Fy hollwch i gael y 12 y bydd y gallwn y Cymru i gyfrifio gyffiniatur hwn yn 2023. Ac mae gymaint wedi eu gwneud bod gweinodau, ac mae y gallwn gwneud gallwn iawn i gael dwi'i hawdd, ond mae David Torrance yn gwaith yng Nghymru, ond mae'n i Tooodydd i James Dornan. Yr 1st ei gŵr yn y gyrdech chi'n gonoid i gyd...]u 5, 6, 7 a 5, a cyfrifio'r rhywbethau chi gydig.  For this morning's session, I want to welcome to the meeting Pamela Dudeck, the chief executive for NHS Highland, Jane Gan, the chief executive for NHS Greater Glasgow and Clyde, and Gordon James, the chief executive for the Golden Jubilee hospital. I have been asking all health boards the financial situation that you are in. Obviously, we see that there is increased demand on all health boards across Scotland. There is also the pressures of heating and operating. The fuel costs rise, inflation rise, there are affecting our public bodies as much as there are affecting the whole country. That is having pressures on you managing your budgets but also the population at large are feeling it as well and maybe their health problems are increasing. I would like to ask you each and turn how you are managing that, and what impact that is having, and how you can see a situation in which you might be able to potentially reach a break-even position. I have come to Pamela first of all. You will see from our submission that our predicted financial situation is fairly, I suppose, a bit scary in one level in terms of the size of the gap that we are looking to for the next three years in trying to resolve that. That is a significant amount of money that includes the adult social care gap because we are a lead agency in Highland but also a proportion of the gap in Argyll and Bute as well. That is our total prediction of the size of the gap that we need to close. First of all, in terms of the work that we are doing around that, I think that again in the submission we set out some of the value and sustainability actions that we are taking as a board, the efficiency actions, but fundamentally for us this has a big focus on redesign and delivering services in a different way, working with our partners to try and optimise the wider public pound in pursuit of good outcomes for our population. There is significant work under way in all of those aspects, either through partnership working programme boards, looking at the evidence, looking at what we can do differently and indeed working closely with our communities. The sustainability in terms of inflation, in terms of the impact of that, with our energy, we saw a 35 per cent hike last year and it is predicted to be around 20 per cent this year. Again, we are engaged in as many energy efficient ways of moving forward as possible. All our new builds will be built to the net zero standards and we are doing risk assessments on any plans that we have at the moment. Our new hospital in Avingmore, Broadford and the NTC were built to the standards that were in place at the time of those designs, but they are at the top of the spec for that. We are engaged with district heating systems in Caithness and we are hopeful that we will be able to do the same over in Fort William and there are a number of other initiatives that are under way through our sustainability, our climate side of business and what we need to do. Highlands is probably the most fuel-poor area of the whole of the UK and this has been one of the most difficult winters for a lot of people in terms of seeing an impact of that in the level of need that your patients are displaying. We have had more of an anecdote response to that in terms of the reports that come in when we are seeing people in the front of our hospital in terms of the difficulties for them and we have definitely seen it through the lens of children and families and the in-work poverty is quite prevalent and that is quite well evidenced across the Highlands and Argyll and Bute. From a health board perspective and a social care perspective, we spend a lot of time looking at access, looking at how we can deliver close to home, albeit that can be extremely challenging in certain circumstances. We are looking at it from that perspective but we are also one of the main employers. What does that mean for our staff? We have a number of welfare and support arrangements for staff. In collaboration with the council, they have done a few initiatives around benefits and additional income maximisation initiatives within our board. I will follow up on some of that. Ite Jane, can I ask you for your perspective from the Glasgow? Yes, we similarly have financial challenges but we are predicting a break-even position at the end of March. That is positive and it is hard work on behalf of colleagues within the health board. We go into next year with a recurring deficit which is similar to that which we had previously. We have worked hard to manage our resource within the framework that we have. We, as PAM, have outlined a number of initiatives to increase our efficiency, to look at our prescribing budgets and make sure that we are using them in the most efficient way. We are looking at some service redesign. We are looking at energy efficiency as well. We too have access to some of the district heating initiatives. We are working towards our new bills being net zero carbon, although that brings with it an initial capital cost, which is slightly higher. There are a number of issues. We are supporting our patients. Clearly, people are presenting a more fragile stage and more frail. We are trying to support them in accessing our services but also in their home to try and keep more of our patients in their home when it is suitable to do so. We are also making sure that those patients who are discharged have their wraparounds in terms of trying to make sure that there is where they require some financial services or advice on home energy or food packages or any of that kind of stuff. We have engaged in quite a lot of work to make sure that, as people are discharged with our social work colleagues that we are working on a whole system basis to make sure that we are supporting those most in need of those services as they are discharged from hospital. Similar to Jane, we are forecasting a break-even position for this year. Our latest submission into Scottish Government for next year, 2023-24, is also a break-even position. However, there is challenge within that. It is about £6.6 million of savings that we need to find, about 2.8 per cent of our overall budget. We are working in a number of areas that colleagues have mentioned, such as procurement and prescribing, and we are aligning with the national sustainability and value programme. We are working in a business case at this moment in time to link into the Clydebank district heating system, which will be positive not just for the hospital but also for the community of Clydebank. That will then allow access for that heating system to social housing around about jubilee in the future. That will really act as that anchor point within the community. We will work to pick up on that. I will go to Paul Sweeney first of all. Thank you, convener. I was going to comment on the idea of how you deliver capital investment that will return such as district heat networks. You have outlined clearly specific projects that you have in mind. Ms Grant, if you could maybe go into more detail about what potential district heat network investments that the NHS GGC is looking at in particular? Certainly looking at Clydebank health centre has the potential to access the process in Clydebank, and we are looking at that too, so that is one of the initiatives. We have also looked at some of the other district heat pumps that are set up throughout some of our premises, and we are looking at the ability to have them in place in the dental hospital in Dyke Barre, Leverendale and Stoghill. We are also looking at the Queen Elizabeth at the wastewater to heat process and how we can maximise that. I heard some colleagues talking about sewer panels and so on, and we have them in a significant number of our health centres as well. Do you have a metric that you use in the board to assess what return on investment you might get against a capital spend? Is that something that you are able to test as a business plan? I have many states of facilities, guys. We have done that process. I would also like to ask about, if you could provide an update, just to all of you, if that is possible, on your repair backlog and capital investment programme to deal with that and cost avoidance efforts, because a stitch in time saves nine. It has been interesting to know what proactive efforts are under way in addressing that repair backlog in your estates. We have a £98 million capital investment in that budget for last year that mainly is around things like the north-east hub, which is in the north-east Glasgow, which is a good community facility. We have spent quite a lot of money on primary care improvement plan premises and so on, new radiotherapy equipment and those kinds of things, because we are trying to cover the whole range of community and primary care and acute services. We have also spent quite a lot of money on a new robot and an assessment centre, a trauma orthopedic assessment centre in Paisley, because we have quite a lot of premises, so we are trying to do that and also quite a lot of money on medical equipment, because we do need to have our rolling programme of replacement. In terms of backlog maintenance, we have a significant challenge there across Glasgow and Clyde, and it is not all in the places that you might expect. There is quite a big number in Queen Elizabeth, because we have quite a large retained estate there, so things like the Institute of Neurological Sciences has a big backlog maintenance, so we are working on a business case just now to replace that, because it does need significant investment. We are looking at a lot of energy management schemes to try and save money to make sure that we are recycling the resource that we do have and not just pouring more money, and we are talking about all of us looking at the net carbon zero. We are trying to do all of those things, particularly as we approach new builds and using the backlog maintenance moneys that we have to refresh our estate in a sustainable way, as we can. I wondered on your retained estate if there are opportunities to achieve capital returns from disposal of surplus estates or investment in surplus estates for other purposes, such as the former acute hospital site at Stoddpill or the east house at Gartneybo. We have a range of disposals, and we have a programme for that. We are also looking at whether we can maximise our use of premises with other colleagues in local authorities and so on. There is a range of issues that we look at on all of those premises to maximise the benefit for the whole population. I think that my question is particularly for Pamela, given the number of older buildings and local hospitals and things like that stretched across Sutherland, Caithness and right across NHS Highland. What programmes are under way at the moment to keep those facilities in good condition in the first place open so that people have those services close to home, but also making sure that all services are not centralised into rig more? Some of those buildings are very old. Some of my family are from Sutherland, so knowing how old those buildings are, how is the progress of work to make sure that they can take some of the new equipment that they originally probably were never built to take? If I start with our backlog maintenance, and that will answer both questions as I started, our backlog maintenance is around £80 million. The majority of that backlog maintenance refers to rig more. Our estate, although it is old, is generally in a reasonable condition, and our head of facilities in the States is indeed risk-assessing all our buildings and has been moving through that in the time that he has been in post. We have opportunities to improve things that are happening. That is quite a reasonable programme. Again, like others, primary care as well, we have a programme of investment. We take a risk assessment-based approach to that, and our high-risk backlog maintenance is now under a million, so he has done a lot to address that. Those facilities, as you say, with the dispersed population that we have, is critical for us to have fit for purpose facilities locally, but there is also a big question to us as to how we use them and how they are modernised. Not just in terms of the building, but what we do in them fit for the future, because there is a real loyalty and a real connection to what has gone before. That is the bit that we need to work hard with communities around, because they often perceive the building as the thing that makes it safe for them. What is important is what goes on within the building. As part of our strategy and redesign, that will be our focus, and the buildings enable us in pursuit of what we are trying to do. However, we have AVI more, we have Broadford two great facilities, we have a redesign capital project for Caithness, and we have the Belford redesign and new hospital planning under way. In terms of that state there, that looks good. Argyll yn bute, we are working with Argyll yn bute closely as to what else we need to do there, but, having visited a number of their facilities, they have some really good facilities down there as well. It is not always the case that they are forgotten in the back of Beyond and we are not doing anything about them, and I think that the figures support that. That is great. Thanks, convener. Paul O'Kane. Thank you very much, convener, and good morning to the panel. I think that perhaps it is following on that theme. I heard what Pam said there about buildings as enablers in its house with the quality of care, and I accept that that is true. I wonder if I can just ask Jane directly on Greater Glasgow and Clyde. The repair backlog at the REH is now over £80 million. The repair backlog at Inverclyde Royal is now over £100 million. Healthcare Improvement Scotland, in a recent report, pointed to the quality of care in Inverclyde being excellent, but the challenges were very serious in terms of the fabric of the building. Do you think that it is sustainable to run with an ever-increasing repair backlog of those scales within those hospitals, and does there need to be a more sustained capital investment from Government in order to do something about that? Clearly, we have backlog maintenance requirements, capital crimes on all our sites, and there are a large number of sites in Glasgow and Clyde, as you are aware. Clyde being a key element of our service delivery, but I would not sink out Paisley or Inverclyde as being the key issues. It requires us to look across our real estate, both in terms of the acute sector and primary care, to make sure that we are maximising that. PAM says that we do it on a risk-assessed basis to ensure that we are using the resources that we have in the maximum possible way to ensure that we are covering the areas that are of most concern to our patients. When we have everything in Glasgow and Clyde from brand new real estate to, as you rightly point out, those that are less so. However, we have spent quite a lot of money on all sites trying to refurbish areas within them to make sure that they are fit for purpose, because in Queen Elizabeth we have single rooms, but in Glasgow and Inverclyde we still have nightingale wards, and in Paisley we do have four and six-bedded rooms, so we have a mixture here, and we just need to manage our resource on a risk-assessed basis to make sure that we are using it as best we can across the resource. Of course, we could use more resource, but we have to sit as a board and prioritise those areas that we feel are going to have maximum benefit to patients. We also have to invest in the areas that are less visible, such as lifts and windows and so on, but they are not the kind of things that everybody wants to do shiny new things. However, we have to make sure that we are spending money on the areas that are the fabric of the building to make sure that they are kept up to pace with us as best we can. On that point about running a repair backlog at over £100 million, do you think that that is sustainable? Given that Healthcare Improvement Scotland has said that there are substantial challenges to the safety and wellbeing of patients in that and staff, do you think that it is long-term sustainable to be running that repair backlog at over £100 million for Clyde, for example? We clearly could do with more resource, and we would be happy to use that if we got some, but we have to base on risk. For my whole career, we have been juggling resource to make sure that we are managing the risk as best we can. The backlog maintenance number is high, and we would like to have more resource, but we have to maximise what we have across the board, and that is what we are doing. I think that it is fair to say that all those stratifices fly their backlog maintenance into significant high, medium and low. If you look at the backlog maintenance and totality, the element that will be significant is very small. As Jane mentioned, that is where we clearly focus and are high based on that stratification level. That is part of all boards' property and asset management strategies. You have wanted to come in quickly on that before we move on. Just a quick question. Good morning and thanks for coming. It is a question for Gordon James. He talked about prescribing, and I know that prescribing is not just medication. It is like diabetes tech, pumps, Abbott Libra, Dexcom and so on. I know that it is how you weigh the balance between the diabetes technology and making sure that we avoid poor blood glucose control. I know that there is a diabetes tech campaign that cannot wait going on there now. I am interested to know how you balance all the avoidance of complications of type 1 diabetes. I declare an interest because I am a type 1 diabetic pump user. I am interested in how you weigh all out as far as prescribing and the costs of all that. Within Golden Jubilee, we do not deal directly with type 1 diabetic patients. I should also declare an interest. I am type 1 diabetic as well and I have an insulin pump. I do not know if that is pre-planned, but I do. Over the past year, within Golden Jubilee, we have saved over £100,000 moving to the best prescribing medicine for our patients. Specifically on the use of technology, insulin pumps and so on, we look at the whole life cost. What does it mean for the patient all the way through their journey, through health and through their life? Within the portfolio within Golden Jubilee, we have the Centre for Sustainable Delivery, and we have an area that focuses directly on innovation, which is called ANIA. It looks at accelerating innovation across healthcare. It is in collaboration with the chief scientist office, and we have just last week seen two value cases. One was for digital dermatology, and the second was for closed-loop diabetic insulin pumps. We are now going to take forward on a national basis with investment, fast-tracking insulin pumps and closed-loop systems that we already have in stock within the NHS and rolling them out across Scotland. We would like to talk about performance issues. Paul Ken, do you have questions on that? Thank you very much, convener. I suppose that I can start with a general question last week's evidence session. We heard some discussion about the lack of prioritisation of preventative care. Obviously, because I understand that we have been a huge focus in terms of acute care, in terms of trying to address issues and backlogs and all the rest of it. Do the panel agree with that assessment from panellists last week that there has been perhaps a large focus on acute care to the detriment of preventative care? I do not think that it is as straightforward as that. We have all been active in the space of prevention for a long time, but maybe not as deliberate, maybe not at the scale consistently across our areas as might be possible. Your health and social care partnerships and community planning, I do not think that there is a board that is not active in and around this. I sit on the national group that looks at community planning and we did a bit of an assessment of all areas. All NHS boards were very active in that space with their partners around prevention and early intervention. There is something to build on there. I think that it is inevitable to some degree. I am from a community background, so I am probably more of an activist in pulling back into what happens in the community, but it is inevitable and acute when you have the pressures that you have and the backlog with scheduled care and everything that you are diverted to that very urgent and pressured situation. I know that the conversations that we have been having as chief execs nationally and locally are very much around how we get a reasonable proportion of investment and sustained investment in that prevention end, because we all know that investing in early years, investing in that primary prevention, is the longer game that will help us in the situation that we are in. I do not think that there is a commitment, but following that through at times in the pressure of our budgets and where our here and now pressures step up can make that a very difficult competing demand. It requires us to look across the spectrum in balancing all the competing demands. Grace Glasgow and Clyde have had a public health strategy since 2018 about turning the tide through prevention, so we have been focusing on that as much as we can. That covers a whole range of initiatives that we are trying to work closely with our public health colleagues and our partners in the health and social care partnerships and the community planning to maximise that potential across the boards area. We have been working, we have the Glasgow Centre for the Population of Health as well, and they are part of our public health setup, albeit they have a wider remit as well. There has to be a key focus on children and young people for the future of our country, and that is what we are trying to do. Things like type 2 diabetes and so on, there is more to do on that prevention agenda. That covers the range of things from the traditional health promotion and putting perhaps more emphasis on things like screening and so on. As people go through their journey, how do we assist them to live their best lives when they have type 2 diabetes and so on? The child poverty action plans are a good vehicle for trying to make sure that we are investing at the right time in that journey. There is a challenge between the here and now in managing backlogs and managing our emergency demand but also making sure that we keep our focus on that. We do, in Glasgow and Clyde, have a population health and wellbeing committee to try and make sure that, at the board level, we are putting enough attention on those things, as well as just in the delivery of the strategy. Given Goan Jubilee is a national elective centre and specialist services in terms of heart and lung etc, our remit is not public health. However, I would agree with my colleagues that public health prevention is something that should be an absolute key focus for us within health. The only point that I would add is the roundabout education and training of our citizens and how we engage with them on a digital basis. I think that it is key as we move forward. I wonder if I can ask about A&E, particularly A&E waiting times, for the territorial boards, rather than Golden Jubilee. The four-hour standard has not been met in quite some time and we have seen the worst figures on record in 2022. I wonder if both Pam and Jane could explain their sense of what is that about staffing issue in terms of A&E and having the appropriate amount of staff and resource in A&E departments, or is it about wider issues to do with where people present? Last week, we certainly heard from some of your colleagues that they would rather people came to A&E than go anywhere else if they choose to present at all, but do you think that it is about inappropriate presentations? I am happy to go first on that. Again, that probably would not be the starting point. Speaking to our consultants in A&E, although we have a proportion of our presentations, it can be about 40 to 45 per cent that come under the minor injuries banner, if you like, the category. They tell us that those are relatively quick and simple to deal with and their issues in terms of their performance come more from the flow into the hospital, the access to a bed and the time waiting to move people into the hospital. That comes from a much wider system issue that relates to delayed discharges and relates to the care home position, the social care position and their ability to discharge earlier in the day. That is the area that they would highlight with us. Certainly, in terms of our performance, our rural generals can be very variable from performing to the standard at 100 per cent to being down to on any given day. I have generally down to the 80s, but I have seen the odd day where we might have had a major trauma or something out in the Highlands where it has gone down below that. By far, the biggest issue for Rhaigmore is being able to get people moved on into their next destination. In the rural generals, it is usually down because there has been some kind of trauma or major incident that has meant it is a little bit more to deal with than it would normally have. That is what the consultants would tell me there. In the wards, it is staffing. It is care home placements. We have lost 104 care home beds in the islands in recent months. Of course. We have a range of issues within Glasgow and Clyde. We have five main ED departments and a number of minor injuries units as well. We would encourage people to use the minor injuries units where it is appropriate. We try actively to do that to ensure that the main ED departments do not become log jammed with people who would be better served elsewhere. We do quite a lot of promotion around that and we would continue to do that. The main issues for us are similar to Pam. We have elderly fragile people presenting at ED departments. We have spent quite a lot of time and you have heard from colleagues at the flow navigation hub to try and reduce the front door demand and to make sure that where virtual consultations are appropriate and only when they are appropriate clinically, that is one of the issues that we expand our portfolio of offering for patients. That has been successful but there is more to do. We have also looked at things like the mental health assessment units to take some of those distressed patients who require mental health assessment away from the main ED departments and we have set up within Glasgow and Clyde some additional services that have proven pretty successful. The key issue is one of flow principally and we too have delayed discharge challenges and we have around 300 on any given day across Glasgow and Clyde, which is a fairly significant number. We are working very hard with our health and social care partnerships and local authorities to maximise the potential because sitting in a acute bed is not best for those patients, never mind those who are trying to come in. There is a range of factors. Staffing sometimes is a factor. We have been pretty successful in recruiting and in recent days some staff but there have been some staffing challenges as well. I would say that flow is probably one of the biggest ones but we also need to make sure that we maximise our performance in flow 1, which is the miners flow, where the major volume of patients comes through as well. It is not one-size-fits-all, I would say. It is a range of things that we need to look at and we are looking at how we can maximise and redesign the flow within hospitals in terms of flow 1 but also the glass flow model in terms of moving patients using our predicted date of discharge more accurately, making sure that we are maximising the number of discharges in the morning as best we can, using our discharge lounges to make sure that patients who are waiting for discharge are not occupying a bed while others are trying to get in. There is a big range of things that we are trying to do at the moment, working closely across the whole acute system and also with our social health and social care partnerships. I would have again briefly, convener, through Jen, you mentioned a number of alternative routes in terms of being seen, minor injuries of course and the board trying to encourage people but it is actually not mentioned GP out of hours which is obviously a key part of that as well. Obviously, Inverclyde has been without out of hours GP's since 2020. There appears to be no plans from the board to reinstate that service and rather to direct people 15 miles up the road in terms of the provision at Paisley. Do you think that that is good first value for money in terms of supporting people to be seen in the appropriate place and secondly what kind of impact that is going to have realistically on A&E front door when people can't see an out of hours GP in their community and I suppose if you might be able to just give the reasons behind that decision. The board hasn't taken a final decision yet. We're still working on a number of impossibilities for GP out of hours and so we're still in business continuity across Glasgow and Clyde for the whole of Glasgow and Clyde and that includes Inverclyde. There has, as you know, been issues around Glasgow and Clyde's GP out of hours and we've completely transformed the service three or four years ago. It was in the situation where you could just walk in and that caused a difficulty because it wasn't an appropriate mechanism. It was probably I think the only board in Scotland at that time who did that. So we've completely redesigned that and we do have a GP out of hours service in Inverclyde. We use there's home visiting service, there's a focus for transport to Paisley if they need it and there's a very large number of consultations being done through by phone now across the whole of Glasgow and Clyde, not just in Inverclyde. So the service model for GP out of hours is changing along with our consultations for things like outpatients and so on as well and that virtual mechanism is going to become more embedded and has become certainly since Covid more embedded across our all service offering and that includes GP out of hours. So we haven't seen a significant increase in ED attendancies in Inverclyde on the back of GP out of hours and we've been monitoring that quite carefully but the board is still considering the options because we recognise there are strong feelings in Inverclyde about the services that we are providing but I would suggest that we do have a service in Inverclyde for out of hours for GPs and it hasn't increased the activity in the emergency department. I think that out of hours has been a challenge for many many years that ran out of hours in another board for many years and it was a constant struggle in terms of sustainability in the configuration that it had and certainly it's been no different coming to the Highlands and I think the bit that's tricky for us and the bit that we really need to work hard with our communities around it is just that perception of what is and isn't happening in their community again a bit like what I said before in terms of what people have traditionally experienced and therefore they think any change means it's a reduction in service it's a lesser quality service and we have many conversations like that in the Highlands there are a number of communities who do not wish to use 111 and feel quite upset with us at asking them to do so when actually what we're trying to do we have we have an arrangement of 111 that can actually help us you know manage the postcode better and respond better with the with the local teams but for me there's something about building up that confidence in communities and help them understand what is a safe service for them just because it's a change doesn't mean it's an unsafe service and I think we have a lot of conversations with communities like that and out of ours is a key one that the if it's not something they recognise they can often feel quite unsafe but it is incumbent upon us to change in that arena because the way that we were trying to to spread a very thin workforce across a patch was probably less safe than than some of the innovative ways that we might try to to work as we go forward and our clinicians want to work differently in that space so it's trying to bridge that gap of understanding and that feeling of unsafe I think and we definitely have got that as an area of work for ourselves at the moment. Thank you we're going to move on to talk about Covid recovery and questions led by Emma Harper. I'm interested to hear about Covid recovery in all three areas and I don't know I mean just hearing from health boards when they come in front of us you know healthcare is really complex you know and I know as a nurse that when I worked during the pandemic providing vaccines as well you could see just how busy and committed and how professional the staff are and you know when I'm thinking about acute care and mental health care and emergency and elective care and Jane you said no one size fits all when you're trying to address the issues of trying to address Covid recovery so I'd be interested to hear about actions that have been taken in order to progress recovery from Covid and what's working and maybe what is new working? We might as well go with you. In terms of Covid recovery we are working hard on the elective backlog as you would imagine and there's a large backlog of patients who are required to be treated and we need to balance that with the increasing or the very high level of demand for emergency care so we're trying to manage both of those at the moment. Has been a challenge and we're working hard to reduce the long waiting patients particularly because and we've had some success on that more so on the outpatients set up than in inpatients which has been a challenge because of the emergency demand over the winter. We've seen our length of stay being quite high in emergency care which hasn't helped us but what we're trying to do is make sure that we're using our ambush care hospitals we're fortunate to have two setups in Glasgow and we're also looking at whether we can ring fence some in beds in Gartnavel and also in Inverclyde to make Inverclyde a centre of excellence for our orthopedic elective work so we've got quite a lot of work going on to look at how we can manage the bed base in a different way to protect that from the emergency care and make sure that we can keep going with our elective backlog we're also and I'm sure Gordon will say but we're using making good use of the golden jubilee and work hand in hand with golden jubilee as one of our partners to deliver elective care. I'm not sure if you want me to go wider into cancer and so on as well or just to that word? I mean I suppose it's a competing priorities with when acute care beds are occupied by people who are not well and we're seeing the the acuity of patients are getting sicker before we even see them in the hospital so I think it's just to make it very clear that there are challenges when you're juggling beds so things like the golden jubilee and the just sequestering beds for elective surgery or the national treatment centre for instance Pamela will that should support managing elective so that we're not having competing bed priorities is that is that what we need to be looking at? We're also yes you're absolutely right we're trying to make sure that we're making use of all the elective capacity we do have across Scotland to make sure we can maximise that and we're also looking at a number of initiatives to keep people out of hospital where it's appropriate you know increasing our remote monitoring and increasing our opat service and so on and we've been pretty successful in delivering reductions in patients who could perhaps have a different service model and I think that that is the way of the future to to maximise the potential to actually keep people out of hospital who are not best served for doing that we've recently done a day of care audit which looks at you know is is is is there anything else we could do for those patients who are in hospital not just those who are delayed in their discharge but and there's things we emerged around things like ahp and perhaps we could move some of those patients and have their ahp activity more in in their home or in the community setting rather than waiting for some of it in hospital so there's a few things emerging from that day of care audit which we are trying to to minimise the bed days and make sure that those beds that we are using are really for acute patients we've talked a little bit to delayed discharge but also if there are things where we can do remote monitoring and so on and treat people more in their home then or in a community setting then that's what we should do and and so it's all of that I think that we need to do then Pamela wants to come in okay thank you so during the pandemic a decision was taken to keep golden jubilee as a green site so in terms of our planned care operation we restarted about 10 to 12 weeks post the beginning of the pandemic which has ensured that we've continued to offer that planned care all the way through and if I look at our surgical throughput between 1920 and currently Lashard the current year we're in then we are seeing a 20 increase in our throughput of surgical services both within knees, hips and eyes and also within our specialist cardiac service as well as as Jane mentions we do work with boards across Scotland and support patients who are waiting have long waiting times and during the pandemic as well we opened our phase one which was our eye centre and we currently do about 30 per cent of Scotland's cataracts so just over 11,500 will be done this year and at the end of the summer we're on plan to complete the construction of phase two which will increase the expansion of our orthopedics general surgery and endoscopy on our site and that's an 80 million pounds investment that we have in addition to the eye centre that opened two years ago so in the coming years the original plan for both of these phase one and phase two sites was a ramp plan all the way up to 2035 but we've been working with colleagues within boards and within government to look to see how we can bring that forward the if you like the full volume throughput of the sites a much earlier timescale than the original 2035 plan Highland perspective I suppose much much like Jane I guess our system has been quite out of balance and the emergency demand has definitely had quite an impact on our scheduled care programme and that has been in terms of the release of beds or the ring fencing of bed that our ability to do that for surgical care so within the medicine side of things just again whole system working across the community into the acute hospital and really trying to get those in hospital interventions and our actions around the planned data discharge and early discharge discharge to assess kind of mechanisms in place as it has been absolutely the case with daily oversight across the system of of trying to make that move and to reconfigure and think about how we again can optimise what we do in the community to be able to to move people out within the elective side of things. It's fair to say that we are still on a number of specialties out of Kilter with our pre-pandemic performance and with those that are that are most challenging being the same areas that we're challenging pre-pandemic I believe in Highland so we have a plan underway around that working with Scottish Government to to set out trajectories and that's been refined at the moment in terms of where we'll get to. Clearly the national treatment centre that opens next month is a huge asset for us and a really positive step forward in that all I care out of Rhaig Mawr will come across into the NTC and the less complex high volume orthopedics will be dealt with within that new centre and that frees up space and opportunity then back in Rhaig Mawr so from our orthopedics and trauma side of things we would expect by October and actually three points during July and October this year that we will have got to the point where our over one year rates will be down below that year and then by 2024 starting to get back into balance with the TTG around that those are the predictions that we have at the moment we'll obviously keep a very close eye on that and surveillance with the ophthalmology eye care service once that's up and running we expect again fairly early on in the life of the NTC to be in balance around our ophthalmology and waiting list there and that will obviously create capacity for the national treatment centre to offer out to other boards in the first instance we will be working with NHS Grampian for orthopedics around their weight and times so we will be taking about 30 or percent from there within that figure that I quoted. Thank you. Good morning panel. My question is for Jane and it's around your gynaecology waiting times I think on a lot of other waiting lists looking much better but can you tell us why there's still issues with gynaecology? So we've had some challenges with gynaecology there's no doubt about it our waiting time particularly patients has been lengthier than we would like we have some waiting list initiatives going on just now to reduce that and the number of long waiting patients is coming down the resource we've had to move some of our staffing resource into obstetrics and that has caused a slight imbalance or over the few months that has risen previously it was in balance and that has caused the issue there however we have an active programme to insource and do waiting list initiatives to reduce that as swiftly as we can and we are seeing some early shoots of that just now and that work is under way as we speak okay thank you we now move on and we again talking about progress a recovery plan we've touched on it quite a lot this morning anyway but questions led by Stephanie Callaghan. Thank you very much convener in the Scottish Government annual progress update back in October said that significant progress in delivering and ambitions of the recovery plan had been made and I'm just wondering is that something that you feel that you agree with or do you disagree with it to any extent and I'd like to ask that of all three three of you who start with Pamela. Can I ask you to repeat the question sorry just so that I answer you right? Yes so just the Scottish Government annual progress report back in October said that significant progress in delivering on the ambitions of the recovery plan had been made so is that something that you would agree with or is it something that you would have some challenges around? I think I'd probably start with saying yes but we obviously would have some challenges around we have worked really hard from every opportunity of remobilisation and recovery to try and step up and bring our system back in balance but I think we've described some of the challenges in the conversation today that we continue to meet and I guess every day we are looking at where we're at and what's what the art of the possible is but that's generally against a challenge position and that's quite a volatile position so you and the experience I have is that we can look like we're making good progress and we're on our way and then it suddenly there are a few variables change and it becomes very difficult again so I don't think it's a smooth path at all but I think it would be fair to say that that definitely there has been movement and progress in some areas but sustaining that and feeling on an even keel with a very confident future pathway is a bit challenging at times. I think progress has been made I think it's been a difficult period for the health service across Scotland and more widely across the UK and we have had to balance the emergency flow and the fragility and frailty of patients which is greater than it has been. We have had a significant increase in things like our urgent sufficient of cancer referrals and that's leading to a backlog there which we have got work to do and make sure that we're addressing that because people are anxious and rightly so so we've got diagnostic challenges there and making sure that scopes and imaging are so on our appropriate resource to handle that backlog and within that we have to prioritise those patients who we think are most in need and at highest risk and that against a significant elective backlog but also the emergency challenges that Pamela has outlined so I think progress has been made. I think we have to reflect on our staff and recognise that they've had two or three years of really significant pressure and we're not starting from a position where they have been through that difficult time and so we have to reflect on how we can support them rather than just keep asking for more and more and more from our staff we have to think about how we can make things easier for them so we've spent quite a lot of time just trying to make sure our staff are supported in an appropriate way recognising that we have a public duty to make sure the services that we are providing are swift and we have access to them at an appropriate level of quality as well but it's undoubtedly a difficult journey through this. I would agree with my colleagues, I think that the pandemic has been challenging not just for patients but for all of us in society and obviously the added pressures of winter over the past few months have been challenging. That said, I do think that we have made progress. I think that within the golden jubilee last year we pivoted to look at long waiting patients across Scotland and you'll see that the number of patients that are waiting for a longer period of time has reduced over the period so I think that we have made progress about recognising that there are still challenges within the system. Within golden jubilee we have the Centre for Sustainable Delivery and we have two pathways that we're working with specialist delivery groups across Scotland so that's clinical and managerial groups across Scotland looking at patient-initiated reviews and active clinical triage of patients and that's really about putting patients at the centre and what we've done through those two programmes is we've removed the need for about 100,000 patient appointments so if I take myself as an example, as type one diabetic, if my control is good then I don't need to see a doctor but if my control was then to go or get worse again then I can initiate that review myself so it really depends on the need of the patient and I think that these changing pathways, how we transform our services has helped as we come out of the pandemic as well. You preempted my next question there Gordon and I was going to ask you about that so I'm really interested in you know how significant is this and is this something that we should be looking at should there be some scaling up, should we be doing similar things elsewhere? We already are scaling it up so almost all the boards across Scotland are engaged in PIR patient-initiated reviews and ACRT which is active clinical referral and triage so as I say it's about 90,000 patients appointments this year that haven't needed to be required but I would stress that that is based on clinical intervention so that a senior clinical intervention is part of that process and then within patient-initiated reviews it's down to the patient to then re-engage with the service or have that realistic medicine conversation with the clinician that is delivering their care. Is there a need to make a real impact on achieving these ambitions? Absolutely, it's having the impact already. Second question. I've got time for that question. Fourth question. Is there other members who want to come in and sit and if you can make it quick for a very other question? Right, I was just going to ask quickly to Jane and to Pamela. The Audit Scotland report said that it doesn't feel like there's a full reflection of the scale of the challenges and that that's had an impact and I'm wondering whether you feel that it's really accurate or whether you feel that actually some of the stuff had to be quite local so there were those high-level targets and things but was it actually helpful or unhelpful then to be making decisions at a local level what you wanted to do? I think it is really important to have that local aspect. I think you need both because there's a lot of learning and there's a lot of a lot you can take from a national direction and support from a national direction but the local context is really important and I think again if you look at Highland as a 42 per cent of the land mass in 36 islands and a very distributed population one size doesn't fit all and the context is different and actually the assets that you might have at a local level are different so that that local ability to assess that and also pool in partners to some of this work is really important and so we're always trying to balance both and I think you know the insights you have as you I guess as we've kind of forged our way in recovery out of the pandemic there was a number of unknowns and I think we still are in that territory at the time you start to understand more and more about what you might need to think about differently and I think we will be on that journey for some time but I think local context is really important in designing and responding to the population needs. I would agree with that I think it is our requirement to have an overarching direction of travel but I think we need to have local autonomy to do that. I think there has been a we have been on the journey for the for the last two or three years I mean but even today we're not out of that journey yesterday I had 487 patients in patients who had Covid that's a large number now they're not all there because of Covid but but they bring with it an added complexity around infection control and so on so Covid in itself is not over in the sense of it doesn't it isn't impacting on our services it still is so that means we have a number of closed wards and so on so therefore our bed base is still quite challenged with that and we need to make sure our patients and our staff are as safe as they can be in that situation and particularly in the wards where as I've described we have you know some nightingale wards still in Glasgow and Clyde and so therefore it still requires us to be in I think some colleagues said over here that it's a complex environment and it is an incredibly complex environment to manage that because we're still managing Covid in a different way and but the numbers are still high so it's not we haven't finished that yet and also I think we had a kind of perfect storm I've worked in the health service for quite a large number of years and you know over the winter period you usually get between kind of Christmas and New Year the new year there's usually a wall or a reduction in the emergency demand this year there was certainly not for the first time in that I think that's probably a whole career because of the Covid and flu and so on as well as the emergency demand so this winter hasn't been what I would call in my experience a kind of traditional winter so and we really are still only in March so it's just you know it's just trying to get out of to balance all of those things but I do think you need local and national depends on your colleagues Evelyn you have a question on this? Steph asked some great questions she asked mine. Emma, you wanted to come in. Yep thanks convener it's basically on the back of Stephanie Callahan's question and it is about I suppose does the Scottish Government enable and support you to do bespoke local delivery because Pamela you're rural NHS Highlands we've got urban in Golden Jubilee and Glasgow and and obviously last week we had Scottish borders here so does the government support you to deliver local plans in that work for your area? Broadly yes I think there are some policy decisions that have been challenging for us I think it's it's no surprise that the rural GPs were you know at odds with the the GP contract we've had a lot of press around vaccination and the fact that that is now a board responsibility and delivered through boards and a number of areas where they are still raising with us that they feel that should be GP led so you know these things come along regularly however the the kind of reality of that is that with the the vaccination programme being the size that it is now actually there are many areas that are not of a mind to be involved in that and also with demand on general practice I'm not sure that we would want to add in that other layer again in the way that it's being proposed so that again in these circumstances we are trying to work with the local context and to understand the rationale for the beyond the you know obviously again there's a confidence and I can understand that confidence in what's been before because it worked very well but what we've transitioned to is a very different programme so you know trying to balance those those different views can be challenging at times on the whole I don't feel constrained I feel that we have got a lot of the levers to look at locality planning and to try and optimise our resources at that level and I think it's for us to drive that in an improved way than perhaps we've done historically if you look at our Gail and Bute who are very integrated and everything is in our integration authority in our Gail and Bute they have great leverage to support their local context and shape and you can see the benefits of that in fact all their secondary care pathways lead to Jane's system and again some great examples of cross boundary cross board working in terms of of that Sophically we've had petitions in front of us about maternity services particularly within the area of caithness and obviously that's been something that's been it's been picked up quite a lot over the over the years it's been an issue and I know you're doing the review happening the moment in that can you give us an update of what's been done to better service women and their babies in that particular west highlands part so we're probably still in the middle of trying to understand what the optimal model can be we have we're looking at you know trying to understand better what the voices of the women are bringing to the table in terms of what they want and the use of the word safe is a fairly common safe and unsafe services is a common term used but again we are trying to understand what it would take for more women to birth locally so the birth rates are though and you'll you'll probably know from the petitions and from the the work of chat the local campaign group that they're very mindful of what the choices are you know what what are the choices that are really before the women of caithness in the context of what's on offer I think we are working very closely with them and certainly in the last fortnight meetings with the chair of chat he has publicly announced that you know the work in relationship is much improved and they're keen to continue to work with us to see what the how we can optimise that but we're still in the middle of trying to understand that we're doing a bit of a I suppose it's a strategic review and strategy around maternity services for highland because you know whilst caithness is absolutely you know it's a it's a big journey um and to do if you're in in labour or you know in that that that state of pregnancy um but so is so is Lochaber so is Sky so is Campbelltown you know and the so we have many very remote areas for which there are there's variation in terms of our birth rates so we are really trying to understand our system and do some deep dives with the the clinician as well to to see how we could I guess shape ourselves better in the future to timescale for this review to so we're really really right bang in the middle of it we are looking to take a revised business case to our May board meeting that will very much set out the resources that we're looking for and on the back of that we have been really looking at the key performance indicators and working with the team live now in terms of you know the rationale for our say section rates or induction rates and and seeking to be able to understand and explain that and improve on that where where it's possible to do so and does that review include getting feedback from from new mothers that have experienced you know have been taken to to read more for example for those long journeys and what they would have preferred yes so we we've got highly maternity voices who are working with us but we are we are also looking at how we can expand the knowledge and intelligence that we have from people that have you know mums that have birth recently and and why they made the choices they've made and and the again the kind of anecdote that I've had from from people is very much around the distance being a choice you know so if you you know do you want to take the risk of it all being fine and and you do manage the birth successfully or do you want to be in the place where you can get all the additional care of things go wrong that is that is the challenge in people's minds it would appear to be however i want to test that out further with the women that experience that okay thanks thanks for that update can we move on to talk about the escalation framework questions from jillian mckay jillian thanks convener how do the the boards feel about the progress that they've made under the current escalation framework and the issues that they've been they've been escalated over so obviously we had escalation that occurred back in 2018 and that related to finance and related to culture and leadership we've also had special measures around some of our mental health services camps and psychological therapies in particular so last year we were de-escalated from the culture and leadership and governance aspect but remain on level three for finance and for the mental health measures so if i start i'll start with the where we're still escalated and finish on the positive where we've been de-escalated so money is obviously the finance and resources is a non-going challenge for us we have worked really hard over the time certainly i've been there i've seen significant progress in our finances and it's very disappointing that we find ourselves in the situation we are again looking into next year however we do have a capability and we will apply that and do our best to to to move forward with that with a with a confident plan and we have a huge focus around that as you can imagine at the moment with the psychological therapies we've made good progress there is a very robust plan in place for psychological therapies therapies our director of psychology that came in a new leadership role has deployed that very thoroughly and very well and we are making direct progress and confident in that plan with cams that has been a slower process cams legacy waiting at list and the model with which they were delivering services which was not in line with the national specification and the staffing challenges that they have experienced has found that with with quite a legacy however again we we've brought in some refreshed leadership there we've had external support and we are moving in the right direction now albeit we still have some way to go and for me that relates right back to the discussion about prevention and early intervention in our work with the council education and health visit and etc that we that early intervention needs to be part of that plan and we are actively involved in it and to create children services planning around that so those are the areas of escalation the de-escalation in terms of governance so governance we were had a full programme around the blueprint for good governance which we had an action plan against and we completed all actions for improvement we are now a pathfinder for the self-assessment of the new blueprint and actually last week had our board development session in relation to the self-evaluation and further improvement and I think that was a very positive session again was testimony to the work we've done and how we can build on that so a board that wants to continue to improve and move forward in leadership we have invested significantly in leadership across the organization and we have a development programme in place which we are reviewing and improving as well and I think we have a very strong team in around that and culture culture is always a funny one for me because when people talk about changing culture I actually don't find that statement very helpful because culture isn't something you just change there are many cultures in a complex system and many different ways that people work what we need to be doing is creating the right environment where people can thrive and work well together and that is absolutely what we have tried to do and we've been very successful we in the post-Sturrick period of closing off all the actions associated with Sturrick and the healing process and trying to look forward as a board to really make a positive impact on that on I suppose in terms of how it feels different for people on the front line I'm out and about lots and have been throughout the whole time I've been in Highland and I've worked on many other boards and I have to say that I have found people very passionate about what they do I have found teams with fantastic profiles of how they're working together with no grievances with no real issues as well as areas where people have really bad experiences and everything in between and we have many ways that people can raise concerns now both confidentially through our speak up independent garden service has been really successful our whistleblowing champion goes out all the time and goes out with the manager and goes out privately so he's accessible to people and we have reports back on that and we have taken every report that's been done with by him by the healing process panel independent panel or through our own reporting of i a matter etc openly through our board so I think we've made great progress I still think I think it will always be a live issue it's always something in a big organisation human organisation with many different beliefs and perspectives we will always have to work on the relational issues and support people we've got Michael West up this week he's been before we've got a big focus on civility and sales lives and taking forward work around team conversations and values culture is an area where I'm particularly interested in given the the number of sites that NHS Highland operates across the number of workers that will be potentially not really coming into contact with an awful of colleagues as well I wonder how you overcome that challenge of making sure that everybody's voice is heard and that you're accurately hearing what is going on at different sites as well given small numbers in places and the potential for some of those relationships to not be very good and people will be much more easily identifiable if they if they do make a complaint compared to greater Glasgow and Clyde some of the bigger hospital sites we have in different places where I suppose raising concerns anonymously is slightly slightly easier we've tried to do that you're absolutely right in those more rural areas where people are living and working together so sometimes own life comes into work life and that can be tricky so we our guardian service actually go out and about and are present in a proactive and positive way within the services I think one of the last times I was down in Campbelltown they were in the hospital present and that is for that on that basis that they're not just somebody it comes along when there's a problem they're actually there to give support and to hear the team and to be a conduit with us in terms of bringing that support and as I said there's also the whistleblowing champions we've had a huge emphasis with our leaders in terms of the importance of knowing what's going on in their system and encouraging that open debate encouraging difference to be celebrated and not excluded and we through our performance framework spend quite a lot of time on the people measures of sickness and absence grievance rates and the temperature of the team and we are building up on that all of the time. Do you feel like you're receiving adequate support to improve not just the things that you're still on on level three on but also those other culture pieces to continue making progress and what other support do you feel needs to be in place to help de-escalate the level three things but also keep improving on the ones that are in level two? I think we're getting very good support around the things that we need to deal with but some of them are pretty tricky. The culture piece is really for us to keep doing what we're doing and to build on that. I think culture comes from the people that are in the system and how we all behave, it's for all of us to own and for us too, the leaders in the system, both clinical, clinical leadership is hugely important here because the culture is not just about how we behave or how well we get along, it's about the standards that we work to, it's about how we interact with our patients etc. That is for us to own and to continue to promote and move forward with which we absolutely as a board see as a top priority for us to have a big focus on and it's certainly something that you would see within the board. I think what we are still trying to get right to is that people at every level see that difference and we still have people who say they don't. Again, that's an indicator that we know about and we need to understand why that is and what we can do about it. We have a number of colleagues that wanted to come in on culture in particular, so I'm going to bring them in now. Can I bring in Sandesh first of all and then I'll go to Tess? Thank you. I was just a little bit struck by what you said about culture because there's a big report that suggests culture is not what it should be in NHS Highlands and Fiona Hogg ahead of your culture has left and then I've seen in the spectator in January NHS drowning paperwork specifically talking about the Highlands, vulnerable patient died to a lack of nursing staff in the BBC on the 14th of February. These are all examples where culture is poor because clearly things haven't been escalated properly and there's plenty of other examples that I haven't got time to go into. From what you've said, it doesn't seem as though you have got on top of culture within the Highlands, so what specific steps are you taking to ensure that culture is where it should be? Can I just check which report are you referring to the start-up report? There's a start-up report but there have been other reports previously that have talked about the culture within NHS Highlands. In terms of recent reports that we've taken through our board formally, those have come out of the independent panel that sat around the healing process which absolutely set out the areas of focus that needed improvement but also as time went on cited improvements that we had made. The recent health and safety case and I'm not saying that there aren't on-going cultural-based issues within our health board. I think that we will always have to work on the culture of our human system. The steps that we've taken and the steps that we continue to take are around early resolution, so being able to monitor and have surveillance of how our teams are through a number of metrics, so sickness and absence, grievances raised and a rai matter and a listening and learning surveys, those interventions are live and on-going and through performance. In terms of interventions, we have a range of interventions that can be from an organisational development perspective, so our OD team working with teams who are struggling and also the guardian service, our independent guardian service who will either on a one-to-one basis with individuals or on a team basis work with them and again there is the whistleblown arrangements. Informally we try to make ourselves all available at all levels to work through some of those issues and clearly where we've had a serious incident like the death of a patient and the falls aspect of that. We have used the formal processes of review and the learning from that taken back into the organisation. Any questions on culture and governance? Over to you. I have two questions, if I may convene. The first question to Pamela and the second question to Gordon. The first question builds on the question from our convener on maternity services. It's the culture in the Highlands and we have a petition that you referred to and you also referred to the fact that you're consulting with women's groups just to say we've heard loud and clear from the women's groups in the Highlands that they feel like second-class citizens, not just in relation to maternity services but general women's health, including endometriosis. Just your feedback on that consultation so that they know that you are listening to them and will follow up would be helpful, thank you. Absolutely, the points that have been made through that route and also through chat, I see that as it comes in and review it with the team and our local team in Caithness and the teams in Rigmore that are relating to those pathways are working much more closely within the locality around understanding those perspectives and looking at what else can be done. I'm very aware of it and we will continue to work with them and try to get to the right place. On your radar, you're working with them and it's one of your top... I've read that, we'll look in the speaker, I would respond to that but certainly if I'm up in Caithness or any of the team we try to meet with those people that we can face-to-face. Thank you. My second question to Gordon. In terms of the employee questionnaire stat, we do have a copy of the different health boards and from the stats that we have, the Golden Jubilee hospital is declining or below average. In terms of staff governance and experience, what are you doing to address the poorer performance in relation to how staff feel in relation to their well-being? We are doing a lot of work around staff well-being. In January this year, we were the first board to launch a spiritual care strategy for Scotland and that puts patients and staff at the centre, so it's about love, kindness and what it means to that staff member or the patient, so that's the first of its type and we launched that in January. We also look at things like physical health, so we have our occupational health service where again staff can self-refer through that. We have mental health, so we have mental health first-aiders who help staff through any difficult times. We also run a series of events around wider societal issues like finance etc and we'll bring on board the Samaritans or mortgage providers etc again to help staff and we have as well as the whistleblowing that all boards have, we have the employee assistance programme where staff is a confidential line that staff can contact and raise any issues that they have as well. I guess the last thing I'd want to say is we have a spiritual care and chaplaincy team. They speak to staff of all faiths and no faiths as well as the public and we are undertaking a number of activities like mindfulness, like breathing to the weekend, so we've got a full programme of staff events that we've been undertaking over the last year. They might say that's cure rather than prevention in relation to staffing. Staffing is a big issue, so having mindfulness is not going to cure issues with staffing. Do you mean in terms of number of staff? People with wellbeing, yes, when they're coming to work and they're stressed because of issues other than... Yes, so that's why we would have mental health first-aiders etc. We look at wider activity in terms of social wellbeing as well, so what's affecting the person within their daily living as well and then obviously how the staff member feels within the workplace as well. So we do things like swatch rounds where it's an open forum, people come and they can have a discussion about issues that are affecting them and that's an open forum, again led by our chaplaincy team as well. We also have a volunteer team within the hospital that support both patients and staff along with our chaplaincy service. Does it concern you that you've got declining performance and below average? During the pandemic we've seen a slight dip. I believe as we go forward into the future years, given the work that we're doing, we will see an increase in the numbers again and we are absolutely committed to staff wellbeing. Just to mention to colleagues we've got, we want to talk about mental health services, we want to talk about staffing issues, we're still on governance and culture, the number of people who want to come in, we've only got 20 minutes, so just to keep your questions. Thank you convener. I will be succinct. This is for Jane. I'm looking at Greater Glasgow and Clyde's website right now and there is loads of information about staff support and wellbeing. From peer support, self-referos, mental health stuff, even stopping smoking and speaking up, it says you're listening. Simply, how is that marketed to the staff? How do they know that they can access these services basically from an education standpoint? We have a variety of ways of doing that. We have team brief, core brief, because I send out a core brief every week to outlining some of those resources. We send out regular briefs during the week at highlighting things to staff. Sometimes issues are raised by our staff that they want to put in those briefs so that we are clear about that. We encourage line managers to have the conversations with their local teams to make sure that we have that. We have a very active comms and engagement department that has worked really hard to make sure that when ideas come from staff that we are doing that, we have launched an internal comms and engagement strategy last year. We are working on the actions within that just now, because communication with our staff is absolutely critical. That internal comms and engagement strategy is the focus of our work to make sure that we are permeating the whole organisation. It is looking at a range of things from things like core values but also things like collaborative conversations to the things that you have described in terms of making sure that we have active staff, mindfulness and all those things, smoking cessation. We have also launched a recent support mechanism for staff where they can access small grants if they are in severe financial difficulty and they do not have to pay them back on a short-term basis. We have a huge range of things that we are trying to, with the communication strategy and through our comms department, principally is the way that we do that. That is all contained within the internal comms and engagement strategy. Paul, you have a question on this, and you want to move on to talking about staffing. Thank you, convener. I suppose to follow it on from that point. Jane, you spoke about 12 months previous and the work that has been done in terms of what Emma Harper mentioned, but would you accept that, in the past 12 months, whistleblower complaints and greater glass and clear have doubled? That suggests to me that there has been a failure in terms of empowering staff to speak out. Actually, a lot of what I hear directly from staff is that there is a culture in greater glass than Clyde of feeling that you cannot speak out, particularly on issues where you might, for example, be the only staff member on a ward in one of our hospitals. Would you accept that? We have tried hard to ensure that staff have access to whistleblowing processes. The speak-up campaign has been successful, and I am not sure whether you judge more people speaking up or less as being successful, to be absolutely honest, because I am keen that our staff speak up. It would be incumbent on us to ensure that the line managers and their appropriate mechanisms are supportive of our staff to make sure that they feel that they can raise things locally, but where they feel uncomfortable with doing that, then there has to be a mechanism in our speak-up campaign that has been successful in that. We have done a whole review. That whistleblowing is a last resort for staff? Absolutely. What we have done is that we have a whistleblowing champion, as others have described. He did a full review of our whistleblowing processes, and there was an action plan developed around that. We have fully implemented that action plan, and at our board meetings and so on, he is very positive about the actions that we are taking on whistleblowing, but it is not something that you can rest on your laurels. It is something that you have to be proactive about all the time, because we want our staff to feel that they can raise issues in a constructive way and that they will be supported to raise those things where they feel that they want to. I wonder if we can expand this, because we are interested in retention of staff, because what we are seeing is a real challenge in terms of being able to keep staff within their roles because of anxiety, stress, burnout and associated issues. Staff in Greater Glasgow and Clyde have, at various points, described the experience of some hospitals as hell on earth. That is a quote from a member of staff. I go back to that point about the single staffing of wards, which was uncovered at the Queen Elizabeth University Hospital. It was uncovered at Inverclyde Royal that that has happened on certainly more than one or two occasions. Much of that information had to be found through freedom of information. I wonder to what extent do you believe that that is a significant problem and how is it being dealt with at a board level? In terms of the one registered nurse on wards, we did have an issue with that, and we have spent an enormous amount of time trying to address that. We have been reasonably successful. It is much less now than it has been. We have a regular reporting mechanism that highlights areas in which we have staffing challenges. The key thing for us is to try and recruit more staff and retain the staff that we have. There is a lot of work going on in that sense, and we have managed to recruit in excess of 200 international trained nurses to try and support our staffing. We have challenges around staffing, as all boards in Scotland do, and we are trying hard to recruit and retain more of them. It is incumbent on us to make sure that our turnover is low, and that means supporting our staff when they are in post and making sure that we are listening to those issues. Sometimes short-term sickness and so on makes those challenges very difficult. As you have heard today, the Covid position does lead to higher levels of absence than it has done, which has been difficult for us, particularly in smaller sites, where there is less flexibility. Would you accept, going back to the culture point, that some staff who have found themselves in those situations have either not reported via datics or with the bling procedures or, indeed, have not spoken out because they do not feel confident or supported to do so, and have felt that there might be repercussions, if they were to speak out and express their concern about being on a single staff ward? We are certainly doing all we can to encourage people to A, make sure that we understand exactly what is going on on any ward that has single nurses, but also to be supportive colleagues who, where they have been under stress or due raise. It is not a subject that you can rest on your laurels. We have to be proactive all the time in trying to support people who want to raise questions, but, as I said, we have been reasonably successful in trying to make sure that the speak-up campaign has been successful. We have got the whistleblowing champion, who is very active, and we have quite a lot of other things through our area partnership forum, who are most vocal if they have things that they want to raise and we are endeavouring to respond to them. Is the board now being regularly informed about where this is still happening, if it is still happening and the plans that are in place to tackle it? Is that being shared publicly through board papers and those sorts of things, or will we require to FOI in the future to understand the picture? A lot of those things would be dealt with in our board committees. As you imagine, my board with a £4 billion budget is an enormous amount of activity at board level, but the board committees are aware that we do most of our business like that, and they are reported through there. We do have the non-executives questioning and scrutinising the performance of the executive team. In terms of wider staffing issues, if I may, I think that there is a particular issue about the national waiting time centre and the expansion of staff. For you, Gordon, there is a need to recruit a large number of staff in order to upscale. Do you think that the time scales and the plan there is realistic in being able to do that? In terms of our phase 2, the new elective centre, as I mentioned earlier, the original plan for the elective centre was to roll out all the way to 2035. What we are doing at this moment in time is we are looking to accelerate that plan. We have set ourselves a target to recruit about 250 staff by September and another 250 additional staff by the end of the financial year. To date, we have recruited 120 of those staff and that is across different disciplines. There is a challenge, as my colleagues have said, around about nursing and some of the nursing workforce. We, like Jane with Glasgow, are utilising international recruits and that has been successful. We are also working with our sister organisation, which is part of Golan Jubilee and the National Education of Scotland, which is the NHS Scotland academy, which is hosted in Jubilee. We are looking at different roles—advance practice roles, perioperative roles within theatres, et cetera, roles prior to being a band five nurse, so different roles in different pathways. That allows us a good opportunity to look at the skill mix that we have to recruit. Obviously, those national centres are crucial in terms of our recovery and in terms of being able to have people not languished in a lot of pain. Do you think that, if we do not meet those staffing targets, that jeopardises the expansion of those services? I think that there is always opportunity for us to look at others. As I have mentioned, some of the different roles—what I did not mention—was bank staff. We also have access to bank staff. We have about 850 people on our bank that we can use, both nursing and healthcare support workers. We will look at all avenues to recruit staff to the targets that I have mentioned. We now would like to talk about mental health services. Questions led by Paul Sweeney. Thank you, convener. Clearly, a major feature of the outcome of the pandemic has been an increase in mental health conditions and demand associated with those services. We have noted that the recent budget allocation of £290 million for mental health funding restored the £38 million provision that was cut as part of the emergency budget review, which, although welcome, is still an effective freeze on funding in this area across the national health service in Scotland. That is being compounded by the recent announcement from Glasgow Health and Social Care partnership with a £22 million cut to their service provision and the consequent loss of 197 positions. I am sure that that will be carried on across Scotland. I would like to invite you to comment on whether you feel that that will have practical impacts on your service delivery and is it a bit of a false economy across them? The public service provision for mental health in Scotland was robbed in Peter to pay Paul in many areas. That is my impression. Is it something that you would share as chief executives initially? We have been fortunate to have quite a large investment in mental health. Despite the fact that we would always like to have more and more, we have had quite a lot of investment. One of the challenges has been the availability of trained staff to support that. The mental health spectrum is a spectrum from self-support to peer support to what you would call traditional CAMHS and psychological therapies. One of our whole system challenges is to make sure that we do not overmediclyze and overimpact. We are working very closely with our partnerships. We work closely with psychological therapy teams and CAMHS teams, but we also work with local authorities and the third sector to make sure that we are signposting people to the right place and that that often is not into health in itself. Although we are not complacent at all, we have seen record numbers of people being referred into our services. It is a tiered system that we need to invest in and make sure that we are not just leaping to the highest level tier. Our approach to that with our partnerships, including Glasgow City, is to work closely with the third sector, to work with the partnerships, to work with local authorities and a variety of other stakeholders to make sure that we are covering all of that. Quite often, it is Pam's point earlier about prevention. If we can get to people to have that conversation before they are overly, before it becomes a real mental health issue, then that is what we believe our investment will be through schools and so on, with young people. There is a whole big spectrum here, but also where people need that service, where that does require them, we have to look at how we support people and how we use people with lived experience to help in those places rather than us. It is a huge spectrum, a hugely important issue, and you are right to raise it because we need to make sure that we are giving it as much attention, if not more, than the physical health part. You are right that if we do not acknowledge what is happening and understand what is happening and respond to that, then we will end up with a disease burden, if you like, in terms of mental illness that perhaps could have been prevented. We need to recognise that. Probably a lot of what Jane said, I would agree with. First, for me, it is really getting into the nub of what is going on in communities and what the shape of those communities look like in terms of mental health or wellbeing versus mental ill health, and then looking at the strategies that we can do either as an organisation or with our partners in terms of how you again shape and respond. For us in the highlands, things like suicide, drug-related deaths and the impact of poverty on our communities and that early years part, they are all really important to us. At the moment, we are trying to get a collective understanding through community planning and through our services what else we can do to shape things differently. Certainly at the mental illness end of things, with our assessment team that was put in place over a year ago, that has been very successful. For our partners, the police and ambulance have been picking up some of that workload and not necessarily the right response. We have been working closely with them and they are seeing the benefit of that too. It is an awful lot to do and a lot to keep an eye on, but for me it starts first with being sure that we understand what response we need and again not just jumping as James says to a medical response when perhaps there is a wider broader, if you look at the health foundation's recent report about inequalities and leaving nobody behind, that will be prevalent in there. We need to look at the wider factors too that can influence how well someone does. Thank you. The board is quite specialised, I do not know if you have anything you want to say on this. I do not have any, but I accept completely the issue of overmedicalising, which can often be counterproductive and maybe not appropriate. However, I am looking at metrics here, just to take Gertaglasgo and Clyde in 2019.  A second referral could suggest that a clinician, i.e. a GP, believes that the patient needs that help and is not getting it upon first asking and has then reiterated that referral. Is it the case that it is budgetary pressures that are then increasing the threshold rather than an appropriate judgment about clinical appropriateness? No, we have refreshed our whole approach to psychological therapy and CAMHS and our reduction rate is much lower now. We have increased referrals, so we have more people coming on to the waiting list, but we have invested in a huge redesign process and we have invested in additional staff and different ways of doing things. We are now hitting the access targets for CAMHS after a period of instability, shall I say. We have completely revamped that. We are moving to a new model across Glasgow and Clyde, because one of the issues is that CAMHS is managed within our partnerships. For small partnerships, if some staff leave or need a highly specialised interaction, we do not have the ability to easily flex across Glasgow and Clyde. That is being redesigned as we speak to maximise our potential to make sure that children and young people particularly have access to those services in a different way. The CAMHS service has been completely redesigned and we have been recently successful in delivering that. However, we are not complacent at the slightest, but it is a hugely important issue for the board and we will continue to be so. We want to come in. Eveline, do you still have a question on mental health? Pam, and then I will go to Eveline for the last question. On adult mental health and the relationship between primary care and secondary care, and certainly when I have been out in GP practices recently, we definitely have not quite got that right in terms of how it comes back together. There is investment into primary care by link workers and community mental health staff being more aligned to practices, but we have definitely got room for improvement there just in, as you say, that relationship between the gatekeeping that can go on that might be too rigid and the process of referral and not losing that person in the middle of it and the clinical conversation that might have a different outcome. So, our teams are looking at that. Eveline, final question to you, then we must pause. Do you have a sense of whether people are put off coming for mental health services due to the long waiting lists and maybe to Pam Laffas? I suppose I couldn't give you a factual evidence-based response to that at this point. I could go off and have a look at that. I suspect that there will be an element of that, there probably has always been an element of that, that if it feels too difficult to navigate, you might not see how you get there. Again, if you go to inequalities and people with greatest need are often in situations where it's very difficult for them to use services the way that we would perhaps set them up. My background was addictions and that was very much the case. There is always that challenge to us about how you get to the people, rather than expecting the people to get to you when they are in that level of distress and in that really difficult set of circumstances. I think that that is an on-going piece that we will need to continue to work at. It does come down to our capability and expertise at considering the applying access through an inequality lens. Again, our communities are often very tapped into where we need to go and how we work with them. I am not saying that we are not tapped in, because I think that we have really strong local community planning groups across the Highlands and community councils who are really good to understand those communities, but we still sometimes create services that are probably more service driven because of the constraints of trying to deliver a service and don't always fully take account of how difficult it might be for somebody to come forward. Sadly, we have run out of time. I want to thank all three of you for your time this morning for answering all our questions. We are going to spin briefly to allow a change in the panel. Now, we move on to our third evidence session, which is part of our inquiry into female participation in sports and physical activity. This session is going to focus on children and young people. We welcome to the committee Rwina Blackwood, who is the head of programmes to children's Parliament, Dr Mary Stark, the Scottish officer for the Royal College of Pediatrics and Child Health, and joining us online and remotely, we will get Ailey Patterson, Inclusion and Culture Development Coordinator for Scottish Student Sport. Before we move on to our evidence session and asking questions of our guests, we are going to see a short film, a documentary that was sent to the committee by Daisy Drummond. Daisy made this video as part of our media studies exam in Drummond High School, Edinburgh. I'm a sharp and then who I could actually see on the TV. My role model was Simone Biles. What do you think to itself young girls from trying out on your sport? I think one of the main reasons is stigma from the media as often it represents unrealistic beauty standards that a lot of young girls especially feel like they need to eat. Boys. So I would say probably the biggest thing would be embarrassment in front of boys. Boys. Because a sport can make your body look different to others and some girls struggle with body injuries. I think pressure, maybe a little bit of gender, maybe more girls and I think media. Boys, it's to do with confidence and a lot of females really struggle with confidence in a new environment especially sport when there's men. Boys, do you think there's enough opportunity and access for young girls to participate in sport? Yes, I think there is but I don't think there's a big enough drive for it. Well there is quite a lot of opportunities, just not as many as boys. No, there definitely needs to be more opportunities and more encouragement. In some sports yes, but in most sports no. There's been more opportunities now but growing up not really. No, but I think we're getting there. Sport for females is growing but it's nowhere now, where it should be. I think there's a lot more than there used to be but there's still like inequality in sport between women and men because the 1500, the 1500 front crawl was only personally added in the Olympics for women. I think definitely more so now than years before however I still feel that boy sport is still widely more encouraged and it's encouraged for them to do it. That is for girls.  Growing up a woman in sport, my main struggle has been my period and sometimes it can make me feel amazing while other times it can make me feel really tired. Struggers would be that I would never be able to play with the boys. Some struggles I think it's just hard to kind of keep up with the image of being especially in gyms, you've got to be strong, men are seem to be the dominant force when it comes to weightlifting and women are meant to be a certain weight, a certain type, a certain body type. The boys told me I wasn't getting math. Yes so when I was growing up and when I was in the swimming club all of the coaches were male so understanding the female body for them was quite difficult and the lack of knowledge it was accessible to them was limited. Yeah I was told I wasn't good enough because I was a girl. Why do you, by the age of 14, girls are dropping out of sport two times faster than boys? I think that leaves to kind of the opportunities to be the budgets in your stuff for a drive to keep going to push on. They just don't see it as being cool and a lot of females don't see it as an important thing in their life. It's more about looking good and not looking sweaty and running around and doing whatever in sport is mine. Because there's not enough influence for us? I think as a girl growing up it can be really hard for us as we have to deal with things like our period and unrealistic beauty standards again which are things boys don't have to deal with but also the encouragement. Girls just aren't encouraged to do it as much as boys have. There's not enough support for girls as a girl though. I think it's a variety of reasons but media coaches and the lack of opportunities for single sex clubs is the main ones. What advice would you give to a young girl who's thinking about joining sport? Just do it because you'll enjoy it and take everything you can for a minute. I think you won't know unless you try and I think once you throw yourself just into something, give it all you've got, that you don't want any further back. You just throw yourself in, launch in and just do what you enjoy. Take any opportunities that you can get. Try it out because you never know you might like it.  Don't listen to what other people have to say, just do it.  Don't give up when things get hard because you'll regret it and keep your bum. Go for it. To try as many different sports as you can, keep trying different things then you will find something that interests you, be it a team game or a racket sport or aquatic in the water or an aesthetic. There's definitely something out there for everybody and I would encourage all young girls to get this idea out their head that they are not as good as boys because I could run rounds around the vast majority of boys when I was at high school and I think that they need to be confident about their bodies, their image and just try it. You've got to try it because I am utterly convinced that there's something for everybody and being such an important part of my life I will never give it up. Thank you so much to Daisy Dormand for sending that film to us. She probably said that in her previous life I taught students how to make television programmes and I really hope that Daisy follows through in her career if that's what she wants to do because she's certainly shown an immense amount of talent there and what a great start to her session today really helps set the scene for this evidence session. So let's move on to talking to our three panellists around this and obviously Daisy's film has highlighted quite a lot of the issues from the perspective of young girls there who obviously enjoy in sport and are actively involved in sport but of course there's a lot of girls that haven't been dropped out of sport particularly around that adolescent age and I think I would like to start on a constructive question about how we address some of the issues that were highlighted in Daisy's film by these girls who are obviously recognising the issues but still getting on with it but for the girls out there who aren't maybe as active how do we start to address that and get them to enjoy for sport and physical activity and to engage more with it so I'll start with Mary. Thank you, you hear me. I think this is an extremely important issue and I think we need to look at things through the ages. I think none of us don't understand the importance of physical activity on our long-term physical and mental health and some people may not remember how much physical activity actually we were all supposed to be doing I mean how many people in this room are doing at least 150 minutes of activity proper activity a week and out with the people in this room are the men in the room more likely to be doing it than the women I suspect yes so we need to address this through the ages we need to get the the toddlers they're supposed to be doing three hours of activity a day so that means they need good play parks they need forest schools they need lots of activities to do and then we go into primary school and I can read more activities so that all children because there's less gender issues in the kind of younger children get them doing things get them active and then when the teenagers come they're ready doing the sports and and then do specific things for that group and on your video your video I thought was excellent video really enjoyed it the first person said that their role model was their mother mothers are very important role models okay so I go running with my my teenager I do sport with my go mountain biking do stuff but not all people all teenagers have mothers that want to do all these things but we need to get the mothers involved you know see what they want to do the women in golf programmes you know cheaper activities for women to do jog scotland all these things we need to be investing in things that don't cost too much money at the moment sport is extremely expensive if you want to do any sport you suddenly need specialist shoes you need kit even a basic aerobics class will cost you 10 pounds a session you know in a in a village hall so it's not accessible and for young girls if they don't see their mothers doing it and they don't see other women doing it they think oh it's not for me it's something that boys do it's something that men do men go off walking up hills and doing adventurous things there's a whole group of generation my my child has not been on a residential and outdoor residential he said no outdoors board and the reason for that Covid there was two years that is p7 residential was closed and his s1 these guys will never get a chance of everything in a canoe or climbing or doing anything because oh tough luck you missed it there's no catch-up plan and what about the swimming lessons we're seeing many more children drowning in Scotland and then we're hearing oh Perth pool oh it's got a year's you know not not going to close this year but are they going to close next year what about the other swimming pools are they afford to run our local pools closed you know there isn't that opportunity so children need the opportunities both genders and we need to put in really good cost effective so everybody can afford it and if children get into doing it then we can get them both boys and girls doing more sport and then we need to look at these teenagers what what is stopping them a lot of it is they need to have different activities from the boys they need to have different facilities they need to have changing facilities they need to be asked like what would make a difference for you because we know if we can get them into sport when they're teenagers then they will be still doing it in their 40s and 50s that aspect i mean that came of course very very loud and clear in Daisy's film that a lot of the girls had an issue in doing sports with boys so we need to separate it at school you know and some of the schools that even have enough PE teachers my boys not had PE for the last two weeks because there's no teachers you know that's both sex is just sitting on their iPads doing something else because there are no PE teachers available so when if they're not getting their 60 minutes in school that is supposed to how are they going to get it out of school you know we need local clubs for them so if you had different things out of school that were just for girls will you put in that didn't cost them money that they could go and be with other girls and do some sport at the same time then that sort of thing does help. Rona, can I come to you? There's no need to pressure make a phone with a gun for you. And we recently did a piece of work around gender stereotyping in education and learning and access to physical activity and sport was a huge part of that and you'll be glad to know though the girls came up with quite a long list of solutions many of which resonate with the film we've just seen but one of the first things was that they felt that teachers school staff coaches should get training in gender equality and to really understand the negative impact of you know gendered language you know strong boys active boys neat girls and the impact that that has so that sort of generic training around gender stereotyping would be really important that girls felt. Nationwide campaigning awareness raising like they said in the film inspirational role models goes a long way to inspire girls to be active. Also to review the curriculum and to see more positive female role models throughout our curriculum and and in sport as well in the school setting. Girls also said that friendships needed to be encouraged that one of the reasons why girls often don't take part in physical activity or sport is because they can't do it alongside their friends or they don't have friends to do it with and that puts them off. So really encouraging sort of and supporting the importance of friendship in that school environment is really important to then encourage the physical activity alongside their friends and whilst I think the girls we spoke to would agree that sometimes they want to be separate from the boys that there is a real need to do sport and activities alongside boys as well and have sort of integrated opportunities. A really big issue is about playground space and that boys often dominate the playing field the playground space and if the girls want to go in and join in that they're not encouraged to they're not they're not allowed to and that that's often not supported by the playground supervision staff it's sort of allowed to sort of happen so huge sways for the playground is taken over often by by football that girls will often want to play but they don't feel able able to do that. So that sort of supervision and that sort of trained supervision in the playground I think is really important and the girls felt was really important. So gendered uniform doesn't encourage physical activity either so the girls wanted to see gendered uniforms removed and to have a lot of opportunities for have a goal at sport you know to encourage girls to try sports that they might not often be seen as being for boys or for girls so girls would encourage to do football and basketball and boxing and sports like that and as it was said in the film like things that really improve girls and support girls confidence is important you know sort of really celebrating and recognising participation and girls engagement in physical activity and sport is seen as really important and also that it's not just in PE that you do sport children often talk about wanting to be more active in the school day a lot of the school day is very sedentary and you can do twister maths and you can do lots of physical activity. It's not just about sport is it? No it's not just about physical activity. I have said that one of the things that you know certainly I've seen that it was a young woman in my life and indeed looking back on my life if you're not particularly sporty or particularly good at sport that shouldn't close off physical activity to you you know and that's something that I think that we need to stress Rona. I think that's coming across loud and clear from the girls and the members of children's parliament and that they want to be active in their lives they want to be active in their school day they want to be outdoors you know and even if it's wet which often is in Scotland you know how can we get around that and still be active even in the winter months you know how can we you know schools often primary schools we work with children off under the age of 14 don't have sort of specialist PE teachers but you know there's a real desire for more active learning and more time outside as well. Yeah it's really good point thank you for making it. Can I bring in Ailey Patterson who's online Ailey? Good morning everyone. It's great to be here although virtually and apologies about that. I'm co-delivering an event here in Lossymouth so I'm able to be there in person. Thank you for having me today. I certainly agree with what's been said so far in such an important point and thank you to Daisy for that incredible video there and we at Scottish in Sport have a very good media team in case she's interested in joining that in the future but yeah certainly first thing first that comes to my head within this area is role models and visibility certainly are areas that I think we need to be improving on within the entire nation in terms of what is seen as a physical female in physically a female certainly needs to be altered but that role that parents club leaders staff coaches officials volunteers have I mean sporting sector is ginormous in terms of volunteers needed to actually run a sport never mind a variety of sports all across the nation so those people that are running these clubs are hugely influential and those roles should not be underestimated in terms of their impact locally and obviously leadership positions like cheese club leaders those are very important to make sure that they're diverse and obviously we have females in those roles not just taking female teams but also the male teams and I think that for the interesting topic and we in Scottish in Sport have gendered sport and actually all of those stereotypes are harmful to everybody nobody wins out of a stereotype in any sporting context so whether that's for the men having that strong element no one wins because actually men feel like they're being over pressured and for the girls sense they're being underestimated which again is of no help to anybody so again that visibility piece of what does it mean to be an active woman in Scotland we don't have to be winning gold medals every five minutes it's actually just with sport and activity and notice a point earlier was said about what happens if they don't feel that they're good at sport but actually what do they think sport is it's very much an assumption of what is around them but actually the variety of sports out there are you can be standing still you can be moving very quickly and slower pace there's such a variety and we at Scottish Sport have 36 sports that are available for our students to take part in nationally with us so we have an array of opportunities for young people to be taking part of alongside education which is usually important but ultimately how we're all raised is again all across the nation very different and what's on our doorsteps from locality to locality so what we can do to support parents and ensuring that how they raise their children is no matter if girls or boys or otherwise identifying that we're all able to kind of have that opportunity to access sport. Thank you very much. I'll hand over to my colleagues now. Stephanie, you have some questions for our panel. Thank you very much, convener. I suppose that one of the things that stood out for me in that film was the fact that you know lots of those girls in that big long line-up said boys and certainly that's something that we've kind of heard that comments and attitudes and that kind of feeling embarrassed and sometimes I suppose feeling ridiculed if you like that that can be a huge barrier for for girls so I'm wondering how do we change boys attitudes how do we address that? Talking about it in school certainly at the school that my boy goes to they got to choose whether they went in the boys group, the mixed group or the girls group and you know not all the boys are big physical rugby players and they don't want to do those things either so there is that kind of middle bit and actually discussing and doing sports and things together at a much younger age before the gender issues become involved because if kids are doing mountain biking or they're climbing or they're doing something then actually it doesn't matter whether you're male or female and they've been doing it for years and it just gradually goes with them it's some of these more team sports are much more boys or girls and it's having opportunities to do sport that aren't the team sports are not necessarily traditional sports and giving opportunities for doing lots of different sports I know a lot of the schools whenever it's olympics used to do tasters of all those different sports but you know that only comes once every four years and that's quite a big time between why can't they do it more often all these different tasters sports to see or actually you could try all these things that you've never done before and give opportunities to do something that maybe just a bit different that might might fit in so you know just talking to to the boys and girls and going actually what kind of sports you know there is that kind of cool rugby group at the schools but not all the boys fit in that group either so you know we're gender pitching the boys as well as some of the girls so it's just and some of the girls want to be in the rugby team you know my boys and a group of girls and boys and the only one of them that plays rugby is a girl you know so we just need to get away from some of these stereotypes on both sides and encourage children to do lots of different activities and find the right one for them thank you um let's talk to the boys you know and um find out how they're feeling about it um from a little bit of what we did with boys around the gender stereotyping project they they were kind of didn't understand or relate to the girls experience of feeling just you know excluded and dismissed so i think there's a job to be done with boys sensitively around the that the understanding of the impact of gender stereotyping on girls and the impact that that has on the girls so i think we need to talk to boys we need to support the boys to understand maybe some of the impact of some of the collective actions and i think we really need to encourage you know friendships between boys and girls in in our community in our school spaces so it's not boys do this and girls do that there's this sort of you know it's there's a friendship and a mutual respect between boys and girls from a young age it's not just to have an impact on sport it would have an impact on lots of things can i bring in ailey yes absolutely one thing i ever say about how our young boys perceive this is it's all learned behaviour not one boy is born with any of these conceptions it's all learned behaviour so whether that's from their parents their community around them or what they see on television or otherwise it's all learned behaviour so i would challenge that point of who are they learning this from and is that um something that we can also be squashing so i think we're speaking to young boys just speaking to men i put in my submission before ending today that men and boys are a huge part of this process we cannot proactive strides towards equity if we don't have men and boys working alongside us so i would definitely say that that is a big area of work so don't just blame the boys actually who are they learning that from the media if we look to the world cup it's called the world cup and women's world cup it's it's completely different you know and the amount of money that goes into this and the investment and there's always an argument on in terms of investment and this before we see any outcomes so i would like to see i know that the government has plans in that space to possibly invest further in the future but i would like to see that area of work really really pushed on as well and even having a video like Daisy's put on national television talking about this and i think my video has stopped working still hear you i think we've taken your video off because you were lagging a little bit so it's best that we can hear you so keep going earlier okay don't worry i'll keep going that's fine and also one thing i would also say on this point is bringing together of young people i think rona mentioned there's something there's no need to be segregating our activity depending on boys and girls taking part actually why are we doing that from a young age is there a any point in particular why young people are needing to be segregated when actually in PE they're taking part together i think the segregation of gender actually sometimes encourages those negative thoughts instead of actually all playing together and saying oh actually no matter for boy or girl you can you can play the sport very well and possibly looking to education to bring in some kind of more diverse activities one that comes to mind straight away is a sport called ultimate frisbee which is running and using a frisbee to shoot in a net rather than something like rugby football or netball which has got quite a lot of different gender stereotypes around around it as well but all of this comes down to societal culture and learned behaviour in my opinion i bring in the emma harper emma thank you convener good morning to you the question that came up around stigma i think has already been answered that was one of the things that came up from the mary erskine school that that's definitely callahan and i were actually able to get some feedback from the young women about their experiences of participation in sport and but i'm interested in what you were saying earlier dr stark about about you know stark young because we introduced a daily mile in 2012 in scotland so i'd be interested if you know is that being sustained the school is still growing and delivering a daily mile because that is simply about you know the kids don't even need gym kit or trainers for that they just basically get out the classroom on days that are on a scotish weather and and you know participate in a daily mile of both genders i'm a great supporter of the the daily mile i think it's a really good initiative the thing with it though is it depends on the individual primary school and when i said to our our local primary to the headmaster why don't we do the daily mile in the school it's a great initiative he says i don't think we need it here so it depends on the head teacher so we need to get all the teachers involved we need to get buy-in from people we can't necessarily force people to do it as government you could say every child needs to do the daily mile maybe but as individuals and places what you're working and everything else you need to have buy-in from local communities so i mean i think it's a great initiative and i think we should be doing more things like that i think we should have forest schools and every nursery and every primary school i think forest school education is great i think we have more outdoor education get children outside doing things founding about their natural environment we're very lucky living in scotland but it's difficult unless we get a local buy-in for these things okay i've got a question that i can always ask later it's about other research stephanie i want to come back to you because we want to discuss about community sport as well so can i get you to lead off on that and then i'll bring jillian mcaillan thanks again conveyor so i'm wondering what are the most important improvements and changes that we could make to community facilities infrastructure spaces to meet the needs of women and improve safety i could ask you first dr stark i think at the moment i think we need to be very much aware that we're going through a cost of living crisis and sport is really expensive okay and it's you know we've got you have to you have to pay your rent you have to buy food and you have to pay your fill bills and you have to pay your council tags so the money for sport is just not there for many many families so we need to do things that don't cost anything so we need every bit of green space that's available to have play parks that are safe good places to go we need to have youth clubs activities for for young people that can go that don't cost anything getting spaces and stuff do you know of examples where girls and women have successfully worked to kind of co-create and design those kind of spaces and it's improved the number of girls and and women using those i think for you know local gyms and local you know we've got a local gym that's been set up by women in our local village um relatively cheap there and she started crossfit classes and it's actually mainly women that go to that of any outdoor spaces so i think there's not a lot of places have not done things you know there hasn't been many there's been some you know outdoor spaces of um somewhere to do your skateboarding or something like that but that's more targeted to the boys the the basketball areas you know the boys overtake that area and and you know the girls don't get a look in so i think it's something we need to do i think we need to be looking at at spaces and things for for highlighting and and doing things for girls having those gym equipment that you have in some parts of Edinburgh where there's you know a stationary bike or different things you can do in a park that that sort of thing would help because people can do it and it doesn't cost any money and they can do it outside but i think we need to be investing in all the local areas and and making things much cheaper i mean it costs a fortune if you want to go for a trip to a swimming pool now so many children won't have any access to to doing anything and mothers will put their child's needs well before themselves so the likelihood of women doing sport as adults makes is is far less likely going forward because they cannot afford the £10 it costs to go to the local aerobics class it's just not affordable I just want to come in in this i'll maybe bring in Ailey because i'm conscious i don't want to leave her to last every time just because she's online Ailey um obviously from a student perspective um does that resonate with you yes absolutely um a quick stat probably make the committee aware of is that at the moment 51 percent of our active student population are female um taking part in student sport so we actually have more female students taking part in sport activity at university and college at the moment than men which is a great statistic to have i think a very unusual one in terms of a multi sport organisation and especially on this topic in particular i do think that the committee should look to the student sector for some best practice on how to encourage predominantly young women to stay active during this transitional process in their lives as well as create good habits friendships strong lasting relationships etc so i definitely would encourage the committee to look to that into the future some of the incentives that some of our university members in particular are doing is actually providing free gym membership for the students who all students um no matter their year or what they're studying at university which is absolutely brilliant and that is due to investment and how the leaders of the university see sport and the um the results of sport and activity to the student population to their well-being basically it's an investment and student well-being is what that is because obviously yes they're being physically active but the other benefits of being active probably far outweigh the services that would be leaned on such as counselling such as mental health such as other peer support like that which as the committee will know is very expensive to run so that is something i would i would say is in terms of a great area of work that we're able to highlight but obviously i know that my local and community friends and colleagues would be it's happy my shoulder saying that many of the local facilities are at risk of closing and i don't know what the again i can't speak for all localities but i don't know what and how that is viewed in each locality is the kind of what is the priority of sport and activity in that space but it isn't sport and activity it is well-being and it is how we view the what's the word activity instead of then probably having NHS costs so i see it as a activity will then stop possibly some services in the NHS being used and that expense being paid so what the investment is now in young people and in their good habits and creation of these ways of life will then benefit us all in the future in terms of that that health cost absolutely and that's effectively why we're doing this inquiry that very piece about preventative measures and runna i don't know if you want to come in on Stephanie's question just briefly to say i think it's really important that we go back to ask children you know the co-production approach is important the you know it's really important we go back and ask children what they want how they want it what it looks like and feels like for them that to take a rights-based approach to it and also to add that the cost of living is having a huge impact on children's anxiety and on their well-being they're worried about their carers their mums and their dads and they're very aware that they can't take part in clubs and activities they can't ask for the cost of kit and uniforms and that's so they're not even you know it's a huge barrier to participating is the is cost and the financial implication and if i may step in i'm just saying obviously mary you come from a rural area i'm getting that loud and clear where there is access to green space on your doorstep you know runna you must see in the urban areas that's just not the case for a lot of children no but recently been working in shetland and the western aisles with the children and they were talking about the lack of good quality sort of play spaces in rural communities you know that they're in disrepair and that they're you know they're not fun places to be so i think they have got the beautiful countryside but sometimes they don't have the facilities and the clubs you know so okay steffanie you got a full up question i can go to your colleagues thank you jillian mckay thanks convener i want to ask the panel coming off the back of um steffanie's questions on on facilities and things on how we maintain that diversity of facilities notwithstanding the ones that are are up for potential closure because of budget cuts i've heard from hockey clubs and various other clubs in in my local area that 5g pitches are almost easier to easier to rent but aren't aren't suitable for for some sports compared to compared to others and could potentially have a slow creep into into sports that are more generally dominated by boys and men the shutting off some some of that sporting diversity for for others i wondered if you had had a view on how we not only maintain that diversity of facilities but also expand it to make sure that to make sure that we have as wide a range of sports available for for people to try as possible as well as those facilities that allow general physical activity to because