleagues on the progress that has been made off the back of the centre’s establishment, which has had financial support from the Scottish Government.

The centre has also led to the development of a rural and island workforce recruitment strategy by the end of this year, because the Government recognises that, for all elements of the health and social care service, but particularly in rural and island communities, the workforce is critical to ensuring that we can deliver services. Having that strategy is critical, and I believe that the task and finish group is meeting right now to discuss continuing that work. I do not know whether colleagues wish to add to that.

On the question about practical developments, the activity that has been given the most focus since the launch of the centre has been developing and delivering some education and training initiatives, principally to rural advanced practitioners. The rural advanced practitioners programme for paramedicine is a practical medicine programme that is designed to support advanced paramedicine practice in remote and rural settings. There has also been some work to develop multiprofessional training sessions for primary care multiprofessional practitioners, to support the continued roll-out of multidisciplinary teams in remote and rural settings.

In addition, the centre has made formal links with the centre for workforce supply, which we established in 2021. During the past two years, it has focused on supporting international recruitment activity, principally of nurses, into health boards across Scotland, including into remote and rural settings. It is currently shifting its focus into hard-to-fill medical recruitment in remote and rural settings, with early work focusing on challenges with psychiatry in remote and rural boards.

The final thing that I will note is the centre’s focus on the development of the credential in remote and rural medicine, which is the first of its kind in the United Kingdom. Roll-out of training delivery activity is on-going. That credential is now listed with the General Medical Council and it is in the final stages of preparation for delivery.

That was a helpful update. For the committee’s information, what is the reporting and monitoring structure of the national centre?

We meet monthly with colleagues from the national centre in connection with their work on developing the centre’s work programme and on the structure of the remote and rural workforce strategy. Through that arrangement, there is a governance team, with oversight by colleagues from Scottish Government, through primary care and other areas under the director general for health and social care. At the moment, we use that process to monitor delivery according to the centre’s agreed work programme. We also proactively monitor delivery of the centre’s work programme as part of one of NHS Education For Scotland’s agreed deliverables, through our sponsorship function in the health workforce.

To supplement that answer on the work that the centre has been doing, the sponsorship of the centre comes through the primary care directorate, so reporting of governance goes through that. As part of wider planning, delivery and strengthening work across Scotland, we have been bringing the centre’s work into NHS Scotland. Although there is a governance route into the primary care directorate—which is where the funding comes from—it is important that the work that the centre is doing and its priorities, particularly around the rural credential that Stephen Lea-Ross referenced earlier, is monitored.

As you are probably aware, the rural credential is about looking at the rural general hospital model and at what safe care looks like. We are bringing that into the work of NHS Scotland’s planning and delivery board. I suppose that that is less about governance and more about ensuring that the priorities are in line and that they are coherent, so that they can deal with the challenges that are currently being faced.

Good morning, cabinet secretary. How does the Scottish Government work with rural integration joint boards, local authorities and health boards to monitor the implementation of the national workforce strategy?

Obviously, local health boards and integration joint boards are responsible for their own delivery, and we have clear expectations that they will ensure that services continue to be sustained and delivered. We work closely with them, particularly on the workforce. We have instituted the areas of work that Stephen Lea-Ross and Paula Speirs have already set out, but there are others, such as the ScotGEM—Scottish graduate entry medicine—programme for rural general practitioners, that ensure that we continue to support new entry into rural and island areas.

We have the highest fill rate in the UK for the priority foundation areas, which is a good thing when it comes to filling the vacancies in rural and island areas, The fact that we are competing well against the rest of the UK is a good thing and shows that the work that we are doing with IJBs and health boards is coming to fruition. Obviously, challenges remain, and issues are clearly outstanding in certain areas, but the progress is there. The work that Stephen and Paula have already set out will, I hope, continue to support local areas in developing their workforce strategies.

In the evidence session last Monday on the Isle of Skye, we heard from NHS Grampian about the huge cost of locums and agency workers and the effect that that has on the board’s budget. What are you doing nationally to try to reduce that cost to all NHS boards across Scotland?

That is a major concern for me. Since coming into post, one of the areas that I have had the greatest concern about is the rise in agency and locum costs. In some areas, that cost is unavoidable, and we need to invest to ensure service continuation. However, I want to take a longer-term approach, and I hope that some of the reform discussion that we will have later this month and, going into the rest of the year, the reform and improvement work can focus on how we make sure that we have the culture and management structures in place that allow greater flexibility for workforce so that we are attracting and retaining staff.

We have a number of areas of intervention including bursaries and golden hellos to try to attract people to rural and island areas in particular on a sustainable basis, so that we can avoid the need for locum and agency cover. That cost increase over recent years is a major concern for me and one that I wish to tackle.

Last Monday, we heard evidence about trying to recruit staff in a care home on the Isle of Skye. It is only half filled because it cannot get staff, which is blocking a 24-bed hospital where some of the people are there for the long term. The same situation exists across all tourist destinations. Housing is critical. There is just no housing at all, because the houses have been bought as second homes or as Airbnbs. However, NHS Highland has a lot of land. What encouragement is there for the board to build its own housing supply so that it can bring in students and staff? When I asked the board about that, it said that it does not have the experience to build its own supply. How can we encourage it to do that?

That is a pertinent question on the wider issues that are beyond the control of the health and social care service in rural and island communities in being able to attract and retain staff. Mr Torrance rightly points to the issue of housing. I know from the most recent conversation that I had with NHS Highland about the situation at Portree that it is looking at what it can do from a housing perspective to support staff with their housing needs.

Wider measures such as the Scottish Government’s investment in the rural delivery plan and the emergency services key worker housing funds that we are bringing forward are designed to give local areas the ability to invest in ensuring that the social infrastructure is there to support people living and working in those communities and that those communities continue to be sustainable.

There are also wider political issues around attracting and retaining social care staff in particular. Mr Torrance and the committee will be aware of the recent decision of the UK Government to make it harder for social care staff to come to this country to work by stopping the dependants of those social care workers from being able to travel. Obviously, we are not in control of immigration and the decisions that are taken for us are having a detrimental impact on our ability to attract people to come and live and work here. Everybody is well aware that the impact of Brexit on our social care workforce was a near 10 per cent reduction in our social care staffing, almost overnight.

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All of that strikes at the heart of the ability of social care providers to provide the services that we need them to provide, which has a knock-on impact not just on the people who we need to be providing those services for but on the rest of the health service, because there needs to be a clear flow through the health service and, if one part is under significant pressure, in this case social care, it has an impact elsewhere.

Paula Speirs would like to come in on the back of that.

There is more that we are looking to do with the boards and the IJBs to support the improved sustainability of services. An important issue with regard to the sustainability of remote rural and island care is how we work across the public sector. Transport is an example of one of the areas in which we do that and, yesterday, we had a session with colleagues from Transport Scotland and regional transport partnerships to look at health transport planning in a way that we have not done before.

There are operational issues, but what we need to do is plan in a much more strategic way. Housing is another obvious area where that is an issue and there is a need to plan strategically how we work with and support people with regard to community planning, economic development and so on. That is a role for us. We have been engaging with colleagues who are engaged in wider public sector reform.

One area that I would highlight to the committee is the single agency model that is being developed. It presents us with huge opportunities to address some of those slightly wider challenges, which is important, because the issue does not just sit with health; it is a much bigger issue.

Before I invite Ruth Maguire to ask her questions, I should draw members’ attention to my entry in the register of members’ interests, which notes that I hold a bank nurse contract with NHS Greater Glasgow and Clyde.

Good morning. What is the single agency model that was just referred to?

It is the single island authority model. We are looking at what is possible with regard to local government and health boards working more closely together. Advanced discussions are going on with the island groups, with various levels of interest being expressed by those authorities.

I would like to dig into the housing, childcare and infrastructure issues. Addressing them would help across the board, in terms of public servants moving to rural and island communities. When I have asked during evidence sessions whether boards are having conversations about housing with local authorities, I have found that that does not seem to have been happening. I totally appreciate the challenging fiscal environment that we are in at the moment in terms of capital, but is there a role for the Scottish Government in providing guidance or a framework that would enable public bodies—local authorities, health boards and so on—to pool their resources, such as the land and buildings that the NHS has, and perhaps bring in private investment, too, to develop housing solutions and childcare solutions that would serve the communities and help with sustainability?

There are frameworks in place around the integration of health and social care that should allow for some of those discussions to take place. Where there is an understanding on the part of IJBs and health and social care partnerships that there are particular workforce challenges in the communities that they are looking to serve, those discussions can start there and spread to other forums. However, of course, where we have that convening power or, indeed, where we can provide that guidance, we will continue to do so. There are good examples of some of that work being done already, and we need to build on those and try to provide that advice on a wider basis.

Could you provide an example of that, particularly in relation to building? We will be aware of lots of good examples of joint working, but I am not sure why things are not progressing; you might have more information on that. We have had the integration for a number of years now—for a decade, even.

I would be happy to follow up on that in writing, and Paula Speirs wishes to come in on that.

Integration has happened at a different pace in different parts of the country. There are some good examples of integration working well, as I was able to see, for instance, in Shetland, where there has been very strong integration in health and social care across all levels of public sector delivery, which allows decision making to be informed on the basis of service delivery. I point Ms Maguire and the committee to that very good example. There are other areas where levels of integration could definitely be better, however, and that is part of the reason why I believe that the national care service is the right thing for bringing things forward from a service delivery perspective.

I am conscious that Ms Maguire is looking at the wider issue of service delivery around social infrastructure, housing and childcare, for instance. I believe that that comes from the discussions that are taking place on an integration basis. Where we can improve on that, obviously we will.

To give another example, work was done at a care home in the Western Isles last year, I think. The health board has been working with the IJB and the council there to utilise that care home for accommodation purposes. That is just a brief example, but we recognise the real challenges around housing in the Western Isles. It has been possible to attract and recruit consultants in the Western Isles, in accident and emergency, for example, but those roles have been turned down because of a lack of access to childcare. We have been working with colleagues on that, and we have been trying to develop a sense of the framework through the task and finish group, which is meeting for the first time today, identifying the enablers and conditions for success—if I can call it that—that we need to have in place but which might not yet be in place because we have not considered that from a wider-Scotland perspective.

That would certainly be helpful. It is not a matter of asking for additional resource; it is about using what is there. If we could have those examples, that would be really helpful for the committee.

Sandesh Gulhane has a supplementary question.

I make a declaration of interest as a practising general practitioner in the NHS.

Good morning, cabinet secretary. I was listening carefully to your answer to David Torrance’s question—you are not taking any responsibility for social care, and it is all the fault of Westminster and Brexit.

No—I have not said that. I was talking about the issues that we face regarding the workforce challenge. It would be remiss of anybody not to acknowledge the impact of making migration to the UK harder and the impact that Brexit has had. Indeed, I think that Mr Macaskill, who represents social care providers, would make those very points, too. Of course we have a responsibility to continue to deliver for social care, and we will continue to do all that we can, which is why we are looking to implement the national care service so that standards can be raised and can become more consistent—both for those working in the service and for those we are providing it for.

When decisions are made for us that are not in our interests and that are detrimental, of course I have to point those out, and Mr Gulhane will understand why I would need to do so. There was a 10 per cent drop in our workforce off the back of Brexit, and the new migration rules will make it much harder for social care providers to employ social care staff. It is understandable that I would wish to make such a comment.

You mentioned the NCS. When are we seeing the amendments?

We are working with the specialist advisory group at the moment on the stage 2 amendments, and we will be providing them to the committee as soon as we can.

Do you know roughly when that will be?

I could not say for certain, but the work is on-going.

When the 2018 GP contract was put in place, did the Scottish Government feel, at that time, that it would have a negative impact on rural general practice?

No. We consulted the British Medical Association and others directly on the implementation of the 2018 contract. It is obviously very difficult to bring forward something that takes a one-size-fits-all approach, while understanding that there will potentially be an impact of that.

That is partly why we are working to ensure that we have multidisciplinary teams coming through; looking at the primary care improvement plan; and providing investments so that we continue to see further investment in primary care in rural communities. It is also why we are continuing to support initiatives such as ScotGEM, which is about encouraging people who are going through medical training to specialise in rural general practice. We recognise the need to ensure that we continue to support rural general practice.

As I said, I was born and brought up in Orkney, and I recognise the role that general practitioners play in rural communities. Those general practices are anchor institutions, and they are a critical element of the sustainability of those communities. I am passionate, therefore, about ensuring that we continue to support rural general practice so that it is sustainable, and so that we continue to have a primary care service in rural and island communities to prevent further ill health among people who might otherwise end up in secondary or acute care.

That is part of the reform and improvement discussions that I hope to bring forward later this month. I will be looking to work with all parties, and others who are represented around the table, to ensure that we take forward the best ideas for how we can put the NHS on a sustainable, improved and recovering footing as we move forward.

I am glad that you said that, because it relates to my next question.

Scottish Conservatives have produced a 26-page document, “Modern, Efficient, Local—A new contract between Scotland’s NHS and the public”, which looks at how our NHS can be improved. I would be keen to hear your feedback on that.

There was a promise of 800 more GPs, and I have heard you say multiple times that we are on track to have that number. Is that the case? How many of those 800 GPs will be in rural communities?

I have already given the example of ScotGEM, where we have people coming through a training system that is dedicated to serving remote general practice. We are improving the situation with regard to GP numbers, which I think are up by 256, or 257, in recent years, and we have a record number of GPs—1,200—in training. I recognise that we need to go faster in order to meet the target. That is why, over recent years, we have added new GP training places to the system. I hope that, through the record level of GPs in training and the work that we are doing with ScotGEM—as Stephen Lea-Ross and Paula Speirs outlined, and as I highlighted—a large number of those new GP entrants will go into the rural communities that we wish to see continue to be sustainable.

I thank the panel for joining us today. I want to ask about the anticipated focus of the forthcoming remote and rural recruitment strategy. Can you elaborate on its key objectives and its focus?

It is about making sure that we continue to see a sustainable workforce for our rural and island communities. It is in development; we have already set out the fact that some of the work is very much live. The focus is on ensuring that we continue to see a supportive and encouraging workforce strategy that ensures that we have a strong recruitment and retention policy for rural and island communities.

Could you outline the scope of the professional roles that the strategy will cover? Is it simply restricted to NHS clinicians, or will it cover the social care and third sector workforce more broadly?

I believe that it is for the social care side as well.

Yes, that is right. The intention is that it will be a holistic remote and rural recruitment strategy that covers NHS professionals, as well as recruitment and retention priorities for social care and social work services, in recognition of the fact that, in such communities, we are drawing from a smaller band of professionals overall.

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So far, there have been two specific discrete focuses for the development of the strategy, one of which has been on remote and rural recruitment practice. That involves looking to improve the embedding of practice across all our rural and island communities in relation to some of the existing support services and mechanisms that are not necessarily fully utilised 100 per cent of the time. In the context of recruitment and retention, we are talking about things such as premier support for housing and so on.

The second focus is on drawing closer strategic links between remote and rural recruitment practice and the broader suite of initiatives that are taking place across Government, for example through the rural delivery plan. As things stand, those are the two broad areas of focus.

Will the work on the strategy intersect with the work of the nursing and midwifery task force and other similar pieces of work?

Yes. I co-chair the nursing and midwifery task force. There are areas of work that it is clear that colleagues on that group are keen to expand on, and given that recruitment and retention is obviously a very strong and live area, there will be a crossover between the work on the strategy and the work of the task force.

To follow up on Mr Sweeney’s question whether social care will be covered by the strategy, the advisory group includes the Convention of Scottish Local Authorities, Scottish Government officials and health board representatives, so social care will be covered.

In considering the recruitment and staffing models, we are looking at a slightly wider element—the issue of what is a sustainable model of health and care in our remote, rural and island areas. We must not look at those things separately. That piece of work involves looking not just at our staffing model, but at what a sustainable model of care is, given that our services are particularly fragile. That is not the case only in remote and rural areas. We are making some immediate reforms in a number of areas. The cabinet secretary referred to the need for longer-term reform, but we need to do the planning for that, because if we do not plan, services could become even more fragile.

The remote and rural implementation group, which is where the national centre came from, discussed a revised staffing model for the rural general hospitals. We have certainly found that there are more GPs, in particular, who are keen to work in the hospital environment. Part of what we need to do now is look at how we deliver not only more primary care in communities, but more acute care in primary care settings. That might include diagnostics or oncology, for example. As we look at our workforce, we need to look not just at our GP workforce and our allied health professionals, but at how we can bring in our acute clinicians as well.

I mentioned that, when we visited Skye last week, we went to the Broadford medical practice. The GPs there said that some of them work shifts in the adjacent hospital, but that they find that complex and difficult to do because they need to have two different contracts, and it can be quite a faff, as they described it, to organise that.

Is any attempt being made to make it easier for GPs to have a hybrid work pattern that includes working in a GP practice setting and working in a rural hospital setting, especially when those settings are located in close proximity?

I would be very interested in hearing more about the direct experience that you have been able to pick up. I presume that that will come through in the report, but if there is anything that the practitioners in Broadford would be able to feed straight in, I would be keen for us to look at that as part of our reform and improvement work. We are keen to look at how we can blur the lines of health boards and ensure that we maximise the operational capacity through better working arrangements for our staff.

However, I am cognisant of the fact that, although such an arrangement might work for many people, there are others who would prefer to have a fixed-point contract that involves working in a fixed-point place. Therefore, we would need to handle that carefully, but I would be very interested in hearing more about the experience that you picked up in Broadford.

An important point of context is that the practice was directly managed by the health board, as opposed to it being an independent contractor model. That seems to be an increasing trend in NHS Highland.

In rural areas, there are more examples of that coming through.

If it is okay, I will add to that.

As part of sustainability, we need to join the different components together. On the example that you gave about our employment contracts being a challenge, part of what the task and finish group is trying to understand is the large amount of work that has been done over the years on what an optimal model looks like. We now need to try to understand what the levers are for making that change happen—for example, addressing some of the employment contracts. It might be that, for some areas, the practices in the health boards are working.

We are trying to get underneath some of that. As I said, the question is how the optimal model works in relation to rural general hospitals in particular. It is not just about the hospital workforce. It is right across the piece. We have not yet got into some of the enablers. That is exactly the sort of work that we are doing over the next few months. It is being done over the next few months because we recognise that some services are fragile.

I will make a point about some of the feedback that we got from the emergency department at Broadford hospital. There was a tragic incident in Portree at the weekend, just as we arrived. There was some reflection on that. One of the points that was raised was that rural emergency medicine is simply not attractive to a lot of people, because they see perhaps one or two cases a week and so professional development is constrained. A different approach needs to be taken on GP-led emergency care, perhaps. Are you considering that as part of the strategy?

Obviously, I am conscious of the need to ensure that we have as equitable access to health provision across Scotland’s geography as possible. Mr Sweeney points to an important conundrum on recruitment and retention. Typically, accident and emergency clinicians look for a fast-paced, ever-changing environment. That is what they thrive on. When I shadowed some accident and emergency shifts, that is what many of the A and E consultants told me. That is what drove them to go into accident and emergency, as opposed to any other specialty.

I have friends and family who use the Balfour hospital in Kirkwall. Far fewer people go through the accident and emergency department there than any of the accident and emergency departments in the central belt, for instance. That will have an impact on the attractiveness of the department. That is part of the reason why we have come through with the initiatives that Stephen Lea-Ross spoke about, to try to get people to specialise in remote, rural and island healthcare as early as possible. That means that they will probably take a more multidisciplinary approach to their training and will understand what they are going into. I hope that they will be more willing to stay in a remote and rural setting, understanding the fact that it is a very different environment from an accident and emergency department elsewhere.

I am also cognisant of the situation in Portree, which was a sad incident. My condolences go to the family of the person who lost their life. We are working with NHS Highland on bringing back 24-hour urgent care to Portree as quickly as possible.

Another issue that was raised in the visit was the hospital’s design. The hospital was a relatively recent investment by NHS Highland but a lot of the clinicians felt that their feedback had not been listened to in the development of its design. Much of that was down to time constraints because they did not feel able to leave the day job to contribute to consultations. In the development of the consultation on the workforce strategy, are you looking to tackle some of the practical constraints that mean that people find that they cannot access consultations?

I can speak to a more local example that I am aware of. I declare an interest in that I am recused from Government decision making on the new Monklands hospital. However, from a constituency perspective, I am very aware of the close involvement of clinicians in that hospital’s design.

If that has not happened to the same degree in Broadford on Skye, I would be keen to know about that to ensure that NHS Highland and others can learn from that experience, so that we have projects that are informed by clinical experience to ensure that we get them right.

Just in terms of the recruitment strategy—

We need to move on.

Okay.

I will ask about education and training. Obviously, for the sustainability of a workforce, growing your own is helpful, and certainly the folk who we have spoken to in rural areas have pointed to that. As I ask this question, I am conscious that some of the solutions would address issues across the country and not just in rural areas.

First, I want to ask about the work on NHS apprenticeship roles. We have heard about roles in dietetics, occupational health, physiotherapy and radiography. It would be helpful to hear more about the development of those apprenticeship roles.

I will bring in Stephen Lea-Ross, as I am not as familiar with that issue, although I am familiar with the incredible work that NHS Education for Scotland does and, in particular, the way in which it is helping to inform some of the initiatives that we have already spoken about, such as ScotGEM and the rural fellowships. I will bring in Stephen on the specific examples that you asked for.

Broadly speaking, over the past 12 months, we have provided about 788 new apprenticeships or apprenticeship exposure opportunities across our rural, island and mainland boards. They cover the range of specialties that Ruth Maguire outlined. Clinically, we have focused on nursing and midwifery support roles and on AHP support roles, including radiography and access-to-theatre nursing roles.

One thing that we are focused on is the transition between apprenticeships and qualified working practice, either as a nurse or an AHP. To date, the most successful pathway for that is the Open University earn-as-you-learn pathway—we currently have 466 students enrolled on that pathway nationally, with around 72 in rural and island communities. That is supporting the transition to degree-qualified education and supporting sustainable progression through a career path in rural and island communities.

The next step in our anchors programme, which is focusing on apprenticeships and access to NHS careers, is to broaden the range of opportunities in those existing professions, focusing on band 2 to 4 support and entry-level roles across nursing, midwifery and AHPs—

I am sorry to interrupt, but I would like to jump in. How are the numbers of apprenticeships available to each health board decided? Do boards have a certain proportion that they are allowed to support? How does that work?

The number that I mentioned is just an aggregate number. Boards are not limited in the number of apprenticeship opportunities that they provide, other than in relation to capacity and available funding. As with our pre-registration training, from a Government perspective, we are looking for a supportive training and development environment. We want to ensure that, through the apprenticeships leads—every board has an apprenticeships lead co-ordinator—there is quality training and then onward retention. We also encourage partnerships between health boards and third sector organisations, including the Prince’s Trust, to try to do some of that early employability engagement.

Boards are not formally circumscribed in any way in their offer—it is based on their local workforce planning.

That is helpful. I am sorry that I interrupted you. Do you want to continue on that previous point?

No, it is okay.

My other question is on how the Scottish Government can encourage universities to support more flexible training opportunities. Most of our references are to Skye, as the committee has just been there. Would it be possible to deliver access to nursing in Portree, for example? We heard from an advanced nurse practitioner that they had offered to deliver that, but had not been able to do so. Obviously, I do not know the full details, but what work can be done to make the most of such opportunities?

10:00  

Again, that goes back to the discussion around the nursing and midwifery task force and looking at how we make sure that we are set up to take advantage of the existing opportunities that are available in higher education institutions. The training places that we have available are not fully subscribed, so for those considering a potential career or a career change, look at the opportunities in your local university. There is also the nursing bursary to help to support a transition to or an entry into nursing.

Stephen Lea-Ross referenced the helpful example of the Open University work. I am very keen to look at what more can be done—the discussion is happening at the task force—around the earn-as-you-learn pathway and whether there are more opportunities for that, so that people can either shift within the health service or come into the service.

To get directly to Ms Maguire’s point about training being delivered as locally as possible, we will continue to work with higher education institutes to see what more is possible, particularly for remote and rural areas. I was at Robert Gordon University last week and saw some of the fantastic work that is being done there around nursing and paramedic training. There is real enthusiasm among nursing students for what they are embarking on and where they are looking to serve their time.

I hope that we can continue to provide that opportunity to others, particularly, for the benefit of this discussion, in remote and rural areas, so that we continue to have people to serve in the areas where we need service provision.

I thank the cabinet secretary for the information on this important issue. I am aware that one of the key issues in relation to AHPs is the link with universities and the provision of a flexible model. Have you had any discussion with universities or other portfolio holders that might help with that?

I have not directly discussed the issue in relation to AHPs, but I am more than happy to take it away for Ms Mochan and report back. Indeed, I should probably be having such a discussion, so Ms Mochan’s suggestion is useful.

We have explored some workforce issues. How does the work to support the workforce link in with the wider need for reform?

It is absolutely central, because we cannot have a sustainable and improving health service without a sustained and improving workforce. I am very proud of our incredible workforce. In the past 14 weeks, I have been able to see some of it in action. As health secretary, and previously as a user of the health service, I have seen the fantastic work that our workforce delivers.

On interaction with the workforce around reform, I am keen to hear directly from the workforce, its representatives and the trade unions on setting out how we move forward in a sustainable way and how we make sure that we continue to see improvements. I am keen to hear from the workforce about its ideas for changing how the health service works to make it more responsive to the needs of the people of Scotland and to make sure that it continues to be sustainable.

Having discussed the issue with people over the past few months, I know that that must be about making sure that we prevent ill health. The public health work that we are doing is of critical importance in making sure that we have a healthier population, in stopping the continued escalation in demand that we have on our health service and in making the shift on the flexibility of our employment patterns. We have seen some of that in the implementation of changes under agenda for change over recent weeks. That is where we will need to go, but that has to be informed by discussions with the workforce, which I am committed to having as part of the reform discussions.

On preventative healthcare, given budgetary pressures across the board in all services, but particularly in health services, how is the Scottish Government ensuring the financial sustainability of health services amid rising costs? What resource allocation strategies are being employed to balance immediate acute needs with long-term planning and a shift towards preventative healthcare, particularly in remote and rural places that are facing the challenge of demographic changes in the workforce and patients?

Ms Mackay strikes right at the heart of the clear challenge that we are facing in the health service and in how we move forward with reform. If resource was aplenty, of course I would be looking to invest far more in primary care services to help with the prevention work and in community and voluntary sector organisations that are doing incredible work across all disciplines.

As part of mental health awareness week last week, I saw some of that work from a mental health perspective in Aberdeen Football Club Community Trust’s work on the changing room extra time initiative. That is incredible work to prevent more acute presentation. If resource was aplenty, we would go there.

Ms Mackay is right that we have to continue to sustain services, but we also need to drive change. That is where I hope that we will all be able to come together to discuss how we move human and financial resource to ensure that we are improving people’s health in the first place.

That will be most acutely felt in rural and island communities. Paula Speirs talked about the fragility of some services, because sometimes they are provided on a small team basis and, if one person moves on or retires, the service is compromised. We need to continue with the workforce planning perspective, but we also need to look at prevention. Supporting people through hospital at home in rural areas, for instance, is an important innovation. The community care model that treats people as close to home as possible has better outcomes, but it also prevents further deterioration in their health that requires greater intervention in the acute settings, which is what we want to avoid.

I am pleased that the cabinet secretary mentioned the third sector and the voluntary sector. They were among the people whom we spoke to on our visit to Skye, but I have also spoken to some who operate across bits of rural South Lanarkshire. Those organisations face logistical issues such as when they hear about funding. Some of them even referred to basic things such as not getting emails back from people in health boards and local authorities about how and where to access funding.

What more can the Scottish Government do to ensure certainty for organisations that are delivering vital services, whether it be in mental health or in other areas of health and social care? How can they have certainty about the most basic things, such as knowing more than a month in advance that they are going to get funding for the next quarter, for example?

It increasingly sounds as though the session on Skye was incredibly productive, and I am ever more regretful that I was not a part of it so that I could hear directly from the colleagues that Ms Mackay refers to.

We are in a situation where we do not have the luxury—although I do not think that it is a luxury, actually—of being siloed; we cannot afford that. We need to use the capacity that is available, regardless of where it comes from. There must be much greater collaboration between public sector agencies. The integration agenda is about much greater collaboration between our health and social care partnerships, or IJBs, and our statutory partners, as well as the community and the voluntary sector. As Ms Mackay rightly said, that sector often provides services that statutory providers cannot provide to the same level of funding. We have to see much greater collaboration there.

We must also utilise the expertise and innovation that are coming through from the private sector. If we can harness that, we have an opportunity to stay true to the principles of the NHS being publicly owned and free at the point of need and delivery. We need to harness some of the products that are being delivered by the academic and private sector to free up clinical capacity for the care that clinicians and health service staff give. We have an opportunity to take forward much greater collaboration, if we can, to continue to improve and reform our health service for the better.

Good morning, cabinet secretary and panel. What consideration is being given to reviewing urgent care and accident and emergency provision in remote and rural areas?

That is under active consideration, as Ms White will understand, given what happened on Skye recently. Sir Lewis Ritchie undertook a review of the services on Skye; with him, I met NHS Highland, and I expect to have a delivery plan from the board for how that review and its recommendations can return to implementation. The review was implemented for a period, but there were issues with sustainability, for the pertinent reasons that we have heard around attracting and retaining staff in rural and island communities. I am keen to ensure that Highland can deliver on that.

That is a microcosm of what we need to see to a much greater extent across the country. We are working with our rural boards in the areas that I have set out, which include supporting our workforce and supporting the work that NHS Education for Scotland is doing to provide education and training so that urgent care services in remote and rural areas can continue to be sustainable.

Sometimes—well, often—incidents pressure test a system. We have heard about the tragic situation in Portree.

Last week, in my area, a little girl called Ivy Mae Ross tragically died; I know that the thoughts of all of us are with her family. That incident highlighted an issue, in that a specialist operations terror attack unit had to be deployed because ambulances were not available to attend the scene. That was not just a single situation—it has been going on for months. At that time, many ambulances were stacked outside the hospital. On that occasion, there was no negative impact directly from that, but it set alarm bells ringing. Given the unrelenting pressures on the Scottish Ambulance Service in my NHS Grampian area, in particular—although those pressures are not unique to Scotland—will you, as cabinet secretary, review contingency planning for serious incidents such as the ones that I mentioned?

Like Ms White, my thoughts are with the family of the little girl to whom she referred. Those incidents are tragic examples that we wish to avoid, and everything that we do as a Government, and as health boards and services, is to try to prevent such situations from happening.

Ms White is correct about the pressures on the Ambulance Service and about those pressures not being unique to Scotland. Unfortunately, we have seen the type of ambulance stacking that we saw at Aberdeen royal infirmary elsewhere in the UK, too. That is partly due to the significant increase in demand that we have seen. We are seeing a clear increase in demand on our ambulance services. We also need to have those services in the right place to respond to incidents such as those that Ms White spoke about.

We have made a significant investment in our Ambulance Service to support an increase in the number of practitioners and paramedics working within it to respond. We are also working with boards on how they can make sure that the flow at their hospitals is working better.

That goes back to the point that I mentioned about the importance of social care to our health service. It is important that we get our social care services working for the people who need them, but delays in social care also have an impact that goes all the way back through the hospital, right up to the front door, where ambulances are stacked outside because of the pressure in the hospital. That pressure is not necessarily in accident and emergency, although that is sometimes the case; it might be about accessing beds in the hospital.

We are making investments in all areas of the system to relieve that pressure. We can see that that is working, but it needs to move faster in order for us to see continued improvement in the services that we have available to us.

10:15  

To follow up on that, it is—as you recognise—a huge issue that there are failings in the system and that some hospitals are better than others. However, stacking—for example in the north-east, where half an ambulance fleet is stacked outside the hospital—puts pressure on the system, so it is clear that there is a failing in the wider system. Will you be tackling that as a matter of urgency?

We are in discussions with NHS Grampian on the point to which Ms White referred and the particular example that she highlighted, which she has also raised in the chamber. We have been working with NHS Grampian to look at what it is doing. That includes work to improve the flow through the hospital so that we are not seeing ambulances stacked up outside.

The national centre for sustainable delivery is doing work to look at how we ensure that those who are in our hospitals actually need to be there and at how we can improve the delayed discharge picture so that we have hospital beds available. Ultimately, that is at the heart of why we have had delays, certainly in Scotland. I cannot speak for the rest of the UK, but that is certainly what I am picking up here. If we are seeing delays in ambulances being able to turn around at hospital, that is largely because of a lack of availability of beds.

We are using the centre for sustainable delivery to identify patients who can be discharged and get them discharged as quickly as possible, and thereby bring down the average hospital occupancy time. We are also working on that with our local government partners. I work closely with Councillor Paul Kelly of the Convention of Scottish Local Authorities, and we have agreed on work that is to be done across Scotland on giving people patient discharge dates, discharging before noon and weekend discharge. We are looking at everything that we possibly can to get people to where they should be, which is either at home or in the community, rather than in hospital.

We are also doing more focused work with our health and social care partners in Grampian on whether anything further can be done to improve the delayed discharge picture and to improve integration in NHS Grampian. I would be happy to update the committee on that work.

Good morning, cabinet secretary. A couple of different points have come to mind while I have been listening to all the questions and responses. I am interested in issues around digital technology and innovation, and in how remote and rural areas can or cannot benefit from that.

During Covid, we saw that the use of NHS Near Me and the attend anywhere service was beneficial. How can we harness what we have learned so far from the use of digital technology in order to support remote and rural healthcare?

That points to some of what I was referring to in response to Ms Mackay.

The use of innovation in our health service is going to be critical. Some of that is already in place—Ms Harper spoke about Near Me, which is currently in use—but there is more that we could do to ensure that we continue to utilise some of that innovation to a greater extent.

We also need to look at some of the innovations with regard to digital technology and the advances—if they are ethically used—in artificial intelligence. Critically, we need to ensure—as Ms Harper was driving at in her question—that that is done in not only an ethical way, but an equitable way, so that those who are in remote and rural areas can benefit from such innovations if they choose to do so, and take advantage of that way of working.

I am very keen to use innovation—as I have set out, it will be central to our being able to see reform and improvement in our health service in a way that maintains capacity and the opportunity for caring by those—the medical professionals and staff who work across our health service—whom we task with supporting patients coming through the system.

With digital connectivity, the resilience of the network, cyberresilience and cybersecurity come to mind. There have been recent issues with NHS Dumfries and Galloway experiencing a cyberattack. Is that more of a challenge in remote and rural areas, or is that the same no matter which health board we are thinking about?

I do not think that there is a particular issue in respect of ensuring that we have greater cyberresilience in remote and rural areas. Having grown up in an island community, I know that when a system fails, physically going to a clinic or hospital service is more challenging, because of travel time, transport connections and so on but, from a cyberresilience perspective, I do not think that rural or island communities are any more likely to be targeted by criminal gangs, such as the one that targeted Dumfries and Galloway, than other communities would be.

On the wider question of the challenges experienced by boards in remote and rural areas in implementing digital innovation, we are certainly seeing some challenges, as those health boards are typically smaller, and they therefore might not have the same level of capacity or capability as some of the larger boards in areas such as digital. Boards and their digital leads are working together, however. For example, the north of Scotland innovation group met yesterday, and the west of Scotland has similar arrangements for bringing the digital leads together. We can deliver several things at once. Those groups are looking at how to use Consultant Connect, for example, and other innovations.

Innovation is actually coming through much more in remote and rural areas than in urban areas, as people in the more remote areas have had to utilise such solutions. As we go around the country we see some really good examples, which should be spread out much more widely. Ms Maguire made a point earlier about considering some models of care, not just for remote and rural areas but more widely.

You have mentioned travel and transport. The Highlands and Islands have a travel scheme whereby patients get travel and accommodation provided for free in order to access healthcare. In other remote places such as Dumfries and Galloway, patients are means tested for travel reimbursement purposes. Is there a plan to review the Highlands and Islands travel scheme to see whether there is potential to apply it to other remote and rural areas where patients are being means tested, as I have described?

As Ms Harper will be aware, there are particular challenges around those in island communities being able to get to the mainland to access services. That means that they often need to travel by plane, which is incredibly costly and requires quite a bit of logistical planning. Ms Harper asked a direct question on whether we would review the situation for people in other rural areas, such as Dumfries and Galloway—the area Ms Harper represents—and the Borders. I am always happy to keep the arrangements under review.

I am cognisant of the financial challenges that are being faced by patients at the moment amid the UK cost crisis and, when it comes to being able to provide any extra funding, Ms Harper will understand the financial fragility that we are living with in government. I am always happy to continue to consider the situation. If Ms Harper has individual examples of where things have proved to be problematic I would be happy to hear about that, in order for us to have an informed review.

We have six minutes left for this evidence session, and three members have supplementaries. If members and the panel can be concise, we will probably get them all in.

On the theme of what you were saying earlier about wanting equitable access to digital and to the innovations that are coming through, what are you putting in place for rural communities for them to be able to access fast internet, fast broadband and mobile technology, which is essential to the future working of the NHS?

Mr Gulhane will be aware of the Scottish Government’s reaching 100 per cent—R100—programme that invests in broadband and supplements digital connectivity as an area of UK Government responsibility. The roll-out is going well and rural communities are being connected in a way that they would not have been had it not been for the Scottish Government’s investment. Work is also being done on mobile connectivity by some of the service providers.

I am racking the back of my former economy briefing brain, but I would be happy to ensure that colleagues in the economy portfolio furnish Mr Gulhane with more information on some of the work that is being done with service providers in rural and island communities to improve the availability of mobile internet connectivity. He is absolutely right that making sure that those areas are able to access digital services is critical, especially when that innovation will be most needed by and will be most appropriate for some of the rural areas.

In response to Tess White, you spoke about people who are in hospital when that is not the right place for them. An issue that has struck me both in my local area as well as during our visit to Skye is the number of folk who are in hospital because of legal complications, if you like—no one has a power of attorney, so decisions about their care are challenging. Is there more that can be done about that? Do we need to raise awareness of the requirements for families to have powers of attorney and other arrangements in place, or does something need to be done in respect of the power of attorney process?

A significant number of people who would be considered to be in the delayed discharge category are adults who have incapacity, which is an incredibly complicated area. I will take up Ruth Maguire’s invitation and encourage people to ensure that they have power of attorney arrangements in place, as well as arrangements that allow for people to get access to the health and social care services that they need. As a Government, we are looking to introduce legislation on adults with incapacity in order to make sure that we are improving the system and the services for it. My colleague Jenni Minto has responsibility for that bill and we are looking at it during this parliamentary term.

I have a quick clarification on my last question. I know that we discussed the capital investment consultation. My question was specifically about the remote and rural workforce recruitment strategy and the design of the consultation for it. I do not know whether you have any comments on how that will be designed to ensure that clinicians and other stakeholders do not feel that they are unable to participate in the consultation due to time constraints.

To answer some of your other questions and bring it back into one answer, for the strategies and plans to be effective, stakeholders have to be consulted on them. In order for us to have an effective and sustainable health service and if we are to have a workforce strategy that means anything, the workforce and trade union representatives must be consulted and must be part of the discussion. They will absolutely be part of the discussion.

I suspend the meeting to allow for a changeover of witnesses.

10:28 Meeting suspended.  

10:29 On resuming—