Health, Social Care and Sport Committee

Meeting date: Tuesday, June 6, 2023

Official Report 736KB pdf

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Scrutiny of NHS Boards (NHS Lothian, NHS Grampian and NHS Fife)

The second item on our agenda is continuation of our scrutiny of front-line national health service boards. For this morning’s session, I welcome to the meeting Calum Campbell, who is the chief executive of NHS Lothian; Professor Caroline Hiscox, who is the chief executive of NHS Grampian; and Carol Potter, who is the chief executive of NHS Fife. I thank you for being with us this morning.

We will move straight to questions. Given the increased cost pressures and increasing demand that health boards currently face, what can they do to reduce deficits as planned and achieve a break-even position?

Caroline Hiscox’s light came on first.

Did it?

It did.

I am happy to take that question. Good morning.

The underlying financial position is one part of a pretty complex picture. I recognise that colleagues on the committee have heard from our colleagues from across Scotland. From NHS Grampian’s perspective, we are looking to do a range of things to address the deficit.

In 2022, NHS Grampian’s board endorsed our new strategic intent, which incorporated our learning from the pandemic. The plan is called “Plan for the Future”. The overarching principles in that and its aim are to move us to a more sustainable health and care system. Obviously, finances are a core component of that.

In the current operating environment, we are very mindful of the interdependencies of our operating performance, our financial fragility, the fragility of our workforce—which is really important—and the quality and safety of our services. In “Plan for the Future”, sustainability and recovery of the financial position are key.

In looking at the overarching position in relation to health and care, we have been very cognisant of the challenges that we are faced with in Scotland and, specifically, in Grampian. In considering financial sustainability and recovery of it, we have been mindful of the projections relating to the Scottish burden of disease study; of the population’s current health and what we in the health sector can do to improve that; of growing inequalities, particularly those relating to health; and, of course, of Scotland’s demographics and the ageing population demographics of Grampian.

On finances in particular, we have a very challenged financial position that is similar to that of the rest of the public sector in Scotland, specifically in healthcare. We have shared that with the committee: colleagues will have read the Audit Scotland report and have heard evidence from other chief executives, as I said.

In 2022-23, NHS Grampian returned a balanced position, which was not our projected position. In March 2022, we reported to the Scottish Government a projected deficit of £19.9 million, but the revenue position improved significantly in March because of a number of one-off funding streams from the Scottish Government and something that we were able to do with regard to our annual-leave accrual. Even though the board has managed to achieve that outturn this year, the underlying financial challenge for Grampian is significant.

It is really interesting and important that we have always achieved revenue balance in Grampian, but we are now seeing a step change in the financial challenges that we face as a board, particularly in balancing the challenges with the operational service pressures that we face.

We have submitted a three-year financial plan for 2023 to 2026 to the Scottish Government, and we have a five-year medium-term financial framework, which was endorsed by the board in April. The medium-term financial framework is to allow us to prioritise the resources that we have for dealing with immediate pressures and, importantly, for moving towards sustainable health and care services.

The medium-term financial framework acknowledges and reflects the complexity of our financial climate, including patterns of funding from the Scottish Government, funding levels, projected rises in costs, our changing demographics and the burden of disease. Under current planning assumptions, NHS Grampian will not be able to balance our revenue position with funding levels and anticipated expenditure over the next five years. The in-year financial position is expected to improve year on year, but we anticipate that we will still have a deficit by 2028.

However, with our medium-term financial framework, we are moving towards understanding what we can do to improve that position. Part of that will be the 3 per cent savings that we have set out relating to the value and sustainability programme that is being driven nationally as well as locally. To be explicit, our annual deficit position for the coming year is looking at £60.6 million in-year, which will improve, but under the current projections we will remain in deficit in year 5.

In trying to balance that, we will focus on value and sustainability and delivering efficiencies where we can. We will then focus on our transformation programmes through our strategic intent and working with our partners in the local authority and integration joint boards to redesign services. One of the biggest changes in the way in which we are spending our money is in relation to staffing costs. We are now spending a higher proportion of our resources on pay costs—54 per cent—and 46 per cent on non-pay costs.

We do not have a particularly different story to tell from anyone else who has given the committee evidence about the cost of inflation, increased demand on our health and care system and the planning assumptions that we are using, in particular around drugs.

We will come on to pay later. Specifically on that last point, what percentage of that 54 per cent is spent on locums?

Last year, our expenditure on medical locums was £17 million. We separate out medical and nursing supplementary staffing and agencies and locums. Medical locums cost £17 million and we spent £12.6 million on nursing agencies and locums.

Is that locum, bank or agency, or is that all one figure?

For medical locums—

I am asking about nursing.

That amount is for agency nurses.

The £12.6 million was spent on agency.

It was spent on agency nurse staffing.

Supplementary staffing is what I consider to be all non-substantive staffing, which includes agency and bank staff.

I am sorry, but I want to drill down into that. I am trying to get at whether the £12.6 million is for bank and agency staff or only agency staff?

It is for only agency staff.

Sandesh Gulhane has a supplementary question on that.

Thank you, convener. I want to drill into that a bit further. How much did you pay for the locum agency fee? I am not asking about the proportion that then went to the medical staff or the nursing staff. How much money went to the agency itself?

I do not have those specific figures in front of me. I will be happy to confirm the amount in writing to the committee. The figure varies. If I speak specifically about nurse agency, the figure varies depending on the agency with which we have to contract.

I am very pleased to say that NHS Grampian is now in the position of having no colleagues working on what we call off-contract frameworks. All our agency nurses are now on contract, which means that the percentage that goes directly to the agency is as low as it can be and is nationally agreed. We have got to that position only in the past month—we had a couple of theatre nurses whom we were having to use. I can get the specific figure back to the committee in writing.

Can we have the figure for both medical and nursing staff, please?

Yes.

Thank you.

Do Carol Potter or Calum Campbell want to come in to answer my question?

In relation to financial sustainability, NHS Lothian fortunately managed to balance the books at the end of the financial year. However, at the start of the previous financial year, we had a financial gap of £28 million. At the start of this financial year, we have gap of £52 million, so it is quite a significant challenge for us.

The largest part of the problem is that we are trying to balance performance with the money. The job of the accountable officer is to do the best that they can with the money that is available to them for the population that they serve; it is about trying to strike that balance. In Lothian, the biggest element of that is the gap between the NHS Scotland resource allocation committee funding and what we actually get. That gap comes out at about £15 million a year, which results in our having what I call a care deficit. Our sites are full and our infrastructure is ageing, so we are struggling to meet the demands of the population. A bit of growth is required over the coming period.

Emma Harper wants to come in.

Good morning to you all. I will pick up on NRAC and some of the other information. The NHS Fife briefing says that the projected increase in the number of people over 65 is 30 per cent by 2043. That means an older and frailer population with more issues. For me, as an operating room nurse, that means hip replacements, knee replacements, cataract surgery and then some. When you are doing your financial planning, including in relation to NRAC, how do you deal with that projected need?

I will use NHS Lothian as an example, and Carol Potter can speak about Fife in a second.

Over the past 15 years, there has been population growth of 156,000. That is some without any additional general practices. That increase would equate, on average, to 21 additional general practices in Lothian, with an average list size of 7,500.

National Records of Scotland estimates that 84 per cent of the population growth in Scotland by 2033 will be in Lothian. Therefore, when I talk about our sites currently being full and being under pressure, that is why I say that there is a care deficit. The largest population growth will be in Lothian and the sites are already full, which is why we are saying that we need to expand our primary care and secondary care capacity.

In the Royal infirmary of Edinburgh, for instance, the accident and emergency department was designed for a population of about 85,000 a year coming through. We currently see 120,000 to 130,000 a year, which is 330 a day. The infrastructure is under quite significant pressure. That is what the population change means. You are quite right that, as the population gets older, increased burden of disease will come with that.

As Calum Campbell has mentioned, the NRAC issue is prevalent in NHS Fife, as it is in Lothian. Since about 2009, we have seen a cumulative shortfall of about £100 million. Just as Calum described it, it is very much linked to the care deficit. We are seeing growing demand not only in our acute settings but in primary care settings.

Fife has in recent years seen a reduction, from 56 to 53, in the number of general practices. We have also seen the list sizes grow, especially in areas of higher deprivation. There is a pressure on and a challenge for primary care and our hospital settings.

On how we will address that going forward with regard to the financials, locally we are taking a two-pronged approach to our financial planning. We are looking at financial improvement and sustainability, and we are looking at productivity. For example, we have an excellent day-surgery facility in Queen Margaret hospital, which has been really key in continuing our performance during the pandemic. We are, in managing minimal investment in the site, looking at how much more activity we can do with the same level of resource. It is not about adding additional cost; rather, it is about seeing how much more productive we can be in relation to increasing our day-surgery capability.

The NRAC gap brings with it a particular challenge in relation to our cost reduction. Our ability to reduce cost is challenged when we have a lower funding base. We are looking at some opportunities, which my colleagues have described. Caroline Hiscox spoke about supplementary staffing, which is a particular challenge in Fife. Although I do not have the breakdown between nursing and medical staff, in the previous financial year, out of a budget of around £900 million we spent £45 million on supplementary staff. That is a mix of bank and agency staff and nursing staff and medics. Reducing our supplementary staffing costs is a real priority for us, as we seek to balance our position in the coming year.

James Dornan joins us remotely.

09:00  

Thank you, convener. I was just making sure that my microphone was off “mute”.

First of all, good morning to the panel. Why do some boards struggle more than others to achieve financial sustainability? All boards are facing significant pressures and costs, so why is there variation?

It would be good to start with one of the witnesses who is not from NHS Lothian, which has kindly explained why it thinks it has greater costs.

I am happy to take that question.

As I said, that is partly linked to the funding envelope, which is the NRAC position, so I will not repeat the point. There are also a number of nuances within that. For example, because we have an ageing population, we are seeing an increase in pressure in relation to medicines. There has been 12 per cent growth in the cost and volume of drugs, which is the second-highest area of spend after our workforce. There are areas where the increase in the ageing the population is more prevalent; people are living longer, which is fantastic, but there is an increased cost in medicine associated with that.

This is not a political statement—I apologise if it sounds like one—but I will make a comment about private finance initiative contracts. For health boards that have PFI contracts, the inflationary uplift that is tied into those contractual agreements often runs much higher than the funding increases that we receive from the Government. For example, in NHS Fife, we see a 10 per cent cost pressure as a result of our PFI contract, over and above the funding that we have available.

There is no single answer; it is a very complex and mixed position. I do not know whether my colleagues—

Can I just come back in to ask a question of Caroline?

I get your answer: you have named some of the issues, but I wonder why there is variation in respect of some of those issues. You talked about elderly people thankfully living longer—he says, as a 70-year-old—but why does that vary so much from one area to the other? That is probably the main question for me.

I am happy to attempt to answer that. When we were answering the previous question, we mentioned the difference and the interdependencies with performance. Put at its simplest, different health boards provide different functions to different populations. There is a key point that we have noticed in Grampian, which puts us in a different place compared to other boards. As peers, we ask ourselves that very question about variation, and challenge ourselves all the time about the differences in our performance and financial position.

As it is for Calum Campbell and Carol Potter, NRAC parity for Grampian is a challenge—to the tune of about £18 million a year. Our positions will be different. Our performance is absolutely related to our financial position. We have touched on supplementary staffing. Depending where we are in Scotland, the requirement to use the right workforce to maintain particular services can put additional pressure on the money that we spend; we have already had a question this morning about agency staff and locums.

In Grampian, in particular, we have used an incredibly lean model over the past decade. We have one of the lowest bed bases per head of population in Scotland, and our performance from primary care and flowing out of hospitals is relatively good in comparison with the national picture.

However, we are challenged by not just the amount of money that we get from the Scottish Government but the pattern in which it comes. If NHS Grampian receives non-recurring funding, we do not have enough resilience in our system to utilise that for core services. Very often, our only option is to utilise the independent sector for things such as planned care.

One of our current pieces of work on which there is regular dialogue at the moment is on what we can do to change the pattern of funding. I am delighted to say that we are receiving, for the first time, a proportion of our planned care funding on a recurring basis. That allows us to recruit to and grow services as core services and to recruit local colleagues to support that, which makes planned care more efficient financially, more productive and more sustainable.

Thank you. Does someone else want to come in on that?

Does Calum Campbell want to come in?

No.

I apologise.

Emma Harper has a supplementary.

It is a quick question about financial planning. You talked about medication, which includes things such as insulin pumps and continuous glucose monitoring. I am a type 1 diabetic and have an insulin pump with continuous glucose monitoring; I have read that there is a 43 per cent reduction in the risk of fatal cardiovascular disease and a 29 per cent reduction in all-cause mortality when we use insulin via a pump. Therefore, we know that we can reduce complications by investing in pumps and such technology, but it costs more money. How do you plan that financially, and do we have a national map of CGM use in the various boards in order that we could see how they compare on complications reduction and roll-out of insulin pumps and CGM?

I am not aware that we have such a map. Certainly, each board—I can talk about NHS Lothian—would look at the balance between such things. You picked the really good example of diabetes; the same could be said about obesity management and exercise. Striking the balance between what we call primary prevention—early intervention—and acute treatment is always a challenge.

We must always look for where we can invest early to prevent disease, but one of the challenges that we unfortunately have with an ageing population is, as we know, that with age the disease burden grows. Although we can delay many things, we cannot always prevent them. However, early intervention is where we can use the universities and others to try to hit the sweet spot in terms of how much we need to invest early to get a proper return on investment. It should always happen that way around, if we can do it.

Thank you.

We will move on to our next theme—performance—which we have touched on a little already.

Good morning, panel. Carol Potter, you talk about the waiting well process and how you send out letters to patients when there are long waits. Can you explain that process for us and tell us what sort of patient feedback you are getting? It seems eminently sensible to do that, but I do not think that all boards are doing it. Is it something that we could perhaps share as good practice?

I am happy to answer that. Supporting our patients who are waiting longer has been a real focus for us. We are in a fortunate position in Fife, having been able to maintain a relatively high level of performance through the pandemic. Although we have delays and patients are waiting longer, we are currently functioning at almost pre-pandemic levels, so we expect that to have helped the position over recent years.

Our process involves person-centred conversations with patients in all specialties to give them information about the expected length of the wait and the reasons for that, and to signpost them to other opportunities, such as online information or self-help guides. That contact keeps the dialogue open and gives the patient the ability to keep in touch with the relevant consultant.

That is a national initiative and colleagues across Scotland have been working on it, so Fife is not a trailblazer, although I would like to be able to say that we are. Colleagues who are here this morning will be adopting a similar approach.

NHS Grampian has also run a “Waiting well” project in the past year. We have just produced our first review report, which I am happy to share with the committee. The project has landed very well with patients who are waiting for too long for outpatient appointments or planned care. We are evaluating the project, but the initial findings are that it has been successful for clinicians and, importantly, for patients. We have identified funding to continue that work.

As well as the specific waiting well project, we have developed our FITSurgery website, we have a process for waiting list validation—again, that is not unique to Grampian—and we have an escalation system between primary and secondary care colleagues for patients whose condition deteriorates while they are waiting for treatment.

That does not solve the problem. Our patients are definitely waiting too long, which has an impact not only on their physical health but on their psychological health. None of us are content about that, but the focus of our attention is on doing the best that we can to manage patients’ psychological wellbeing and to mitigate their concerns.

NHS Lothian is very similar. We doing as much as we can and are piloting patient-focused booking to reduce our did not attend rates by offering appointments at times that are convenient for patients. We are using text message reminders and virtual appointments and are doing as much as we can with patient-initiated follow-up: rather than automatically bringing patients back and giving them information, we let patients highlight when they want to come back. We are also moving to as much online booking as possible.

We are evaluating all those measures to see how effective they are and I will be happy to share the final reports when they come in.

NHS Lothian’s performance standards seem to be deteriorating in a number of areas. How are you going to get on top of that?

There are areas of strength and areas of weakness. If we look at planned care and the treatment time guarantee, data for March 2023 shows that NHS Lothian was back at around 90 per cent of our pre-pandemic capacity, while the figure for the whole of Scotland was about 78 per cent. The figure for outpatient appointments in Scotland is about 86 per cent; Lothian is at around 100 per cent. I may have the Scotland figure wrong. There are some particular hotspots within those figures.

Urology is under a lot of pressure, which is a particular cause for concern. We are seeing a significant rise in the number of men presenting with prostate cancer. We are doing something about that by moving to three-session days at St John’s hospital and by trying to recruit an additional surgeon. We have also altered the pathway for men who come in with possible prostate cancer. It is a particular pressure for us. There are significant challenges in relation to theatre staff and there is a major focus on recruiting and retaining those staff because lack of capacity there can really limit our system. Getting that infrastructure in place is important. I touched on the fact that our sites are regularly at 100 per cent. That will be a problem for us.

09:15  

We have challenges in our A and E department—I gave you figures for the size of our A and E department versus the population that we serve—but one of our biggest waits is in elective orthopaedics. Therefore, at a time when we are trying to free up beds, we will have to ring fence beds in the Royal infirmary of Edinburgh for elective orthopaedics to try to ensure that we do not cancel those procedures on the day. That means that we will have to do some orthopaedic rehabilitation out at East Lothian community hospital.

We are trying to alter those pathways and take those steps for each of those specialties, but it will be a long journey and, without additional infrastructure, we will struggle.

I note some of the points that you made about capacity and constraints. Those are a major concern. For example, you mentioned A and E departments being designed for a lower population. Do you have other metrics for assessing capacity and bottlenecks? I refer to process mapping of your services and areas of constraint around, say, key items of capital equipment such as computed tomography or magnetic resonance imaging scanners. Are those areas that you have identified as needing extra capital investment that would improve patient flow? Have you identified particular examples in your analysis of operations?

I am happy to start on that question. Our picture is similar to NHS Lothian’s but, to answer your question specifically, one of the most helpful emergent pieces of work that we have undertaken in Grampian has been what we call a breach analysis of our 62-day cancer pathway, which is access to the range of services that are required for a patient and their family in receiving a cancer diagnosis. As in other parts of our system, we have reviewed and renewed our process as part of that breach analysis. For every step in that pathway, we are asking how long it takes, what bits are working well and what components are challenged. We designed that work with colleagues who do that day in and day out, and it has been shared across Scotland.

You asked about bottlenecks; that work has allowed us to identify bottlenecks for each cancer type and, therefore, to target the resource to the right place. For prostate cancer or colonoscopies, it helps us to understand whether the delay in performance relating to the 62-day target is because patients cannot get access to theatre for a surgical intervention in a timely enough way or because they cannot get access to an MRI scanner or other imaging. We now have that information, which we have not had before, to a level of detail that is incredibly useful to our primary care and secondary care colleagues and allows us to target the finite resource that we have to make the pathways as efficient as possible.

Some of the other work on sustainability and what we do with the bottlenecks is not just about having more of the same kit, but involves some brilliant innovations that are under way. We spoke earlier about sustainability and planned care. Innovation has to be part of how we move forward with that. I will give a couple of examples.

I have been talking about the cancer pathway, so I will speak about our ability to use artificial intelligence in that. Grampian, in collaboration with the centre for sustainable delivery, is piloting a piece of work in breast and chest X-ray imaging. Chest X-rays are a pretty standard diagnostic tool; most people who come into hospital will receive one. However, it has always been a challenge for us to do that X-ray and report in a timely way. In Grampian, we are now piloting artificial intelligence alongside the expertise of our radiology colleagues, which allows us to develop algorithms that prioritise patients who have red flags on their chest X-rays.

The formal process that we followed historically meant that patients’ images were in a queue system from when those patients attended until the images were reported on, and imaging reporting was a bottleneck. In contrast, artificial intelligence has allowed us to prioritise images and, potentially, to improve our pathways and access and alleviate bottlenecks.

I will build on that with a few examples. I will take the question in two halves: first, I will talk about capital investment and secondly, I will address bottlenecks more generally.

In the past 12 months, we have purchased two additional CT scanners, which has supported the throughput of our radiology patients—a particular challenge in Fife—and the wider pathway. We have a rapid cancer diagnostic service, which is helping how we see and treat our cancer patients, as Caroline Hiscox has touched on. Through some innovation with slightly different ways of working, we have developed the use of a procedure room in Queen Margaret hospital, which has allowed us to release one theatre per day in that site. That is where we do our day surgeries. The change has released a bottleneck in elective care, which has allowed throughput. We and the consultants are challenging at specialty level what more can be done on a day-surgery basis that does not necessarily require the specialised in-patient care in the Victoria hospital in Kirkcaldy. That is an example of where we have looked at redesign innovatively.

I will address other bottlenecks by coming at the matter from a slightly different angle. We often talk about bottlenecks at the front door of the hospital. By that, we are referring to ambulances and emergency departments. However, we have considered a step earlier in the process, which is the front door of the patient. With our colleagues in the health and social care partnership, we have been looking at how we support people who are in care homes in a different way. We have improved access to urgent care for a number of our care home residents, which has involved, through our flow navigation centre, professional-to-professional contact—what we call prof to prof. That has allowed care home staff to have direct access to a clinical professional in order to discuss a resident if they have concerns about their particular health needs.

Advanced nurse practitioners and allied health professionals are part of multidisciplinary teams that are essentially doing virtual ward rounds within care homes across all seven of our localities. We are also working with the Scottish Ambulance Service to deliver direct unscheduled care into care homes.

I mention that because it has directly resulted in a reduction of about 220 emergency admissions or attendances per month to just above 100. That success is attributed to the wider whole-system approach. We took a step back, looked at the problem from a slightly different perspective and involved different teams and professionals from across the NHS and the partnership. That approach has been better for the care home residents as they have been kept in the place where they live, with care wrapped around them, and it has avoided bottlenecks with ambulances or at the front door of the hospital.

You have both highlighted what sound like quite impressive process improvement activities. From a cultural perspective across the health boards, how do you disseminate best practice? How do you benchmark against each other so that you are able to say, “Right. That is an excellent workstream. How do we carry that into the national picture so that we can make an impact?” Do you have a protocol or process for doing that?

The national Centre for Sustainable Delivery tries to work in areas where there have been potential improvements. It has several workstreams across a number of different specialties and aims to optimise performance in specific areas. The chief executives of the health boards meet every month and share information. We also use Discovery, which is a national benchmarking tool that enables us to look at our performance and infrastructure against that of other health boards. We can identify variations and try to explore what is behind any that we see. The tool allows us to question why things are different and what is happening that is different to our own boards so that we can try to identify where there are opportunities for improvement.

Do you think that that is effective? Could it be more efficient? Are there ways to improve it further?

There are always opportunities to improve. Part of the reason for having the centre is to allow us to explore that. There are no massive steps that need to be taken, but there will always be incremental improvement.

Is there team-to-team collaboration across health boards, but at a lower level than the boards, in which teams can teach others about operational approaches that they have done well?

Not only do we work as teams, with all the chief executives coming together regularly to share learning, but we work regionally. Calum Campbell, my colleague Ralph Roberts from NHS Borders and I meet regularly, and our teams come together once a month. We share learning on a variety of areas. I am sure that the boards in the north of Scotland, where Caroline Hiscox is, do something similar.

We have a similar set-up in the north-east and the west. The ownership and motivation of our colleagues in all specialties to improve things and move things forward often results in a lot of informal networking. We also have a range of formal networks across Scotland in which best practice is shared.

To add to Calum Campbell’s narrative, I note that in the recent past the CFSD has established specialty clinical groups in which clinicians from different specialties come together to do exactly as you have described—to ensure that we do what we can to share best practice in different contexts. It is important to say that, despite the pressures that we have described, we are hugely proud of our colleagues across health and care, who come to work every day and keep the show on the road. They do an amazing job and are genuinely trying to improve and to find solutions all the time in order to make the system perform more effectively for patients.

This question touches on financial sustainability as well as performance. Do you think that there is a need to fundamentally transform the way in which services are delivered, or is how they are currently delivered is just fine but there is a need for some of the innovation that you have already mentioned?

Undoubtedly, that question touches on performance, financial sustainability and the fact that healthcare has an insatiable appetite for resources. However, the reality is that, if we look at the demography of the nation over the next 10 to 20 years, we see that we are just not going to have the workforce to provide the services in the format and style in which we currently provide them. There will have to be a fundamental rethink of how we provide the health services that best meet the population’s needs. That is where demography is taking us.

I support Calum Campbell’s position. How we transform nationally and locally has to be part of our consideration. The Scottish burden of disease is forecast to increase by 21 per cent in the next 20 years. That specifically relates back to Calum Campbell’s point. If the current models of care were to remain extant, we would need approximately 33,000 whole-time equivalents on top of our current workforce. As we know, that would be a challenge. Working more to transform our system to empower communities and provide a better balance of enabling wellness as well as responding to ill health is the sustainable way forward.

There is also a consideration around having a slightly different dialogue with the public about what a modern NHS looks like. Instead of our traditional approach of looking at the services that we deliver in hospitals, we need to look more widely, to the third sector, our services in health and social care partnerships, and to primary care in particular. For example, the role of community pharmacy is hugely important; pharmacists can offer a lot that might mean that someone could avoid having to see their GP or attend hospital. We also have community optometrists, who are linking more closely with our ophthalmology services.

We need a different dialogue about services. We all talk about going to see our GP, but what we really mean is that we are going to our local primary care provider, who might well be an advanced nurse practitioner or a physiotherapist. We need to shift our language and engage in dialogue with the public. We need to listen to the public, but also communicate the wider role of primary care practitioners.

09:30  

I want to ask Calum Campbell about NHS Lothian’s hospital sterilisation and decontamination unit. Everyone has been talking about increasing the work that you do within a theatre complex, but you cannot do anything if you do not have any kit. Your specific sterilisation unit is severely under the required capacity right now. What steps have you taken, and what steps are you taking, to ensure that you can meet not only the demand right now but your ambitions going forward?

One of the conversations that we have had with the Scottish Government is about the fact that NHS Lothian would like to take forward a capital programme for a national treatment centre. We recognise that decontamination capacity, not only in Lothian but in other boards in Scotland, is fragile, so we have proposed that we look to expand the decontamination capacity for the national treatment centre in Lothian, which would be at St John’s hospital. That would not only increase decontamination capacity to meet Lothian’s needs, but would create some resilience within the Scottish decontamination capacity to make it more sustainable.

Forgive me, but do you plan to expand that?

Yes.

What steps have you taken already? You need to have done something already. In addition, one of the questions at the very beginning was about a lack of money and how you have a deficit. There is a lack of capital to support new things, especially plans to do that. How will you achieve your plans with that deficit?

The issue in Lothian is that, although we have enough decontamination capacity, we do not have any resilience around it. Our decontamination unit went down recently. When it went down, there was not enough capacity elsewhere in the country to support us, so we had to get support from down south. We moved instruments around the country.

We have enough capacity currently. We are trying to protect that infrastructure, but there is simply no resilience within it. I do not see a shortcut to our becoming more resilient either in Lothian or nationally without that expansion. That is why one of our primary capital priorities is additional decontamination capacity. I do not see an alternative or shortcut to that.

We will move on to the next theme.

We have talked a little bit about Covid recovery, the challenges of performance in relation to pre-pandemic levels, and where we are currently. A lot of responses have touched on Covid. We absolutely cannot ignore Covid. We have just come through a pandemic, and we are still recovering. A lot of folk think that there will be an overnight fix, but there will not be.

I am interested in hearing your thoughts on the recent NHS overview audit, in which Audit Scotland stated:

“The Scottish Government did not engage fully with NHS boards on the preparation of the Recovery Plan”.

What do you think about that statement from Audit Scotland? Have you made changes to the recovery plan that adapt and evolve it, based on knowledge that we have learned from the pandemic?

We have a Lothian strategic development framework, which we have openly shared with the Scottish Government. That will have informed some of the planning there. We are very clear on our capacity in relation to out-patients and in-patients for each of the services that we can provide. To a degree, the unknown factor is the demand coming in.

You are quite right to say that it will be a long journey. For example, there is a lot of pressure on social care colleagues, which limits the flow through our system. When the flow is limited, the amount of activity is limited, and that affects the recovery period for the system.

You are quite right to flag the challenge that Covid has presented. Although we were under pressure pre-pandemic, we had a really good waiting list position, but it will take us many years to recover from the pandemic.

I echo Calum Campbell’s comments. Prior to the pandemic, we saw significant challenges.

My background prior to becoming chief executive was as a finance director. We saw the financial challenges before the pandemic, as well as challenges around our emergency unscheduled care and in relation to elective treatment in our hospitals. In some respects, the pandemic has exacerbated the problems that we were already facing.

I will talk specifically about the recovery of waiting times. There is a challenge around the financials and cost involved with that. However, equally, we are considering a range of opportunities to increase the throughput of our elective capacity to aid that recovery. As I mentioned earlier, we are looking at removing any barriers to procedures, including using day surgery. We have also spoken this morning about digital solutions and how we can support our patients using those. We are using a patient app for pre-assessment ahead of surgery, for example.

As Caroline Hiscox touched on, teams and clinicians continue to review how they can work differently. They are very committed to doing all that they can for their patients. As we have described, we have a range of improvement actions that the centre for sustainable delivery has outlined. We are working collaboratively. However, despite all that, there are workforce challenges, which is a limiting factor, and our capacity is struggling to keep up with demand. I know that that is an area of interest to the committee. The issue is prevalent across all areas.

We all have robust and detailed forward plans in relation to our ability to address our waiting times—both the length of the waits and the size of the waiting lists. However, the challenges remain. As we have already outlined, there are several specialties that are particularly stretched for a variety of reasons, including the available workforce in the particular area.

What key things would you ask for that would really help to shorten the recovery period or to enhance recovery?

The biggest step would be in relation to social care flow. Our colleagues in social care are under significant pressure. That limits the capacity in the NHS. We have to accept that health and social care are fundamentally linked. My biggest ask would be that we ease the burden on social care.

We need the continued support of our colleagues across health and care. As Carol Potter has already mentioned, there is the question of how we engage effectively. We engage locally through routes such as our community planning partnerships and our locality networks. However, how do we truly harness the empowerment of local communities, as we did in the pandemic, in designing our NHS and social care, going forward? The NHS and social care are inextricably linked. It would help us if we were to work with local populations, as locally as possible, to support citizens as well as to be supported nationally. Having conversations with the public that are engaging and in which all levels—local, regional and national—are truly listening would help us to move recovery forward as quickly as we can.

Okay, thanks.

David Torrance joins us remotely.

Good morning. My questions are about the recovery plan and the progress that NHS boards have made. How accurate is Audit Scotland’s assessment that the October 2022 progress update does not fully reflect the scale of the challenges that boards have faced and the extent to which that has hampered progress towards recovery by many boards? I put that to Carol Potter first.

Thank you, David. It is good to see you.

Audit Scotland has a unique opportunity when it comes to seeing the overall picture across NHS Scotland and triangulating all the different data and metrics that it looks at. It would be remiss of me to counter what it is saying about the challenges that all boards face. As we mentioned earlier, there is no single solution for recovery. There is a short-term focus on addressing our waiting times and dealing with the pressure around the front doors of our hospitals, but we also need to focus on the longer term.

There are lots of conversations taking place among chief executives about horizon 3. At the same time as we balance the immediate priorities for recovery, we also need to look over the longer term at the health and wellbeing of the population more generally and at all the factors that are associated with people’s life circumstances. We know that housing, education and lots of other metrics affect people’s longer-term health prospects.

Audit Scotland has made a reasonable assessment. As a former accountant, I am not going to challenge its perception. I recognise the comments that it has made.

To expand on what Carol Potter said, in Lothian sites are very full most of the time. On top of that, what will dictate the pace of progress is the workforce that we have, and there is a significant workforce challenge. In March, there were about 4,200 registered nurse vacancies in Scotland. That goes back to the points about agency staffing. The sites are full and we need the workforce. There are about 1,500 non-registered nurse vacancies in Scotland. We are trying to get the workforce there, which takes us back to the point about demography. We need the workforce to deliver the performance, but the workforce costs money. There has to be a balance. Audit Scotland was quite right to highlight what a significant challenge that is going to be.

I agree with Carol Potter and Calum Campbell. The evidence that was presented in the Audit Scotland report, although it is specific to Scotland, reflects a growing body of global evidence on how we manage effectively the interdependencies of risks that are associated with more infectious diseases, the cost of living crisis, a very fragile health and care system and climate fragility. The work that was presented in that report and the work that we are doing as individual boards through our delivery plans to move towards recovery will start to address that.

On what has changed, in Grampian we have absolutely noticed a change in our demand profile, as Calum Campbell has done in Lothian. In the last week of May, bed occupancy in Aberdeen royal infirmary, which is our main tertiary and secondary care site, sat at 106 per cent, whereas an optimal system should sit at 87 per cent bed occupancy. We must take a step back, learn from the pandemic and look at the evidence in the United Kingdom and globally on sustainable health and care systems. Our workforce is a key component of that. Although our workforce numbers have increased in the past year, that has not happened across all domains and it does not apply uniformly.

In Grampian, we have some highly specialised areas that are fragile. We are doing improvement work around that. I specifically cite psychiatry and paediatric anaesthetics as fragile professional specialties at the moment, where we have a small number of specialists coming through. We are working with NHS Education for Scotland and others on the pipeline. That is specific to our medical profession, but the demand-profiling workforce is key to our recovery.

09:45  

Are there any particular areas that you can highlight where good progress has been made? What are the reasons for that?

With apologies for the repetition, I return to the ability that we had in Fife during the pandemic to protect the capacity of the day surgery unit at Queen Margaret hospital. That was key to enabling us to sustain our elective programme and is fundamental to the post-recovery plan. We are expanding that further.

We need to be able to ensure that we maintain the balance of demand so that we balance the need to address the challenges that Caroline Hiscox described in capacity, unscheduled care and emergency demands on our services with the need for a throughput of patients who have been waiting too long for elective procedures. That is about how we use our infrastructure in a planned way. Calum Campbell mentioned some work at the Edinburgh royal infirmary on protecting beds. That will be key.

I am happy to add to that. One of the key things that we have done well, and continue to do well, in Grampian is to work as a much more integrated system. I have reflected several times in this conversation on interdependencies. We now have teams that are absolutely working together.

As you will know, we are challenged on the majority of our performance metrics. The relationships between unscheduled care, planned care and cancer services are very apparent. In relation to the work that we are doing with our primary care colleagues, Grampian has one of the lowest attendances from primary care into the front-door services at hospital per head of population. Despite the challenges, our primary care colleagues continue to play a good role in that. We also have one of the lowest admission rates. Of course, our social care sector is challenged, but our work to manage issues across the system has meant that our delayed discharges have been pretty constant and they benchmark reasonably well against those in other parts of Scotland.

We have focused on improving other aspects of care where challenges remain. On psychological therapies, we made a commitment not to have any citizens in Grampian waiting more than 52 weeks for their appointment, and we have now achieved that. That is still too long a wait in relation to the target that the population deserves and expects, but we are improving it incrementally.

Child and adolescent mental health services in Grampian remain high performing in relation to the first appointment. The national target is 18 weeks, and a young adult in Grampian should get access to their first appointment after between six and eight weeks. That is great, but it also creates a follow-up challenge for us with regard to secondary appointments. It is a good-news story that creates a challenge.

We are seeing incremental improvements, but as we have discussed, the recovery will be slow and will require transformation as well as improvements. I mentioned the innovations relating to artificial intelligence and imaging. Similarly, our ability to do a one-stop radiotherapy piece of work for cancer patients has been significant and positive for patients who are suffering from cancer and require radiotherapy.

Caroline Hiscox mentioned some work with the partnerships. The question was around where we have seen success, and I want to highlight that one of our successes, which has shone through, has largely been about how we have worked as opposed to what we have been doing. We use the term “team Fife” in a lot of the conversations about how we are approaching the challenges that we face, but there has been a relentless commitment from colleagues across all areas—whether that is in the health and social care partnership, our acute service or our leadership teams—to focus on the expression “complete, not compete”.

Our focus is on the end point or intention that we are working towards. Whether that has been around the challenge of delayed discharges or redesign around the front door of the hospital, all those programmes of work have been successful where the teams have worked together in a really collaborative way. It is about the relationships and not necessarily what they are doing but how they are approaching it and that single focus. In our briefing, we mention our operational pressures escalation levels tool. That language is used across the organisation. We have a shared language, a shared approach and a common purpose.

During the pandemic, we all recognised that when we came together to work collectively in a collegiate and collaborative way—whether with the public, our teams, across the community planning partnership or others—that was where we saw success. We need to build on that and develop it further.

Calum Campbell, I want to ask you about audiology. FLAAG—families failed by Lothian audiology action group—has said quite a few things in public that I would like to raise directly with you for a response. It feels as though there is a lack of access to British Sign Language tutors, as well as a lack of access to speech and language therapy and appropriately qualified professional support for deaf children. What support are you putting in place for families who are affected, and what would you say in response to FLAAG?

The first thing that I have to do is apologise for the whole issue having started in the first place. The Scottish Public Services Ombudsman’s report and the work that was done through the review was quite a wake-up call in Lothian, and we are grateful for the efforts that went on around that. Jacqui Taylor, the independent chair of the audiology review, made a number of recommendations, and NHS Lothian has followed every one of those recommendations. We have communicated widely across speech and language therapy, health visitors and the five local authorities. We have been very open about the challenges. We have tried to contact every single affected family. I will come back to that in a second.

However, I make the point that we do not use only British Sign Language. We make British Sign Language available, but our speech and language therapists will say that there are other forms of sign language. I am not aware that we have in any way limited speech and language therapy.

Less than a month ago, we met a group of MSPs, and the same comment was made to us then. We have put additional resources into speech and language therapy. I accept that there is a balance and that some families might want more, but where we believe that there is a need for speech and language therapy, we have not limited it, and we have significantly invested in it. There are challenges for us, and it has been a long journey. We have retrained all our staff. We believe that we have got to everybody, but we can never be positive about that. One MSP flagged up that we had missed out one person. We have reached out to them to say, “We think we’ve missed you. Please come forward and we’ll check.”

We think that we have done everything that we reasonably can. We have tried to make available British Sign Language, although we make the point that other forms of sign language are available. We have communicated extensively and made available a telephone line throughout the period—I think that 24 calls have been made to it. If anybody, including any MP, MSP or councillor, flags up anyone to us, we will follow that up to make sure that we catch everyone.

The development of speech occurs between birth and the age of three, which is when speech becomes fluent. The average age at which issues are identified is about four and a half. My understanding is that 2018 is the cut-off. What is happening to potentially affected families?

The British Society of Audiology’s original review covered 2009 to 2018, and there have been two subsequent reviews. All children, from 2018 up until now, about whom we have auditory brainstem response concerns have been back to us and checked. The 2018 cut-off was the first cohort, which followed the first review. As I said, two subsequent reviews have been carried out. We have tried to be as extensive as we could in addressing the issue.

To be clear, are you saying that you feel as though you have identified everyone who has been affected?

I caveat that by saying that a month ago I met some MSPs who flagged up one family whom they thought we had missed. We asked them to let us know who that family is so that we could follow that up.

We believe that we have identified everyone, with that caveat.

You have increased your resources in speech and language and audiology services, and you do not feel that there is a lack of access to BSL tutors for those who want that.

I believe that within the NHS, if someone requires BSL support, we are able to get that. I cannot talk about the situation more broadly than the NHS.

NHS Lothian’s written evidence notes that you do not have a low-secure forensic unit and that there are no female high-secure beds in Scotland more widely, which means that people are being managed in units that are not suitable for them. How is your health board managing the lack of forensic mental health capacity? What could the Government do to improve the situation?

As we all know, mental health is sometimes a bit of a Cinderella service. We are having to use our medium-secure unit for some patients who could cope well in low-secure care and we have a high-secure female patient in that unit as well. Effectively, that is squeezing us—we are losing 25 per cent of our medium-secure capacity because of low-secure individuals being in the medium-secure unit and the fact that we are accommodating a high-secure female patient in it.

We have put together business cases to try to expand our capacity. We need to get right the balance between psychiatric wards, intensive psychiatric care units, low-secure and medium-secure capacity and high-secure capacity for females across Scotland.

I will touch on one other area: the rejection of CAMHS referrals. I note a significant increase in the pattern across Scotland in the past five or six years. In 2017-18, 11 people were re-referred in Fife; last year, it was 46. Over the same periods, in Grampian, the figure was 161 and it is now 260, and, in Lothian, the figure was 287 and is now 416. Why might GPs need to try more than once before they are successful in getting CAMHS referrals? Is that due to capacity? Are the thresholds higher than those that have been assessed by GPs as appropriate? I would be interested to get your insights on what might be going on in relation to that trend.

I was relatively quiet earlier when we were talking about improvements. One of the challenges that NHS Lothian had before the pandemic was to do with the waiting lists for CAMHS and psychological therapies. The board was escalated for that. Over the past two and a half years, those waiting lists have continually reduced.

In Lothian, we have developed pathways working with partners around what we call tier 2 CAMHS, because too many young children were being referred to tier 3 CAMHS when other support services at level 2—support in the community, rather than medicalisation—would be more appropriate. We have worked hard to develop those services, and we believe that quite a high percentage of those patients could be seen there. They will be considered and will then be directed to the appropriate place for them, depending on their clinical presentation and need.

10:00  

I am happy to add to that. Similarly, we have an increasing referral rate, not just in child mental health but in adult mental health.

Specifically for CAMHS, we use the choice and partnership approach—CAPA—and triage and redirection of patients will be about identifying the most appropriate place for them. No child or young adult will be referred into our system without being signposted to the appropriate service for their level, as assessed by clinicians in Grampian. We are using and embedding the national framework for decision making in CAMHS. As well as planned appointments, we provide an emergency service: all emergency referrals in Grampian are seen within seven days.

I will build on that. Certainly, over the past few years, the complexity and the mix of referrals has increased. Prior to 2021, about 50 per cent of young people were classified as high priority. That has shifted to about 80 per cent. However, there is earlier redirection into other areas of support through schools and online tools. Mental health nurses are now being rolled out into GP practices. That is certainly helping. Innovation has been an area of focus across Scotland: there are different ways of looking at pathways and adapting the CAMHS service to more appropriately support the spectrum of needs of our young people, all the way through from initial treatment.

At the moment, we have a test of change with our education colleagues who are supporting those with complex mental health needs as they turn 18 and start to move into adult services. We are looking at how we can support them with self-help tools and in other aspects, as well as face to face. It is a slightly different approach but, as colleagues have also mentioned, our performance has improved and the long waits have been significantly reduced.

However it is a complex and growing area. The past few years have been extremely difficult for our young people across Scotland.

Are you confident that the level of re-referrals—I accept that it might be a narrow metric—will start to fall, given the measures that you have put in place, which mean that GPs are now aware of a more appropriate referral pathway? Is that what you are saying?

We hope so. That goes back to that communication between the multidisciplinary teams that are working with our general practitioners and colleagues, on the appropriateness of referrals.

Thanks. That is great.

I refer members to my entry in the register of members’ interests. Is there perhaps a case for some change of language or measurement from “rejected” referrals, which sounds very hard—about people not being seen—to “redirected” referrals, where a referral to an inappropriate service, because of the level of need or complexity, for example, could be redirected to a service that is more clinically appropriate for that person? That referral could apply at either end of the care spectrum, whether that be limited intervention or very high-intensity intervention.

That is very fair. The answer is yes.

Thank you.

Good morning. In last week’s evidence session, we heard from the State Hospitals Board for Scotland about its use of induction and peer support in recruitment. Its representatives said that there has been a focus on development of a peer support network throughout the organisation, that a number of its staff are now trained as peer-support workers, and that that has proved to be successful. I am interested to know whether similar schemes are being developed in your boards. If so, how successful have they been and, if not, are you planning to bring in something similar? Carol Potter is nodding, so I go to her first.

We rolled out peer support in the organisation back in 2021. The initiative came from a number of our clinicians who had been involved in peer support in previous roles and who also had a general interest in it, so it is a great example of us listening, hearing and doing. I apologise that I do not have the details to hand. A large number of staff across the organisation—many with clinical backgrounds—are trained in peer support, and that is widely known and advertised across the organisation.

We have a huge range of staff wellbeing initiatives, and we are really proud of that. We know that we do not always get it right, but we want to listen to staff. We have everything from physical staff hubs on every site, in our hospitals—we have been very fortunate to be supported through our health charity to do that—to healthy wellbeing groups, financial wellbeing guides, menopause support and sport and leisure passes. There is a range of initiatives.

Also, importantly, we have a staff listening and counselling service for which there has been high demand. Our spiritual care team has reached into the organisation to provide one-to-one support, reflected practice and staff listening. It really goes to the heart of how people feel about life in general and about the workplace—peer support is one aspect of that.

It is similar for us. Caroline Hiscox said that staff have been great throughout, but they have had a hard time.

We have tried a number of initiatives, not only to try and recruit staff but to retain them, and there are a number of wellbeing initiatives across the organisation.

We also have “Speak up” ambassadors, because—as Carol Potter said—we do not always get it right, and when we get it wrong we have to try and create a culture where people can speak up about that. We want them to speak up early so that we can intervene early.

We recognise that a significant number of our staff are over the age of 50, so—going back to what your colleague said earlier—the wellbeing initiatives are there to try to intervene, support them early and help all the way through. There is a lot of emphasis on our workforce and our culture to try and get them right, retain our staff and keep them healthy.

I mentioned our new strategy; one of the key things in that is our strategic intent to prioritise workforce wellbeing in a way that we have never been able to do before. We are on a journey with that and, as Carol Potter said, we do not get it right every time.

We have an overarching “We care” programme, which includes a number of initiatives that include peer support and investment in wellbeing and the capacity to support the wellbeing and culture of colleagues who are working in Grampian. That is not only for those working in NHS Grampian, but is for colleagues in the health and social care partnership who are employees of the council. We try to spread the initiatives as broadly as possible. Our peer-support model for psychological first aid has been rolled out in 11 service areas. We have “Speak up” ambassadors and an app called Trickle that allows colleagues to raise questions and have them answered.

Despite all that, the impact on our workforce during the past three years has been significant. I recently worked in staff governance where we reviewed our sickness absence data, and NHS Grampian’s sickness absence data is reasonably benchmarked with that of the rest of Scotland. However, short-term absences have gone up, and the most common reasons for long-term absence in our workforce are anxiety, depression and stress. The evidence is that our workforce continues to be challenged by those.

Making the working environment the best that it can be is important for retention, particularly for people who are working for longer in life, given the demographics of our workforce. There is some specific work going on in relation to that. For example, 82 per cent of NHS Grampian’s workforce is female, and a proportion of those women—I cannot remember the percentage—are at an age at which they experience menopause symptoms. We had an amazing response to our menopause awareness week, with an uptake of more than 2,500 employees who were interested in understanding what we can offer.

It is about responding to our workforce and continuing to listen. That is for those who are in the workforce now, but it also ensures that people who are considering working in the health and care sector see it as somewhere that they will be looked after, too.

Caroline Hiscox has pre-empted my next question, which is about an assessment of sickness rates across the workforce. I wonder whether the other two boards can comment on their sickness rates.

Also, what action is being taken to support people to return to work? There is a lot of focus on reducing vacancy rates and I am concerned about the pressure that that puts on staff who feel that they have to come back. There is always a willingness among staff across the NHS to come back so that they do not feel that they are passing pressure on to other colleagues, knowing what they have been through in the past few years. You have all mentioned counselling and mental health support. Often in organisations the counselling that is offered is quite short term. Is it limited in your boards, or do you have a longer-term approach?

In Lothian at the end of March our sickness absence figure was 5.86 per cent. That is made up of 3.2 per cent short-term absence and 2.65 per cent long-term absence. Breaking down the short-term figure, about 86 per cent was to do with physical health and 14 per cent was to do with mental health. For the longer-term absences, 65 per cent was for physical causes and 35 per cent was for mental health reasons. Therefore, your question is well asked.

For years we have invested in a pilot that provides psychological therapies, working with the occupational health service. We believe that it has been very successful, and I say that because of how heavily it is used. We are doing a full evaluation of it. We have agreed to fund it for another year, again through the NHS Lothian Charity, but if the evaluation comes out positive, we will look to bring it in as part of our core occupational health service.

Just to develop that—I will not repeat what colleagues have said—we have an absence rate of around 6.7 per cent. I do not have the breakdown in front of me of short-term versus long-term absences, but it will be very similar to that of colleagues elsewhere. Again, the most common causes are anxiety and stress related.

I think it is important to acknowledge that the stress is not necessarily work related. It is difficult for us to get that level of granularity, but we need to look at staff members holistically. Working with our trade unions, we want to have a tailored focus on whether we are providing the right support at the right time for particular individuals. It is not one size fits all. Some members of staff will welcome, seek and ask for counselling and spiritual care support and other services with some of the softer skills, whereas for others that might not be appropriate, so we are looking to tailor that appropriately. It is also very linked to the fact that our workforce is ageing.

The other area that we are looking at, which has been topical this week, is the range of support that is available to staff who have long Covid. That is a complex issue across the wider population.

With regard to the actions that we are taking, I echo what the other witnesses have said, but there is always more that we can do.

That is great.

Something has been raised with me on a couple of occasions by long-term staff who have worked in core services. They have mentioned that some of the challenges that they face in their teams are related to the way in which modern funding streams work. Specific pieces of work are funded, which drains out some of the really experienced nursing staff into specialties that are then fixed. The core teams sometimes struggle with getting experienced staff, which has a knock-on effect on their ability to support new staff who are coming through. Do you recognise that in your services? Are there particular areas where that seems to be happening?

10:15  

I cannot think of a particular example, but workforce is a problem and we have quoted sickness absence figures.

There is something that we could look at. My background is in nursing, and I trained through an apprenticeship model and worked on the wards as a nurse. We need to go back to asking whether someone really needs to go to university full time to become a nurse. I am not against degrees or honours degrees, but it is possible to train nurses effectively on wards.

NHS Lothian has been very successful with agenda for change bands 2, 3 and 4 by using what we would call modern apprenticeships. We used that approach in mental health and had more than 100 applicants for 20 jobs in the past two years. We will pilot an apprenticeship model this year for registered nurses, who will be much more present on the wards.

Those nurses are not eligible for modern apprenticeship money. If we had an ask, it would be for the rethinking of some of those elements. A lot of people find it difficult to give up a job and go to university for three or more years, but using the apprenticeship model would mean that they could be in employment, which would help our workforce. They would also come in with more hands-on experience than they would get from an academic programme. There is certainly a place for academia and I am not diminishing that, but it would be better to have a balance.

I recognise what Carol Mochan says. Priorities often come with short-term funding. For the individuals who take up those posts, they provide a great opportunity to do something different and to gain more experience. Those short-term priorities are important and it is great that we can fill those posts, but, as Calum Campbell has said, if we do not have a different pipeline and cannot redesign our workforce, all we are doing is moving people around and leaving gaps in the system.

It will come as no surprise that some specialties are perceived as being harder work than others and that some are more attractive. Because of the vacancies in our workforce, people can choose where they go. We need to do something to redesign the workforce. Calum gave an example about nursing. I have been asked about apprenticeships for allied healthcare professionals in Grampian. We should look at how to create pathways that give people portfolio careers and mean that we have the right number of colleagues coming through to reduce the number of vacancies. I recognise what you are saying, and we are trying to deal with that in a number of ways.

I absolutely recognise the points that my colleagues have made about alternative roles and pathways. There is an expression, “earn as you learn”, that picks up on Calum Campbell’s points and is about supporting staff to come into the organisation or supporting existing staff to undertake studies while they are working.

It is also important to focus on apprenticeships and youth employment initiatives. We saw some of that coming through during the pandemic. We have a member of staff whom we used as an example in our strategy, which has a strong theme of staff wellbeing and recruitment. A member of staff who was furloughed from a media job during the pandemic joined us as a support officer in the vaccination clinic, was encouraged by staff there to join the nurse bank and is now a student of mental health nursing. That is a fantastic example of the wider role of the NHS as an anchor institution, and it shows how we can look at differently at career pathways.

I have a quick supplementary question. When I did my nursing training, there were two intakes every year, which meant that entry-level and more experienced nurses worked together during their training. Should we be thinking about doing that again? Having students at different levels in classrooms or on site would make it possible to offer peer support and mentoring. Should we be considering that?

I would certainly be very supportive of that. It would stop the feast and famine situation—it is very good when the new students come out, but that happens only once a year. It would be good if we could even that out in any way, and having two intakes a year would be a good way of doing that.

I remain a registered nurse and, in my previous role, I was the nurse director in Grampian. We had a very live debate between our academic partners and the service in relation to the pros and cons of that model. I do not think that we will ever land on one view on the issue, but I recognise Calum Campbell’s point. As well as considering the intake, or output, and whether it is once or twice a year, we need to consider the attrition and uptake rates in the nursing profession. We need to consider the number of places in each academic institution and the growing gap in the uptake of those places. That is one part of the picture.

Convener, can I ask another wee supplementary question?

Yes, if it is very short, because we still have another theme to cover.

Okay. Professor Hiscox, you mentioned paediatric anaesthetist consultants, who might have to work in different NHS boards to achieve certain competencies or skills. Is it easy for anaesthetists to work across boards, when it comes to competency and inclusion? Do they have to do the training on infection prevention and control, fire safety and moving and handling, no matter where they are?

My experience is that doctors in training who wish to specialise in paediatric anaesthesia may come to the north and get all their places in NHS Grampian or they may go across other boards. I would need to double check this, but their training is partly with NHS Education for Scotland—that is their statutory and mandatory training, on health and safety and infection prevention and control. They will do components of that through NES and Turas, which should be consistent, and they will have to do specific training in each board.

For substantive consultants and trained doctors, the reality of working across boards is more complex. You have highlighted one aspect of that, which is to do with the governance around our induction and the different policies that health boards have to keep clinicians and patients safe. We could make improvements on that.

Thank you.

Carol Mochan has questions on our final theme.

I am interested in dignity at work. We no longer carry out the staff survey, so I ask each of the health board representatives to feed back on how they ensure that staff have the ability to feed into the system and on the overall trends in their board. Through your staff governance, how do you monitor that and ensure that changes happen if they need to?

We have a range of opportunities for colleagues to raise concerns. Of course, we hope that that does not happen, but the reality of large organisations is that there will always be different perspectives. Therefore, it is critical that we create the opportunity for people to feel safe in escalating concerns to their line manager and having that level of mediation or discussion, or in going into more formal human resource investigations and so on.

I mentioned that we have confidential contacts in the organisation, and everyone has the opportunity to use the whistleblowing procedures, if that is the route that they choose. We have our human resources processes, and we have strong and positive working relationships with our staff-side colleagues. I mentioned other things that we do on raising concerns as early as possible through the Trickle app and a range of question-and-answer sessions.

We are working on our culture, on creating the psychological safety for people to challenge poor behaviour when we see it in action and on supporting colleagues with education and training to give them confidence to challenge such behaviour. Our evidence of that goes to our staff governance committee, which monitors the situation; we also have advisory clinical networks that feed in, as well as our Grampian area partnership forum.

As for overall reports, we have just considered our whistleblowing report in committee, and we had a report that broke down our bullying and harassment cases—I am trying to find the figures for that. I think that we have identified three cases this year that staff escalated to be taken through formal processes and which are under investigation. Those are our governance processes.

Are you confident that people are well supported on whistleblowing? Do you feel that they would do it if it was necessary?

As I said, our whistleblowing report has just been considered at committee. We interview every person who raises a whistleblowing case. The feedback was that colleagues who raised concerns felt listened to and well supported during the process, which is because we have in place a process to appraise each case individually.

Our governance position is similar to what Caroline Hiscox has described—it involves the staff governance committee and reporting through that route. At our board meetings, we will be bringing in bimonthly staff stories as part of the introduction, to provide an increased focus. Culture, how staff feel and whether they feel listened to are given the highest level of attention by the executive team in NHS Fife and at board level.

We have similar initiatives for whistleblowing processes. We have the “Know who to talk to” campaign and we are rolling out a toolkit on talking. We have had a very small number of whistleblowing cases, which makes me slightly curious and makes me want to dig a bit deeper to ensure that the culture throughout the organisation at all levels and in all teams is what we hope it would be, and to consider whether we can do more.

We approach all of this in a range of ways. I have emphasised the importance of visible leadership—as, I know, my colleagues here today will have done. I do regular walkabouts with the employee director. In our health and social care partnership, the director does the same alongside staff-side representatives and, likewise, that happens in our acute setting. We have visible leadership and we share information with staff, including through written updates. I have mentioned the focus and concerted effort across the organisation on team Fife and the sense of belonging. We hope that that will develop and nurture the culture that we hope for in the organisation.

Such work is a priority for us, but we can always learn more. When we leave the meeting, I will speak to Caroline Hiscox about the Trickle app, which I would like to hear more about.

Our position is similar. We have a small number of whistleblowing cases, which we always deal with as best we can. We have “Speak up” ambassadors who take people through the process.

The same as my colleagues outlined, our governance structures involve the staff governance committee. The employee director and I co-chair the NHS Lothian partnership forum, and all the other partnership forums link into that.

We are finding that a lot of our staff are coming back—in nursing, 25 per cent retire and return—which is a good indicator. We have supportive staff networks, and some, such as our black and minority ethnic staff network, are driven by our staff. I am a big advocate of networks, which provide peer support and are there to support staff throughout.

The issue is one of those things that you will never be finished with—it is \like the Forth bridge; you have to keep going round it. I do not think that we always get it right, but we try to get it right.

I thank the witnesses for their attendance and their time. We will have a short break to change to the next panel of witnesses.

10:29 Meeting suspended.  

10:37 On resuming—