Good morning. Welcome to the 25th meeting of the Public Audit and Post Legislative Screw-ty-ny Committee in 2017. I ask everyone in the Public Gallery to switch off their electronic devices, or at least switch them to silent mode so that they do not affect the Committee's work. We have apologies this morning from Jackie Baillie. The first item on our agenda is a decision on taking business in private. Do we agree to take item 3 on the agenda in private? Thank you, the committee signals agreement.  We will now take evidence on the Auditor General for Scotland's report on the NHS workforce planning from John Burns, who is the regional implementation lead for the west of Scotland and chief executive of NHS Airshire and Arran. Tim Davidson, the regional implementation lead for the east of Scotland and chief executive of NHS Lothian. Good morning. Caroline Lamb, national board implementation lead and chief executive of NHS education for Scotland. Malcolm Wright, who is the regional implementation lead for the north of Scotland and chief executive of NHS Grampian. None of you have requested to make an opening statement. I believe that that remains the case, so we'll just go straight into committee's questions with Colin Beattie. I've got one or two random questions that comes out of this. Clearly, this is only a snapshot of about 60 per cent of the workforce of the NHS. It's not 100 per cent of the workforce, and probably that's worth bearing in mind. Looking at the Auditor General's comments in her report on paragraph 50 on page 27, she says that there is a risk that the sheer number of workforce plans and the number of different workforce groups involved may become a barrier to effective working. In your own submission in paragraph 4.2, you say that it's not really clear how all this is going to be handled, but this is not something that's come up overnight. I mean, workforce planning has been on the go for a while, and I find it a little astonishing that in such a key area it's not clear how this is going to happen, and that you're going to wait for a national workforce planning group to provide leadership. Haven't you been providing leadership in your own areas? I could start. I mean, I think the difficulty has been that we've been too many leaders, perhaps all plowing lone furrows, and so we've had policy leads at government level. We've had health boards, 22 health boards, each determining their own workforce plans. We've got councils, of course, producing their own workforce plans, and increasingly nothing we do in the health service can be seen as being divorced from the broader public sector workforce, and in particular the health and social care workforce issues. And, of course, we've got recently the new kids on the block with the integration joint boards, 31 new authorities, all of which have a responsibility and a role in developing workforce plans. I think that the key thing from us that comes out of the Auditor General's report that we agree with is that it is now time to try to pull together all of these various lone furrows into something that's more coherent, and that's something that has been lacking. But supposedly this has been scheduled to happen for a long time. It's not something that's happened overnight. I mean, pulling this together has been an aspiration for a number of years. I think to be fair, the regions are very new constructs. We've only been appointed as regional leads for the last six months. Integration joint boards have only been in place for 20 months, so I mean, I think there is a new landscape, and that's a new opportunity for us to work more collaboratively, which is what I think we're seeking to do. To that, I think one of the other key recommendations from the Audit Scotland report was about the data that we have and making sure that we're able to better use that data and join it together. I think that one of the recommendations, one of the actions in the Scottish Government's workforce plan part one around having clear leadership about pulling that data together is really important, and that's work that's now under way. I think there's some real opportunities there for us in terms of new approaches to data and new tools and techniques in using that data to forecast, not just to look at the position that we're in now, but also to use it much more intelligently to forecast where we might be in the future, based on multiple scenarios. Looking at page nine of your report, the top paragraph, you say, work is under way to try and bring key workforce data together into a single platform. That sounds like a very big job. Has there been a budget attached to this, if so, how much? You know, what resources have been diverted to doing this? Right, it is a big job. So, in the current year, NHS education for Scotland has received an additional allocation of 100,000 from the Scottish Government to start the work on that. I think it's also important to remember that there are lots of pockets of capacity and capability around this, around Scotland in different organisations. So, it's not just about additional funding, it's also about making the best use of the resource that we already have in the system, and it's very much as well about looking at how we can join up technologies, not just within health, but also more broadly. So, we're working with the Care Inspectorate and with the Scottish Social Services Council to look to pull together the data that we've got within health and join that up with the data across care. In fact, there's a workshop of interested stakeholders from across health care and wider than that happening tomorrow, which will be the first of a planned series of workshops to make sure that what we're doing in pulling together the data in a single platform responds to what stakeholders need out of that. 100,000 pounds isn't going to dig you very far on an IT project. 100,000 pounds is what we will be using in the current year to get additional capacity to pull together the technical aspects of joining the data up. I think that the challenge will then come when we start to need to look at data analysts and data scientists to make sure that we're able to make best use of that data. So, there's a technical aspect to this, and then there's the taking of what we've got at the moment, which is described to me as an ocean of data and turning that into a wealth of intelligence. You've given some examples of the different IT systems that are going to have to be brought together. It seems a very complex business given the sheer number of systems. Yes, and we don't underestimate the complexity, but it's not about pulling all those IT systems together, it's making sure that we're able to join up the data that's in those systems. So, it's not about trying to move to a single system within which we hold every bit of workforce data, it's about creating a data lake that pulls the data that's relevant from those systems and is able to join those up. I think that there is some quite good experience of doing that, so if I look at the UK medical database, then there's areas that we can learn from in our approach to that. I said that I was going to bounce around a little. On page 10, the last paragraph, you say it briefly, because I just want to follow up on just a developer point that Colin has just made. When you're talking, Caroline Lamb, about that IT project, do you speak for all of the boards? So, when you're saying that we are developing this, are you saying that all of the boards are involved in this throughout Scotland? Presumably, there's a project team, that's not you individually who are dealing with this? No, it's not just me individually or indeed my team individually. All the boards are involved in this. All the boards in Scotland will be users of the data platform that we've been charged with developing. We are at early stages of this. As I said, there's a first workshop that pulls together a number of stakeholders happening tomorrow, so we're at early stages of this and we're starting to scope out exactly what's required. That involves identifying what data we already have, but also identifying some of the gaps where we might need to collect additional data to give us the best possible intelligence for the future. So, there's presumably a staff that's been assigned to do that, which has a recruitment challenge, I guess, but also it begs the question of when will this be done? Yes, we have got staff working on this now. As I say, we're at early stages, so we need to understand exactly what the scope of the project looks like and that will be informed by the workshops that are starting to happen. So, we are starting to scope that up. We're looking towards having a proof of concept that will demonstrate what can be done with the data early in the next calendar year, but that will then be very much an incremental process, because we need to start with what we've got and then look to develop that. So, when will it be done? I can't give you exact timelines at the moment. A speculation of ballpark? I really wouldn't want to speculate. The position that we're in at the moment is that we are starting to understand what data we have and starting to look at the complexity of joining that up. There is then another stage of identifying the data that we don't have and that will be another stage of complexity in understanding how we pull that together. At the moment, I think that it's premature to give timelines, but we are working very hard to get to the point where we will understand exactly what we're able to do and how quickly we're able to do that. Thank you, Colin. Page 10, the final paragraph. When you're talking about reducing senior management costs, is that across the whole of the NHS or just within your own boards? The whole of NHS Scotland. The whole of NHS Scotland. What was the actual cash savings there? Who would have that figure? We could probably supply it to the committee. I'd be interested in seeing that. Just looking at the comments on doctors and the impact of our services on page 33, which I think you've got a copy of. We're talking about older GPs, contributing on average a greater contribution of working hours and younger GPs. It's probably the final paragraph of the SPICE briefing. Do you agree with that analysis? I'm sorry, could you repeat that question? What the saying here is that over the last few years older GPs working on out-of-hours services are contributing on average a greater contribution of working hours than younger GPs? Would you say that's a correct analysis? Yes, absolutely. That's what we've seen. I mean, one of the things that I think we allude to in our submission and I think we do need to talk about is there has been a significant societal shift in our workforce. And aspirations around work-life balance are far more apparent now than they have been over the course of my 34-year career and I think the difficulty we're having in staffing services that require intensive 24-7 rotors reflects that. So I think that is a very significant issue here. And of course the growth in less than full-time working is a signal of that as well. I mean, we do pay relatively across the NHS our workforce well and so staff can have a good standard of living working part-time and without the extra payments of out-of-hours. And I think people are significantly increasingly making work balance choices that would tend to move them away from intensive out-of-hours rotors. In the submission, you indicate that the pattern of students in training and so on seems to indicate that a large proportion of them will be moving into part-time work rather than full-time work. Yeah, what we indicated is the number of trainees and these are postgraduate trainees rather than students, not to their postgraduate training level. So we have seen a consistent increase in the number of postgraduate trainees who are training on a less than full-time basis. And there are two impacts of that. One is that it means it takes longer for them to qualify as consultants or as general practitioners, but also it may indicate, we don't know for certain, but it may indicate that they're more likely to want to work less than full-time once they're fully qualified. To that, because my reading of Salus Richie's report, I very much agree with the analysis that is here. And in terms of, I think, one of the points he was trying to get over was how do we make this more attractive for young GPs to do some out-of-hours. So I think he was arguing the case that if more GPs did out-of-hours but to a lesser extent, then the burden wouldn't be so much placed on some of the GPs who were maybe towards the end of their career. And I think the second thing to add into that is the diversification of the workforce actually doing out-of-hours work. So over recent years, we've seen quite an increase in the number of advanced practitioners, for example, who are working alongside GPs to provide comprehensive out-of-hours care. So it is about GPs and distributing the load, but it's also about a multi-professional workforce that can provide the service. Clearly the older GPs are coming up to retirement, so how do we cover this? Can't they just keep churning out more GPs? Is there an additional cost to this changing pattern of how GPs are working? And how can you incentivise them? We talk about a work-life balance, but in fact, at the end of the day, we need people to cover these jobs. I think it's a broader point when looking forward to our workforce plans that I think we need to think very carefully about who we are recruiting to medical schools and being clear about the requirement for 24-7 working, if people want to work in the NHS. There was a tradition over the last few decades that, particularly in the medical profession, junior doctors took the burden of the 24-7 workload, and then once the doctor became a consultant, they would go to work much more daytime Monday to Friday hours, apart from their on-call commitment. If you compare that and contrast that to the nursing workforce, where generally speaking, we recruit nurses from day one with an understanding that they're going to be working shifts and covering 24-7 workforce patterns. So I think that when we're thinking longer term and you'll know from our submission that it takes a minimum of 15 years to train a consultant from start to finish, so if we raise our gaze a bit and think beyond the next 10, 20 or 30 years, I think we have to look at the recruitment principles for bringing undergraduates into medical school and make sure recruiting people who understand that a career in medicine for the future will involve significant 24-7 working. Into that, I think recruiting people into medicine in the context of a multi-professional workforce. Actually, advanced nurse practitioners, allied health professionals who are taking on extended roles, pharmacists who are taking on extended roles, radiographers who are taking on extended roles. Maybe 10 or 15 years ago, when people recruited into medicine, the pattern of the service that we have now is very different from what it was before. So I think societal expectations are really changing. People's expectations of having a work-life balance and the amount of hours that they're going to work. So I do think it is about, as Tim says, it's about the expectations of doctors coming into medicine, but it's also about diversifying and broadening the workforce that we've got in the NHS in Scotland. During the course of this session, I'd like to lead some examples of some of the things that actually are happening to make that reality. So who's going to drive this change? I would suggest that we're already driving some of this change. If I look at some of the examples in my own board in Ayrshire, we're already diversifying the workforce in the out-of-hours area where we're bringing together, yes, the GPs, but advanced nurse practitioners, pharmacists. We're bringing in social care into those teams and we're bringing crisis mental health teams. So there is a wider multidisciplinary approach and that's helping reshape and it's looking to the future and it's trying to then ensure that we develop that workforce because that's proving to be, I think, successful and I think addresses some of the challenge around the GP workforce and I think that's where we need to be focusing in that broader workforce because I think that that will be where we'll make the difference. So is it up to individual boards now to drive this change or should it be done nationally?  I don't think it's a lie. The Roar, I think it's a both and so if we look at the government's policy and around pharmacists, for example, that is very much that they're going to work alongside GPs who want to extend the role of pharmacists, so that is national policy. So pharmacists who are being trained through university and through their postgraduate education are being prepared for very different roles and certainly on the ground within primary care, within Grampian health board, for example, we've got just under 60 pharmacists who are working in primary care settings alongside GPs doing some of the work that GPs would have done before. So it is partly about national policy, but it's also about making sure that these things are implemented on the ground in order to support GPs who are under tremendous pressure at the moment. An example of the national element of that, then, obviously, there is a huge training programme around pharmacists and pharmacy technicians to support them in working alongside GPs and GP practices. So the figures that I have are that we've got 178 pharmacists and 41 pharmacy technicians in those in those programmes. So as Malcolm says, it's a combination of the training being provided on a national basis so that everybody's trained to the same standards and then NHS boards being able to take advantage of that and pull those people in to work alongside their GPs. What you're talking about will relieve the pressure on GPs at a local level. It doesn't necessarily encourage them to do out-of-hours work. Well, the point that I was making, I think, does require a national approach, but also, of course, in collaboration with the universities. I mean, the point that I was making really was that if we project forward what do we need from our workforce increasingly for in particular unscheduled care services and critical care services, we need a workforce as you've described yourself that is able to work 24-7. I think we've been more successful in that, in nursing. I think there are lessons we can learn from that, but essentially I think the expectation needs to be set for undergraduates considering entry into medical school that the health service needs to operate 24-7 and people should expect to work shifts for the majority of their career. And we also say, of course, looking forward, the normal retirement age for NHS staff is likely to be, you know, 67 or 68 fairly shortly. And so we do need to look at how staff towards the end of their careers working into their mid and late 60s can work in these intensive services. And so we may well have to frontload quite a lot of that so that there is the possibility that younger staff cover the 24-7 shifts more than the older staff and older staff maybe have the opportunity to do a bit less. It's a size that this work-life balance is an important factor for a lot of the younger doctors.  Is that going to actually persuade them? Well, there is the problem that, you know, we do have some polarities here, some irreconcilables. But interestingly, I mean, now we're, I think, forming the view that for every medic who retires, we need to be training 1.5 to fill those medical posts to reflect the fact that people want to work less onerously and increasingly want to work less than full-time. So the point Malcolm's making is that if we have more staff working less onerously, I think that is a more attractive proposition. The problem at the moment is that in particularly pressurised specialties in the particularly acute 24-7 services, like pediatrics is an example where we really struggle. The intensity of the 24-7 requirement really puts people off. Isn't what you're saying going to result in a much higher cost to the NHS? Not necessarily if we have more people working fewer hours. I mean, you know, I suppose generally speaking, the more whole-time equivalent staff we have, because they all have holidays and they all have sick bay and they all have, you know, leave entitlements, et cetera, then probably there would be a marginal increase, but fundamentally I think that is the answer. We are going to have, we have to recognise increasingly amongst the workforce that we are going to have more staff wanting to work less than full-time and less intensively out of hours. So the only proposition I think is to have more people working fewer hours less intensively. One of the things I'm really focused about is how we make professional careers more attractive in Scotland, because we're in a UK labour market, we're in an international labour market, and what are the things that we can do in Scotland would differentiate us from other parts of the UK? I think one of those things is around really pushing the whole multi-professional workforce. So to say that doctors coming through, be it a GP or a consultant, you're not on your own, the service doesn't fully rely on you, but you're part of a multi-professional team. So, you know, an example of that would be the work that's gone on and it's been led by Nes and Caroline about using radiographers and developing radiographers to read images and do reporting and work alongside consultants and doing work that consultants, some work that consultants would have done previously. Now that is a development that we're seeing happening in different boards at different rates around Scotland, but it is actually happening. So, you know, the notion that the consultant radiologist and the radiographer and the technicians are working together as part of a multi-professional team, and if you add in to that, you know, good links with the university as opportunities to do teaching and research, actually you create an environment that people will want to come and work in. And I think focusing on what can differentiate Scotland vis-a-vis the rest of the UK, I think that's where we need to be focusing our energy. I'd like to ask you to support that. I think it's really important that we focus not just on doctors and what they've traditionally done or on nurses and what they've traditionally done, but on the much broader team across NHS Scotland and look to ensure that every member of staff is able to contribute up to the level of their skills. And not just that, but also that we have clearly defined career pathways for staff so that staff can see ways in which they can develop and grow their careers and that we're able to make the best of their contributions. I think that it's important that we recognise that we've started to make those changes. We've been looking beyond the traditional workforce and considering how, with the professions that we have and the skills that they bring, how we maximise those skills. And it's about the value that people have in the job they do and the contribution they make. And we're seeing that across a range of disciplines and colleagues have identified some of those areas. I think that's something that we will build on. It doesn't take away from all of the challenges that we face in terms of workforce planning, but we must plan not for what we had but for what we're going to need in our redesigned health and care system for the future. Thank you. If I might just, before bringing in Alex Neil, just to pick up a point that's been made there, the joint written submission that you put in at the start talks about the continued growth of the workforce as a response is not feasible and a continual expansion of the workforce would be neither affordable nor available. What it says is, the focus will be on how we utilise the existing workforce more effectively in the future, which I think was the point that certainly Caroline Lamb you were alluding to, but you also talk about in your submission there are circa 350 different NHS roles, many of which have different training and education pathways. Within each of those, there are subspecialities and roles, which can vary greatly between departments, services and organisations. So if it is the intention to meet the future demands by staff redevelopment rather than recruitment, that has huge implications for the NHS. Is the NHS set up to do this? Are the training providers set up to do this?  I think the answer is we don't know yet and this is the huge problem and there is no plan I think across Scotland or the UK that accurately at this stage describes what a redesigned health and social care workforce might look like for the future. That is the huge challenge that the Auditor General is throwing down in her report, is that we have an aspiration to fundamentally redesign the way in which we deliver care, that we shift the balance of care into the community, that increasingly we are going to try to encourage our population to take more responsibility for their own health, to increasingly self-manage their condition, to be able to utilise digital technology and digital interactions with health rather than necessarily turn up at centres, that we are going to have increasingly an integrated workforce in the community. So what does that mean at the moment? For example, we have consultant geriatricians, we have district nurses, we have social care staff. Increasingly we are going to have to be thinking about a workforce that is a generic workforce providing care right across the spectrum of health and social care, rather than individual professionals providing a little slice of somebody's care in the community. So that challenges that at a very high rhetorical level, I think some of us kind of understand that challenge, but distilling that into exactly what is the workforce, what is the role, what is the job description, what's the grade of pay, we're still a long way away from that. I would add to that. Just now, with the introduction of regional delivery planning that we are responsible for leading on, that's given us an opportunity certainly from a west perspective to look across the west of Scotland to think about workforce in that wider context. I think that as we develop those plans, rightly we will be bringing forward what those workforce consequences are as we shape. And now we need to link that with what's happening in the integrated joint boards and ensure that the workforce planning is linked from those very local plans, through board plans and where appropriate is connected and linked into regional plans. I think it's as those service plans develop, then some of those questions around what that future workforce needs to be will evolve further, but I think it will build on work that we've already started. Another level of complexity in this is that we also need to work with the regulators and with the professional bodies that set the curricula for many of our clinical cohorts of staff. The shape of training report on medical postgraduate training, which has now been signed up to by all the UK countries, is a really important development in terms of getting more flexibility into medical training, which is absolutely what we need for the future. We just need to make sure that that now gets speedily implemented through the regulators who have responsibility for this. I do think we need to work at multiple levels. I think there are UK dimensions to all of this, so decisions that the Department of Health and Whitehall take around training numbers have an impact on training availability here within Scotland. I think we are making improvements in terms of our national workforce planning. We're at reasonably early stages about regional workforce planning. I think that health board workforce planning is well developed, and, certainly from a Grampian health board point of view, we know what our workforce is like. We have a good idea of where we want to get it to and the measures that we need to take to get from A to B, if you like. I guess that the point that I want to get over is that we need to be highly adaptive at a local level to changing labour market conditions. For example, work that we have done with the University of Aberdeen around introducing physician associates, which is a new role that we can attract in people from a science background who wouldn't normally come into a health service career, give them a three-year training programme, give them their degree certificate at the end of it, give them professional oversight and supervision, and they are working to support GPs and consultants in Grampian health board today. We've had a number of faces in that programme coming forward, so having local adaptability and responding to local labour market conditions is also going to be really, really important. It's the balance between having the national workforce plan with all of the data in it, but lots of flexibility locally to make things happen on the ground. Just before the committee on older explorers, Tim Davidson, you said something at the start, which I think the rest of you were agreeing with. Did you really just say to me, there is no plan that we are sitting here with a crisis and there is no plan in existence to sort it out? Is that really what I'm hearing from you? Well, I think the evidence shows that where there are multiple plans, there are probably too many plans and there's perhaps a distinction between the short-term operational plans that boards have hitherto been doing and what is now needed is a longer-term plan, so no, let me just continue. Mr Davidson, Colin Beattie posed the exact question right at the start. Who hasn't done this? This is not rocket science with respect. Any business person knows that you develop a workforce plan. Collectively, we have to hold our hands up and say across the entire system that we have not worked sufficiently together to align long-term, future horizon planning together with short-term operational plans. Who has not done that, Mr Davidson? All of us, from health boards to government, we've failed to pull together the link between short-term operational delivery and longer-term workforce planning. If I can just clarify what I was saying about a plan, we are being now challenged by the Auditor General to come up with an explicit workforce plan that shows how, over the short, medium and longer term, we can fulfil the policy imperatives of shifting the balance of care from hospital to community and deliver some of the major policy imperatives, like improved elective capacity in hospitals, for example. At the moment, we do not have a workforce plan that describes at a national, regional and local level how we are going to do that, how much it is going to cost and where the workforce is, and that is now the challenge, absolutely. I must say that I find that extraordinary, however. Can I just explore this a wee bit further? My feeling ever since the time of the Cabinet Secretary, I felt sometimes as though we were planning the journey for the next two or three years using the timetable from the two or three years past. It seems to me that fundamental to all of this is that there is a missing link. If this was a business and you were writing a business plan, the first line in the business plan would be your sales forecast for the period of the business plan, because the number of people you need working for you, the skills you need, the location of those people, the equipment you need, the estate you need, the whole thing would depend on your anticipated level of sales. You can never get it absolutely right, but that is your planning tool, is the business plan and line one is the forecast for sales. It seems to me that I tried to get this started when I was the health secretary, but I could not find anyone who understood business planning quite frankly in the whole of the Scottish Government. What we need surely before we get into workforce planning is to understand over the next three years, over the next 10 years, and as you rightly say, Tim, over the longer period what is likely to be the shape and size of demand on the health and social care system. There are a number of factors that we can be pretty sure about. We know the forecast from the Registrar General on the level of population. We are pretty sure about the overall age structure and we can break that down into regions as well as into a bore level that is fairly accurate. What we do not know is what diseases are likely to emerge and all that sort of stuff, but as you say in here about workforce planning, we need some scenario planning. We had a report during the summer which pointed out that 25 conditions account for 70% of NHS activity. If you even get that 70% right and you do not get the other 30% as accurate, at least that is a major improvement in where we are today. Would you agree that the starting point in all of this should be a proper systematic forecast of the shape and level of demand for the period covering the planning scenarios? From that, and only when you can get that level and shape of demand, are you then in a position to take a decision about what kind of workforce and what size of workforce and what location of the workforce needs to be in order to deliver on that level of demand. Not just the workforce, but it would also determine the shape of tomorrow's estate, the use of artificial intelligence. For example, the Japanese last week announced that they have just developed artificial intelligence that can diagnose bowel cancer in 10 seconds with 98% accuracy. If we introduce that into GP surgery in Scotland in the next two or three years, that is going to change a lot. I just picked that as one example. It is never entirely accurate, but surely the starting point has to be not how many workers we need, but what is the level and the shape of the demand going to be? That determines everything else, and there is no work being done on that long-term. Is that right? I agree that that is the starting point. If I look at the work that we are doing in Ayrshire and the early work that we are doing around regional delivery planning, that is exactly where we are starting, is looking at the population health need. We are then trying to work through how, with innovation and technological change, we might look to deliver services differently, that service model would shape. I agree with you that that takes you forward to understanding how you are looking forward to adapt and innovate around your workforce, how you deliver services and your estate and infrastructure and assets. I do think that— In that document, John, it needs to be updated at least every year to take account of the kind of changes that you are talking about, obviously, even if it is a 20-year plan that should be updated regularly to take account of these developments, because some of them are foreseen, a lot of them will be unforeseen. The other thing is that you say that is harming in Ayrshire, but surely that is the starting point at a Scottish level. It is not being done at a Scottish level. I think that a lot of that information is available at a Scottish level. It is not pulled together, Malcolm. What we should have and what I certainly tried to set in motion was a national business plan for health and social care at that time up until 2030. The first three years would be very detailed, because that would need to cover the budgets for the next three years and all the rest of it. The further out you go, the most strategic in longer term it obviously becomes, and therefore the further out it is less likely to be as accurate as the next three years. However, the point is that it has to be a strategic document that includes basically an operational plan for the next three years on a rolling basis, so you update it every year. If you pull that into one document so that everybody knows exactly what the plan is, the problem is, as Tim rightly said, is that there are hundreds of plans covering everything under the sun all across Scotland with 53 and more organisations involved in delivery, and nobody is pulling it all together. Surely the starting point is to look at the bring together the forecast on the shape and size of demand over the planning period, and then from that deduce the workforce requirements, the state requirements, the equipment requirements, the financial requirements and so on and so forth. Surely that should be done as one document, and the Scottish Government or the health service at a Scottish level needs to be the one that does that. Can I respond specifically on that? I think that this goes back to the early point that I was saying. That's exactly what we've been saying, is that there are lots of plans. Health boards do have plans, but they've tended to be short term in nature. Increasingly now we have a new set of authorities, 31 integration authorities, who have a responsibility also to develop their workforce plans, and of course we have 32 councils who also have responsibilities for workforce plans, so there's no lack of planning, but the issue is how does it all pull together. The first recommendation of the Auditor General's report is that improving understanding of future demand to inform workforce planning. The opportunity that we have looking forward is that we will have a Scottish Government committed to pulling all of that together to our national workforce plan, we will then have regional workforce plans, we will then have health board plans, we will then have IGB plans. Is that going to happen? This is going to happen now over the course of the next year, two years and three years, but the problem responding to Mr Kerr's question about is there a plan? Of course there isn't a plan. We have not yet got a plan that reconciles the population demand that we're facing, and you'll see in the Auditor General's report published last week, a significant increase in the over 65 population in Scotland at the same time as a reduction in the working age population of 16 to 64, and now the health service going into real terms reductions in funding. Our challenge now is not just to pull together demand with workforce projections, but also to pull together service plans with workforce plans with financial plans. My point, Tim, is that it has to come together in one document. If you're running a business, I used to work for a multinational that was three times, four times the size of the health service in Scotland, and we produced plans every year, long-range plans that were updated every year. The people worked alone in Europe. We had 15 different countries where we were operating, but it was all pulled together as a corporate plan so that everybody knew what the sales targets were and what they needed to do in terms of workforce and all the rest of it to deliver that. It's not rocket science, and I don't think that the expertise exists within the health service. I haven't seen it to bring it together the way it needs to be brought together. I think that we need to buy in that expertise to get it done much quicker than is happening at the moment. The message from the auditor general's report last week was that it should be done sooner rather than later. I don't think that three years is an acceptable timetable to wait for a national plan that brings it all together. I understand the difficulties, I understand the challenges, I understand how desperate sometimes the organisation is, particularly now that social care is part and parcel of the plan. However, given the forecasting software that we have available to us nowadays, which is widely used in other health systems, and not to mention the business planning software that we have, it's not beyond the wit of man or woman to pull this together in the next 12 months, in my view. I think that that really should be the goal. I think that the danger is that everybody is away doing their own thing, and nobody is pulling the whole thing together, starting with that top level on demand. I think that the regional dimension that we now have, that we have been working on over the past six months, I agree with you that there will be some national themes and directions. However, if we look across the three regions, the populations do have differences. I think that planning on a regional basis, so in the west of Scotland, we are looking at regional delivery planning for 2.7 million, looking at the population health need, and bringing in working with colleagues regionally and nationally to help to bring that together. Those first plans have to be in place for March 18. The regional delivery plan, the relief delivery plans, are looking at how we deliver our services. They are not going to address everything in the— Will those include an assessment of the level and shape of demand for the longer term? That is what we are trying to do in the west of Scotland, to start with the population health need, because by understanding that and understanding then how we will adapt, because we need to adapt and change, because this is about planning for what we had, for what the future needs to be, and it needs to be different. We need to adapt in the workforce that we have. Colleagues have mentioned that we need to be able to adapt, but I agree with your fundamental point. That is what we have been asked to do through the regional delivery planning, is to provide that strategic forward look to use and understand, as best we can, the demand data that is there and certainly being used. It is complex, and I think that we will have to look at that first one to three years, but with a forward horizon in terms of what we see ahead. Your point in terms of recognising that medical technologies change all the time, we need to keep those plans refreshed and updated, and indeed, as our populations change, we need to be able to reflect those plans as that demand changes. Will that plan include the financial plan? Yes, it needs to have a strategic resourcing framework. Is everything as a big fault in the national delivery plan, it does not mention the funding, it does not look at where the funding is going to go and all the rest of it. If it is a genuine plan, it has to have a financial plan as part of it. We need to have all the elements that you have described, including the workforce elements and the strategic resourcing elements. Who regions will be doing the same in the same timescale? I can add in from anorthoscotland perspective that we have a pretty good handle on the demography in terms of the burden of disease, the age profiles changing what people are going to need. I think that each of the regions will have a requirement for a slightly different profile of workforce. If you look at the north of Scotland, which is covering something like 60 per cent of the land mass of Scotland, it has got only 25 per cent of the population and the dispersing of that population in remote and rural communities, we need and are going to need more of people with much more general skills who can work with people in the local communities using technology to avoid people having to travel to specialist centres when they do not need to travel to specialist centres. I think that we have a pretty good idea of what is the money that we have got in the system. We try to forecast where we think public expenditure is going to be going and what sort of envelopes of money that we have got to work with in the future. We have a pretty good handle on the shape of the workforce that we have got in the north of Scotland and we are really developing to say that if we are not going to be able to hugely increase the workforce in terms of overall numbers, I do not think that that is a realistic possibility, how do we use the workforce that we have got in a different way, how do we diversify the workforce, how do we give people more general, broader training, how do we expand people's roles in order to fit them for the burden of disease and morbidity that we are going to be seeing in the future. I think that workforce planning is very important, particularly to inform Caroline and inform the Scottish Government about what are the undergraduate training numbers, what are the postgraduate training numbers, what are the nursing training numbers and so forth. That is helpful, but as we have said in our evidence, this has got a really long timeframe and the thing that we can be absolutely sure of is that when we make a decision here, things will happen in the middle, so by the time those people graduate, we are living in a very different world. The point that I was making about adaptability is very important. From a north of Scotland perspective, I think that we have got to handle on that, I think that we have got to handle on the money, I think that we know the burden of disease, we know the kind of distribution of services that we want and I think that it is about growing those generalist skills for our workforce in the future. Good, that is very helpful. Can I just, because you referred to, and this is where I wanted to focus a wee bit on, is the whole pipeline from undergraduates into medical school right through the pipeline, because in your paper you say that last year 860 Scottish downmysile school leavers applied to medicine through UCAS for the first time and Scottish medical schools were seeking to fill only 834 home fee at EU places in that year. When you look at the paper by Spice, the first thing that strikes you is just, I do not think that this is the fault of the health service, I think that the Scottish Funding Council is slacking here, the lack of proper data in terms of applications, dropout rates, destination figures and all the rest of it. The absence of reliable data is astounding and I think we need to write to the Scottish Funding Council to rectify this, because how can the health service plan ahead if that basic raw data is not available and it should be easy to collect? I can list later for the clerks where I think that that is missing, but if you look for example at the figures, the University of Edinburgh in terms of Scottish EU applications for medical school last year, 1372, 192 offers and 115 were accepted, which was 40 per cent of the offers. My point is that if you have 192 offers to Scottish and EU students and only 40 per cent of them take up the offer, and I realise that there's maybe a bit of fat in the number of offers from what we need, but surely if we are going to have the pipeline of medical graduates that we need, we need to substantially increase the number who are being recruited. I mean, I've got a letter just yesterday from a constituent and this is a late young woman of 18, she's got all the qualifications you would need to get into medical school and she's been turned down. It seems to me that with 1,372 applications, presumably all of those had to have the minimum entry requirement, although they wouldn't be treated as presumably as an application, of which only 192 offers, of which only 115. From 1372 applications, we end up with 115 of an intake. Now, we can't go on like that, but we're always going to have a doctor shortage unless we train far more doctors. Now, I understand obviously, if you take the GP, the percentage you want to become GP, it's difficult to fill the training posts, and Tim referred to some of the reasons for that that need to be addressed. But we will continue to have overall shortages if we don't recruit many more people into medical school. We all know that domiciled applicants from Scotland are much more likely, eventually, to practice in Scotland in the same way that people who are from rural areas are much more likely to go back and practice not necessarily in the rural area where they came from, but in any rural area. Do we not really need to do much more? I know that we've increased the intake by 100 recently. I don't know if that's this year or next year, but it seems to me that we need to go a lot further if we are going to get the pipeline of undergraduates and graduates that we need for tomorrow's world. If I can make a number of comments in response to that. First thing, your point about the data is really well made. The Auditor General suggested that it would be helpful if we were able in health to track that data. Within there, we already index every undergraduate student who starts on a nursing course. We've done that for years and that's proved incredibly useful in being able to track attrition, completions and, indeed, being able to then see where those graduates go in terms of employment. We would really welcome an opportunity to do exactly the same around medical undergraduates as well. That's the first point because I think it is really important that we're able to track these folk through and see exactly where they go. I hope so. We're working with Scottish Government and others on that. Surely it should be treated as a matter of urgency. How can we do workforce planning if we don't have the basic raw data required to do it? I agree and that's what I was saying earlier about needing to identify the data that we don't have and to make sure that we're able to get that data. That is absolutely part of the work plan. The second thing I'd say is that, yes, we are clear that the evidence does seem to indicate that we are more likely to retain doctors in Scotland if they came from Scotland in the first place. I think that we need to be careful with some of the data because there is obviously a difference between applications and applicants because applicants will make multiple applications so that will explain some of the reasons why offers are not being accepted because those applicants will have made applications to more than one institution possibly in Scotland, possibly outside of Scotland. However, I do think that there is a real focus and indeed Scottish Government has a real focus on trying to increase the number of graduates who stay in Scotland and also in trying to widen access to medical school places and indeed in trying to encourage our undergraduates to think about general practice as a career. You're right that the number of places in undergraduate medical schools has been increased, so there was an increase of 50 for I think intake 2016. There's also been the establishment of the Scott Gem, the Graduate School for Medicine, which is absolutely focused on both general practice and indeed attracting students from a wider access background. That will take its first intake of 40 in 2018 and Scottish Government has recently written to all universities asking them to submit proposals that would help to fulfil those strategic objectives of retaining more doctors in Scotland and indeed attracting more doctors into general practice. They're looking to put between 50 and 100 extra undergraduate places into the system around that, which would be very welcome too. Can I just add in to that? I mean, I think we need to see and I think we do see university medical schools as key partners in this work and I fully support what Caroline has said and I think it goes more luckily as well. I think that there's evidence that if you grow up in an area, you go to a medical school within the area, you're more likely to stay within that medical school and I think the widening access programme that we've seen with our local university in Aberdeen is seeing some 20 people coming through to that who would not have gone into medical degrees otherwise and I think that's hugely encouraging. I think that the local element of all of this and the university and the local health and social care system working hand in glove and drawing people out of the local population who've got the ability to do medicine and really supporting them through a medical degree and they might have thought, it's not something that I'd want to do or I'd have an expectation to do but to create that expectation into them, to really support them, get them through the medical degree, they're going to be more likely to stay both within Scotland and locally as well. The other missing data is in relation to drop-out rates. I mean, I know at one time we'd a real problem with drop-out rates with nurses, I think at 35 per cent and it's much less now, I think it's substantially down. Year on year, yes. What is it now? Of the top of my head, I can't remember if I can get you that information. I mean, we don't know what the drop-out rate is for medical students after second year. Sorry, Tim. You mentioned Edinburgh University and I just thought, you know, we should make one or two points specifically about how we're trying to make a link between all these multiplicity of a local individual plans and then coming together a number of us were recently involved in a meeting with government and with all of the universities in Scotland looking at how we do, in fact, increase not just the number of student places in Scotland, but particularly the Scottish domiciled students who are more likely to stay. Those figures that you're referring to, you know, the Edinburgh University, the 1,300 and whatever applicants, Caroline's point is really important here, that candidates are applying for a minimum of four places and so however many applicants there are, that is probably divided by four in terms of the number of individuals. So the actual number of Scottish applicants and the actual number of Scottish officers is actually very close and the Scottish numbers applying are actually falling at the moment and so therefore actually the relationship between Scottish domiciled applicants and officers is very, very high, but the numbers of places are controlled by government and so the fact that I think you mentioned Edinburgh University only offered 115 places. I mean, they're only allowed to offer 115 places to Scottish domiciled, sorry, to home student places, so at the moment the numbers and the proportions of the rest of the world, the rest of the UK, Scottish domiciled etc., is set. So the point that I was making earlier in response to Mr Kerr is at the moment universities have their plans, government has had long-term plans, health boards have had short-term operational plans. We are absolutely wedded now to trying to pull this whole thing together so that the whole thing does align, but the problem is that because we have currently a very broadly similar number of Scottish domiciled applicants and offers, we need to grow the potential pool of applicants from Scotland and that includes, for example, work with the most disadvantaged communities. Edinburgh University in 2017 offered 30 places, so 30 of their 115 places came from the two most deprived quintiles of the Scottish school population. It just gives an indication of how this endeavour to expand the number, but also expand the pool within which the universities are fishing for candidates for medical school is improving. So when you say that there is 860 through UCAS, in my day you can apply directly to the universities or through UCAS or both. Is that the total number or is that just the number through UCAS? It is my understanding that all applications now go through UCAS. I think the figure that we quoted was first-time applicants, so there will also be some applicants who are applying for the second time. Clearly, part of it sometimes is that supply can create demand in itself. If you increase the number of places, that can generate more demand as well, because I think that some people are just put off because they think that their chances of getting in are so low. That is an interesting point, because we now have the data from the 2018 application cycle, which shows that there were 920 applicants from Scotland applying for the 2018 entry. That would indicate positive movement. Maybe we need to do a bit more. It is the construction sector. Trying to get young people to go into the construction sector is very difficult, because of the image that it has. Obviously, we have a lot more work to do in the schools to try to get the bright pupils to apply for medical school. Can I finish up by just one question on a completely related but different subject? That is the impact of the pension changes in 2010. For a lot of people listening out there, this is a lot of money. In 2010, I think that I am right in saying that you could build up a private pension fund tax-free of £1.8 million, a lifetime allowance. After a number of changes, it is now down to £1 million. You can put maximum £40,000 a year into a pension fund tax-free, so it does not take a lot to work out that that is 25 years of maximum pension contribution and you have reached your lifetime allowance. Certainly, from talking to my own GP and from talking to numerous GPs in Ayrshire when I went down to meet them and talking to many other GPs across the country, although they do not make a big issue of this publicly, privately, they are telling me that they are retiring early because of these pension changes. What a number of them are doing is retiring on Friday, on Monday they collect their pension, not the state pension but their private pension, and then they might do a couple of days being a locum. A lot of those people retire now at 55-56, who previously would have probably carried on until 65-ish, certainly into their 60s. We get them for two days at 180 per cent of the cost of what it would be the previous week to employ them, roughly. We then have to employ locums for the other three days because the original GP is not there at 180 per cent of the average cost of a GP under a normal contract. We are not in charge of pension policy, none of us were consulted. The consequences of these changes were never properly examined but we know from talking to GPs one consequence is what I have described early retirement and we are losing a lot of GPs who otherwise would have been happy to work on but don't see the point. Indeed, I remember in Glasgow, Greater Glasgow and Clyde Health Board, when the third change was made that year, the availability of GPs for out-of-house services went down by 40 per cent. When you spoke to a number of the GPs in their 30s and 40s, they said, well, what's the point of doing that for hours? It just means a later retire at 52 instead of 55. So what can we do about it? For example, have you looked at—we are in the middle of a GP contract negotiations. It seems to me one of the things that we should be looking at to see if it's possible if whether GPs can go on to some kind of pension scheme similar to employees in pension schemes in the national health service, a superannuation scheme that doesn't have necessarily the same limitations to the same extent. Those are HMRC rules that apply, whoever the employer is, whether you're in the public sector or the private sector. I'm just asking the question, do we not need to look at is there something that we can do to deal with the consequences of these changes because clearly they are one of the reasons why not the only reason, but they're one of the reasons why we have this increasing shortage of a period of GPs. Can I come in on the back of that? I mean, I don't have data on that, but like you, I speak to a number of doctors and I know that that is an issue. I think it's actually a really good example about the limitations of workforce planning because things can happen like changes to taxes on pensions that actually have a profound impact on individuals and what they make decisions about in terms of their future that is actually out of our control, it's not within the control of Scotland and that happens. I think another example of that and again we've led it within the evidence is the changes to permit free training in 2006. My understanding is that we went from some 4000 doctors who were coming from the Indian subcontinent to about 400. That's the sort of thing that you can't predict within a workforce plan and it happens and you need to adapt to that. Part of that is how can we incentivise doctors to continue in their careers, what is it that would make it good for them to continue to offer their service because at the age of 60, many of them at the prime of their careers, they're very, very experienced, they're really good diagnosticians and actually losing them from the national health services is a major loss, so what can we do to help them to continue to work? Again, there's a sort of short, medium and long term view of this, so I think just like you and like Malcolm anecdotally, that is the view that people have decided that it's no longer worth working, they've reached their annual lifetime allowance and they take their retirement. Obviously, over time, as the younger workforce then matures, as I was saying earlier, the normal retirement age will be 68 for NHS staff and I think people will be expecting and sort of calibrating their working careers based on not getting their occupational pension or their state pension until they're at the moment, say, 67 or 68, so I think in the sort of medium to long term that will change. It's also, I'll come back to doctors in a second, but it's also, of course, the short, medium and long term issues around nursing, so we still have a generation of nurses who, when they were employed 30 or 40 years ago, could, well 30 years ago, could retire at the age of 55 or mental health officers, who have mental health officer status, who could retire at the age of 50 and we're seeing that sort of spike of that generation getting to that age beyond 50 and towards 55 and, of course, they are taking retirement. The new generation of nurses coming on will be on a different set of terms and conditions, we no longer have the mental health officer status, we no longer have the special classes of early retirement, so we've got a kind of an interim period as my generation comes towards their mid to late 50s, and then the younger generation coming forward, so the short to medium term around that generation, unfortunately as unpalatable as it might seem, is we have to get these people back beyond retirement. We have to have a plan that says take your retirement and come back, yeah, well that is, so we are doing return to practice, we are trying to be as flexible as we can be, and if someone is saying, I'm going to take my pension, so if you don't allow me to come back to work, that's fine, I'm still leaving and I'm taking my pension. If you want me to come back and work, then I'm willing to come back perhaps part-time, so increasingly across medical staff and nursing staff, we are for that, I think, for the next probably decade until that generational thing changes, as I've described, we're going to have to be encouraging them even more so to come back to work. Tim, in what percentage are actually returning to work, even if it is part-time? I don't, but we have an increasing return to work number, definitely. Right. Can we get some figures on that if you've got them? I can give you numbers on total nurses. We've got 364 have started on programmes and of those, 246 have completed and are moving into employment, but I can't tell you at what stage in their career those were, they may well have been people who took time out for other reasons. I'm not only interested, for the purpose of this discussion, on GPs who have retired and returned to work or not returned to work, and is it part-time? Those numbers will be very difficult to get for us, because, of course, the vast majority are independent contractors, they're not central re-reports. Surely, for doing workforce planning, that information should be getting collected? Well, it currently isn't. Should we not rectify that then? Well, yes, possibly, but at the moment independent contractors do their workforce. Yeah, but their contractors to the health service are so fine. Yes, indeed. But not as individuals, they're contracted for our practice. Yes, but surely we can ask the practice for the information. We can ask, yeah. As the Auditor General said, we need a far better grip on the data around GP practices. It seems to me that this is a pretty important bit of data that we should be collecting. Yes, it is, and I think that the data is important, and as Tim says, they are independent practices, and I don't think that they're under any obligation to disclose that data. However, through the integration joint boards, we have a pretty good sense of where our practices are, who is planning to retire, who will be coming back within practice, and I think aggregating all of that to look at the trends that we've got here and to say that there are a whole set of national trends that GPs and consultants are making these decisions because of the pension rules, and what is it that we can do nationally to give greater incentives to keep them in practice? But I think, and I think if you look at the Auditor General's report last week, that this is the kind of information on GP practices that absolutely needs to be systematically collected, and I realise under the existing contract there's not a contractual obligation, that doesn't stop us asking for it, and some may give it, and some may not, but at least if you get enough of a return to see what the trends are, that helps, but I hope in the new contract there is an obligation to provide the required data, because we can't get through another 10 or 15 years without getting the data we need from GP practices, otherwise what force planning and that whole chunk of the health service will be meaningless. Okay, thank you. Thank you. Just for a move to Monica Lennon, Tim Davidson and Alex Neil both talked about pulling it all together. Are you able to tell us who has the ownership of pulling it all together? Yeah, I think fundamentally Scottish Government, but increasingly we are working towards that aspiration in a more collective way, as I was saying earlier. Before the Scottish Government had the policy imperatives around the long-term planning and the undergraduate numbers, the training numbers, et cetera, and boards really were focused on short-term operational delivery plans of perhaps only one year in looking forward, or perhaps two or three years, but as we were saying earlier, you know our plans really need to be a minimum of 15 to 20 if we're talking about medical workforce, so the way in which we're working now is the Scottish Government increasingly working with the three regions, increasingly working with their constituent health boards and IJBs, so it is and partners, so as I said earlier, councils, universities, but ultimately the Auditor General has challenged the Government to come up with our workforce plan for health and social care in Scotland and it'll be the Government's responsibility to pull it together. Okay, so just to be absolutely clear, if I'm sitting here in three years' time and we're having a similar conversation it will be a failing of the Scottish Government who has ownership, is that what you're saying? Well, you put in words in my mouth, I said earlier, I said, yeah, so my response would be we have a collective responsibility, all of us as accountable officers within the NHS to work together, but the responsibility for pulling it together is the Government's, absolutely. Monica Lennon. Thank you, if I can stick with Tim Davidson for the moment. Tim, you did say that collectively health boards and the Scottish Government have failed to coordinate sufficiently. Can I just keep the focus right now on patients and ask all of you just to explain in terms that the public can understand what consequence does that have for patients now and going forward if we don't start to get this right? The immediate one perhaps would be around the failure to recruit to GP vacancies and so what that leads to is for example GP practices not being able to register new residents arriving in an area, we have that as a significant pressure in Edinburgh, so we have restricted lists for example where family members, so if a family has a child the child will be registered but someone coming new into the area is not registered and the health board has to reallocate that person perhaps to a practice not immediately within their immediate locale, so that's one implication. Another is where GP practices fail and collapse because they can't recruit to staff and so we have to health boards then have to stand in and directly manage those practices and that's been an increasing phenomenon across Scotland and in my own patch in Lothian we've had over the last five years an increase in that from perhaps two or three practices failing in a year to perhaps seven or eight practices failing in a year. Now the population context is important here so at the moment when a health board steps in to recover a failed practice because they've been unable to recruit to vacancies normally retirements or people leaving or maternity leaves or whatever then we have to step in and we have to create a what's known as a 2C contract where we directly employ the staff and run the practices though it was a directly employed bit of the NHS and our latest data for this current year is that the number of practices that we have to being directly managed as a consequence of GP's practices not being able to recruit represents about five percent of our patient population. Now on the other hand the very reason that we've stepped in is to make sure that those practices then continue to provide services so for patients they shouldn't see an ongoing impact beyond the short-term disruption that often is the case but those are two examples the third example I suppose I would quote is the significant increase in waiting times for elective services which is as a consequence of not being able to recruit sufficient numbers and and there are real hotspots there you know so for example and that sometimes is not a failure of workforce planning it's the coming together of a range of perhaps difficult to predict issues like in a team of in my case urology at the western general currently I mean my medical workforce vacancy rate in Lothian across the piece is about five percent just under five percent actually four point eight percent but in particular specialties on particular hospital sites because of for example maternity leave genuine long-term sickness absence or vacancies we have a vacancy rate of something like 27 percent in in that specific specialty and so where that happens urgent cases and cancer cases for example are prioritised and routine cases are prioritised at a lower level and therefore patients wait longer so those are the sorts of things but I mean in all of those cases as I'm hoping I'm expressing to you you have a huge responsibility and an ability to step in and mitigate the impact of that so if we look at where GP practices fail and collapse and the health board has to step in I think you've explained that the service continues but is that sustainable and what impact does that have on NHS boards as a whole it's a lot of pressure to absorb increasingly I think the resilience of practices will be based on on bigger population sizes so generally where practices fail it's where they're relatively small either single-handed practices or perhaps two or three doctors working in the practice and generally speaking my personal view is that the resilience of a practice is greater if there's a bigger practice population with a bigger number of gps working in it and that is not only resilient in terms of being able to cope with for example you know you can imagine a single-handed practice with one maternity leave is 100% deficit so but also I think that when I said earlier about how onerous the work is I think bigger practices generally allow a better spread of how onerous the tasks are you know particularly when we're offering early morning opening late evening opening you know that kind of thing so I think the I think the answer at least part of the answer is to encourage what we're beginning to see which is practices merging practices and neighbouring practices taking over failed practices and merging the practices and I think that's a significant part of the solution and that sort of solution can work well in a in a city environment or in large towns and settlements but I think once we get out to remote and rural areas of Scotland where you know peripherality is a is a is a major issue and you've got single-handed practices are very small practices then you have you know one gp who takes decisions you know legitimately to retire then you know suddenly you've got some real problems on your hands and I come back to the point about adaptability and I think it's the board's responsibilities and I think we do this to get close to practices to keep in touch with them and to diversify the workforce within the practices so it's not completely dependent on individual gps so might what might work in a large urban area will definitely not work in a in a remote and rural area so I think the solutions need to be different. I think that we are working with gp practices early on at the first sign that they are feeling under pressure or there's a risk factor of vulnerability what we've been doing in Ayrshire is working with them to try and support them to continue and clearly where that doesn't happen then we step in increasingly using multidisciplinary teams increasingly using skills of pharmacy physiotherapists to enhance and support that practice in terms of meeting the needs of the population so you know early engagement with them is very very important. One of the things that came across in the earlier Q&A was that there isn't a lack of leaders at the top of the NHS or indeed the government but it sounds that there's a lack of leadership this is really important it's you're all in the hot seat today but it's not about pointing fingers we're all looking for ways to improve what would your message be today to other colleagues to people who are listening in and people who will be reading this official report afterwards because we'll probably take further evidence you know what what can colleagues do what can people who are passionate about the NHS do to to work differently to achieve you know shared outcomes. I think one message would be that we are completely committed to the national health service in Scotland to a sustainable workforce within the NHS in Scotland and I think about giving that leadership that is alongside clinicians alongside GPs alongside consultants alongside nurses diversifying the workforce supporting the workforce making sure the workforce is trained you know and recognising the challenging situation that we're heading into you know financially we're not going to be able to expand the numbers within the NHS workforce significantly so I think it is about support it's about training and it's about diversification and and also I think to say that workforce planning is really important you know particularly for the the undergraduate and postgraduate numbers but I actually think flexibility and adaptability workforce planning can only take us so far it'll get us to a point but we know there'll be things coming across the bars that cannot be predicted and won't be predicted and I actually think the combination of the work that Caroline's describing and what we do at a very local level to support practitioners you know I hope we would all agree that our role is to lead that change and to support and encourage our staff in doing so. I think that what I'm seeing is actually a strength of leadership across the NHS across all the professions some very strong clinical leadership coming forward I think looking at the opportunities recognising the need to to adapt and to change perhaps how we do things and to look at workforce differently I think we've come a long way and the professions have worked to help evolve and change some of that so I think that people are in leadership roles and beyond because many people are in different types of leadership role are beginning to coalesce around this this work and see the importance of it and I'm encouraged by that. Reality from the figures that we saw about the growing our population is growing the older population is growing our working age population is reducing and our real terms funding is declining so that reality means that even that I think will only take us so far and so some of the things we talked about earlier about Mr Neil mentioned for example you know the introduction of new technology I think robotics artificial intelligence new technology alternatives to traditional workforce models I mean there was a media report just a couple of weeks ago somewhere south of the border where for example using digital reminders for medicines compliance for people living at home for example rather than a home visit from a carer to support medicines compliance all of that and probably a whole raft of things that we haven't even thought of yet has to be in addition to all of the flexible workforce requirements because the arithmetic just doesn't stack up the working age population is not growing in pace with our overall population so we need to have workforce solutions but we also need to need to have supplements to to people thank you again not to just to add to what my colleagues have said I think one of the changes that we are starting to see is people working together much better so I think even in the short time that the regions have been established and also the national boards coming to work together we have seen a change in what we're able to achieve in the pace of that as well and that's about bringing us together collectively people who understand of the ijbs who understand the the particular circumstances in their localities and then pulling that together with health boards and increasing into the regions I think that collaborative working is absolutely crucial in terms of us getting to a better place around all of this I think there's been a step change in that collaborative working across board boundaries certainly within the north of Scotland and I've had colleagues describing it as it is a sea change in in difference of attitudes so if you take a hospital like Dr Gray's in Elgin and there's been some well publicised staffing challenges there a real recognition that part of the solution is not just working with Aberdeen, Rowland, Firmry but it's working across the health board boundary into Ravemore and in Vanessa and there are very active discussions going on now at a rate that would not have happened six or nine months ago so I think that whole move towards seeing things in a regional dimension as well as an individual health board dimension that has really started to gain some currency okay yeah and it's good to see some some cultural change happening and some of my colleagues I think both on the right and left here have have better business brains than I do and I guess there's a lot the public and private sector can learn from one another but this isn't a business with shareholders and customers this is a public service it is our beloved NHS and patients frankly don't have anybody else to go unless of course they can afford extortionate private healthcare and I know that in some cases constituents of ours are having to beg, steal and borrow because they're desperate because they have been on waiting lists for 12 months and longer and there was a health debate in Parliament yesterday and Jackie Baillie or convener isn't here today but she read out a long list of her constituents who have been waiting for knee operations and other types of treatment for longer than a year. Shona Robison the health secretary you know she said it's not good enough she was you know she's quite angry about that but we're all getting constituents through the door we're getting emails we're getting real stories of distress is there a point in which we have to say to constituents that there's an inevitability about some of this? Well I think there's an inevitability of trying to reconcile the policy imperatives that we have and so what we are trying to juggle whether we're wearing our health board hats or our regional hats are so we have a statutory duty to live within the resources available and those resources are now declining in real terms as the Auditor General's report says so we have that statutory duty we also have a statutory duty to shift the balance of care and support and improve primary care we've talked a lot about GPs for example and we also have to improve our deteriorating performance on waiting times now at the moment those three things can appear apparently quite difficult to reconcile so we have to save the most significant amount of cash we've ever been challenged to do and so whether that's four or five percent a year on a sustainable recurring basis of cash savings that have to come out of the system in order to cover the fact that our costs are growing faster than our inflationary uplift so whether that's to fund drug inflation acute drugs at eight percent a year, GP drugs at four percent a year so at the moment it is looking extremely difficult to reconcile saving five percent recurringly a year in order to fund demographic pressures and prescribing growth for example and improve access to elective targets and improve resource allocations to primary care and you know frankly I think the the issue about bigger macroeconomic policy issues for both this Parliament and the UK Parliament around the responsibilities of citizen and state issues around income tax for example are really important here I think what's becoming clear to us and I think the challenge the auditor general lays down to us is that we now have to reconcile that in our plans so our regional plans that we are developing and the national boards are developing their equivalent of the regional plans and national board plan and all of those plans then come together with government will have a regional plan we will address the challenge laid down by the auditor general which is that we need your service plans to be reconciled with your financial plans to be reconciled with your workforce plans now if there's a consequence of that we say our view of the workforce we need is neither available nor affordable if that's what we say then that generates a whole different conversation about how we're going to respond to that both at a political level and at a service delivery level and when I was referring to Mr Kerr about us not having a plan that's really what it was meaning there is currently not a published plan that reconciles our service aspirations financial requirements and our workforce requirements and we need to pull that together. I was involved in a different kind of planning before that I came to Parliament I'm a town planner and I would never say that you can have too much planning or too many plans but that point that you've just made I mean before you can start to develop a plan you need to have a real vision of what it is you're trying to achieve is there clarity around the vision? I think there's clarity around the vision I think the lack of clarity is about how we get over what timescale and how much it costs and if I go back to one thing that Alex Neil was saying about you know can we not do this in 12 months I think if it was simply a question of saying how many more you know if our elderly population is going to grow by 40% in the next 10 years what does that mean for how many more gps how many more district nurses how many more you know whatever and we would say we need 20 of those and 40 of those and 100 of those and that's another 50 million thanks very much but the reality is that we're not going to have as we're saying in the short to medium term the next five or 10 years we're not going to have 40 more gps or 40 more geriatricians nor are we going to have the resource in the short term to pay for it so where I think the 12 months challenge that Mr Neil was putting down is extremely challenging is so the alternative plan hasn't been invented yet and that is what integration authorities are about that is what the regional plans are about that is what the need for innovation is about is we've got to come up with solutions that frankly haven't been invented yet not just in Scotland I might add but across the western world all of these this is not a uniquely Scottish problem. I mean if I can open us up to the rest of the panel in previous sessions particularly when we've looked at health and social care integration you know we've been reassured that the integration isn't new that people in the NHS and local government have been doing this for quite a long time but the boards themselves you know they are a relatively new creation so previously built you know I've taken comfort that this type of collaborative working isn't new and that we aren't starting from a standing start so but is it you know because I feel like we are getting mixed messages in terms of the integration integration joint boards I think it's true to say that we've always worked together across health and social care and we've had various initiatives over the years I think the IJBs take this to a new level and and certainly from my local patch I think the changes that have been made and say reducing the number of delayed discharges from acute hospitals I think that they've been halft in space of about 18 months or so and I put a lot of that down to the relationship between the board chief exec the local authority chief exec the appointment of good chief officers and I'm working together collaboratively to make sure that we make those changes to what where patients are cared for so we don't have patients staying in hospital who shouldn't be staying in hospital and also making sure that IJBs aren't you know doing things that you know create a negative effect within so you know very much looking at the whole system so I think we are seeing changes in terms of occupied bed days for and schedule care across Aberdeen city across Aberdeenshire and across Murray and I think that's all good I think the challenge that Tim's talking about in terms of elective care I think that that's a very significant challenge at the moment in terms of people waiting for outpatient appointments people waiting for hips and knees and cataracts and and all of those conditions and I think when you know to take Mr Neil's point looking at the population profile and the morbidity profile that we can predict into the future that is going to be a real challenge so I guess you know one of the things that you know concerns me as an accountable officer is just the ability to care for that for that population and making sure that those people get their operations when they actually need to get them we've been working in partnership and collaboratively for for many years and and beyond just health and social care much much more widely in our communities from an airshare context then the introduction of integrated joint boards has I think created a much stronger local and community focus in terms of our planning and in terms of how we look to shape services and I think it's allowed us to have stronger partnership links and collaborative links with education third sector and other parties so I think it has been had in those and it's still very much fledgling in in terms of its its its life but I think we have seen change but as we have said throughout the discussion in this morning we need to make sure that we continue to join up that planning at locality level because there's a strength in planning at locality level but making sure that joins that whole system across a board and where it should then make those links into regional delivery planning that we make those links across all aspects of service planning workforce and resourcing but I think it's a very in airshare it's been a very positive development in your joint submission for the committee today you addressed the matter of affordability of plans and again it doesn't look like an easy task so we understand that boards are required to deliver affordable workforce plans but you're suggesting to us that you've got a situation of limited information on the future funding that you're going to receive alongside the Scottish Government requiring you to provide workforce projections for three years so again this seems to be quite tricky how challenging is that on a a scale of one to ten ten being very tricky I think it's very challenging because this is a very complex you know this isn't a linear arithmetic proposition we are trying to look at so many variables and factors I think what we have to be clear about when we develop these plans is what assumptions we've made and we need to understand and bring our best intelligence to what that environment and those environmental factors are whether it's finance whether it's changes in technology and as long as we're clear on those assumptions and and we're going to have to to take I think some some risks in terms of developing these plans because as we have said I think in a number of occasions this morning some of what we need is a is a an adaptable and different set of skills within our workforce so we do need to start to train for some of those and so we need to make some you know carefully consider the assumptions but assumptions nonetheless if we're going to be able to look beyond that one-year horizon which I think is very important Have the tools to do that to take that informed approach to risk? I well I think that it's not new we do that that is that is part of what we do there is no doubt from what we've heard this morning that you know some of the developments around workforce planning tools and data and so that come forward will assist significantly in that process but I think we we have got you know people in our our teams and in our boards who have an understanding and an expertise they have small in number around workforce planning and and the fact that we have already made I think some important shifts and changes demonstrates that we can make some of those assumptions but what I think we need to be is perhaps boulder in terms of looking beyond that shorter horizon into some of those longer horizons. I think that you accepted the premise that I think the order to general was was making that we're not going to be able to significant increase the NHS and social care workforce numerically and if we also accept the proposition that the the training pipeline particularly for medical staff is is very very long so whatever decisions we make today the world will be completely different by the time they graduate they'll be completely different by the time they finish their postgraduate education but if we look at it from the point of view we have a workforce and actually what we need is a workforce that is adaptable that can be trained that can be developed so it's not about just producing a practitioner who can do that and and and that's it we produce practitioners who are flexible adaptable and are able to progress their careers and the point I was making about the importance of partnerships with local universities and colleges of further education are absolutely critical so you probably are closest partners in in grampian are the north east scotland college robert gordon's university and Aberdeen university where we can have discussions with them we can project our local workforce requirements and they can do the training and you know actually getting nes call and Aberdeen university to work together for example in terms of getting people who may be interested in say nursing degrees and giving people the confidence and the numerical skills to do a nursing degree and then articulate them through robert gordon university or the open university there's lots of examples of all of that so that we actually take the workforce we've got and say well how can we develop them and I think that's going to be the key to planning in the future as well as getting the high level numbers right I think it's the local adaptive action that's going to be really important and I think it's also important that we've focused a lot this morning on medical and nursing we really need to look at the whole workforce and we need to look beyond health into health and social care and we need to make sure that as we go forward these professions and these jobs are valued they're valued by society and they're valued for what they bring and offered to communities so we need to make sure that yes absolutely a focus on medical nursing but we need to make sure that's much broader so that we have a sustainable workforce across the whole system that's there to support those other disciplines I had a final question um convener but your point there about people feeling valued I can't find exact statistic but I think it's from the last staff survey I think for 2015 am I right that it was over two out of ten people working in any given health board so that they intend to leave within 12 months is that partly due to people not feeling valued is it due to just lack of morale what's your understanding of that well we've we've done as we will all be using the beyond the staff survey and using eye matter which gets right down into teams looking and in Ayrshire we've had a very positive response to the eye matter where teams are looking at you know their value and how they work and in their roles and and then how they might look to their own local team improvement plans so we've had a very high level of positive staff engagement on the back of that and I think that's a much more sensitive tool in terms of working with teams so of course there will be challenges within staff, staff are busy and staff will be feeling the demands and pressures on on the system but I think if we put the right approach in around wellbeing and supporting staff then we can we can help to support and manage some of the concerns that staff rightly express I would agree with that and I think the eye matter tool is an evidence-based intervention that's been worked up very very carefully and certainly the results for NHS Grampian most recent results show a 70% employee engagement index so that is how well the employees are engaging with the organisation about commitment about involvement against a range of scores and those scores have been going up over the last three years and and we've got just under 80% of staff saying they've got sufficient support to do their job well that's good but that also implies that there's 20% of people who don't and we've got much lower scores about do we think we've got enough staff to do the job properly so there are real concerns about you know the numbers of staff we've actually got and I guess you know one of the major challenges of NHS Grampian is the supply of trained workforce particularly around nursing workforce and we're doing all the things that we've described you know return to practice programmes they've been hugely successful and we need to move that much much further forward but I do think the thing that makes the difference is the leadership is the engagement and creating an environment where staff feel valued and supported and are really committed to their work and certainly from my point of view that is certainly one of my top priorities to create that sort of environment where people feel valued and I think that the crucial difference about using the iMatter tool there is that it's not just about filling in the survey it's then about having a conversation with the team and developing an action plan so so that is actually I think across boards across Scotland actually leading to real improvements in the way in which staff feel valued and engaged and are able to have those conversations about what improvements can be made to help them feel even more valued and engaged and that's really important. It's good to get an example of some planning working well can I just jump back to my last question on affordability really from my own information other colleagues might understand this better than me but for medical workforce it says that interesting you say that boards only have to give a one-year projection I don't understand the background to that but given that you've pointed out that there's a training period of 15 years plus what's can you explain that it seems a bit odd to me? Can I maybe just say that the it's not just the information that's in board workforce plans it's used in terms of looking at the number of both undergraduate and postgraduate training grades so over the last couple of years particularly we've been looking at medical training on a specialty by specialty basis so that's very much looking at the actual profiles within that specialty so that will be around what the consultant population currently is how much we expect that to reduce through retirals over the next few years and also looking at the training population so how many trainees we're expecting to achieve satisfactory completion of training but also where we've got people going out of training from a turn to leave or for so that we can actually factor in all those so there's actually quite a complex mechanism that now looks at what we need in terms of medical training in each specialty and that is a little bit informed by board's workforce plans but actually there's a much more sophisticated profile and goes on behind that. Thank you. I'd like to continue the discussion a wee bit on service redesign and perhaps give you an opportunity to to summarise and give us your thoughts on this but firstly could I just jump back briefly to the university admissions issue that Alec Neill raised and ask you Caroline. The information that we have in front of us for the universities doesn't give us any information from St Andrews or Dundee medical schools because it says here that that information isn't publicly available from those two institutions is an explanation for that. Reason I ask you this is we covered this when I was on the equalities committee and we were looking at university admissions to medical schools from across the population and so on so I'm wondering why we don't have data from them and can we get it? I think that that's a question for the universities. The university decide what information they make publicly available and certainly I think it would be up to the committee to ask them to provide that data. They certainly gave a commitment as I understood it during my time on the equalities committee to supply that. Related to that, Tim, you did mention that we're becoming more successful I think in getting undergraduates to enter to go to medical school from across the population sectors. That was a key concern for that committee at that particular time and is that borne out, is that beginning to bear fruit for us do you think? University of Edinburgh is on our board as you know the medical school ahead of the medical school is a non-executive director of our board so we have extremely close relationships with them and we were talking with them just as recently as last evening so the particular thing that I referred to was a briefing from the head of the dean that said the proportion of Scottish school pupils from the two most disadvantaged quintiles who received an offer from Edinburgh University was 30 applicants so I think that is a step in the right direction. The point that I was making I suppose is that we need to further increase that and also there is an issue about some universities don't interview applicants so it's an entire paper based and academic qualification led criteria for appointment and the point that I was trying to make earlier probably clonzerly was that increasingly I think I would want to encourage universities to actually interview staff and interview candidates for university to see if they have the aptitude to do the job that we require them to do so we do require them as I was saying earlier to work 24 seven rotas even if they're working part time and less intensively or whatever we do require them to fill GP roles we do require them to work in rural and remote areas in Scotland and I think actually the two things go hand in glove if we broaden the scope of applicants that would include broadening to remote and rural areas for example and I think I think there is it that my hunch it is just a hunch but I think my hunch is that just as we believe that Scottish domiciled students are more likely to remain in Scotland I think possibly remote and rural domiciled applicants would perhaps be more readily willing to go back to work in remote and rural areas so I think that's the kind of thing that we are beginning to see some and I think to be fair to Edinburgh university and I'm sure the other universities are doing the same things I think there's a real appetite to get into this now in a way that I think Edinburgh are demonstrating. I encourage you by that but perhaps for you directly Caroline I think you said that the limitation in numbers is set by government then take numbers has that changed over recent years given what we know that GPs see their own futures they see it perhaps more of short time, part time, working different lifestyle changes, different demands on them so are we reflecting our numbers and our intake numbers based on that kind of performance from GPs? Yeah so the number of the intake to undergraduate medical schools was increased by 50 I think for 2016 onwards we've then seen Scottish Government are establishing a Scottish graduate entry medical school which will have its first intake next year in 2018 and Scottish Government have also announced that there will be additional places focused on trying to retain more graduates in Scotland and also focused on trying to attract more people into GP training again from 2018 so we are seeing an expansion in undergraduate numbers yes. I wonder if I could just talk to the whole service redesigners I mean I'm trying to be very positive about this I mean Scotland's NHS probably is the best performing in the UK patient satisfaction is the highest it's ever been there's record investment there's more GPs there's a bit nearly 3000 more GPs than there were 10 years ago yet the public perception is that their expectation perhaps and their demand is it beginning to outstrip our ability to deliver even a really good service to the public so in the broad context of service redesign what are the key messages you could give to us and give to the public who may be listening to this kind of discussion what kind of changes do we need to to make so that when we're perhaps again as Liam said if we're looking at this next year or even in five years what would we expect to see it would begin to manage these expectations that the public may have of their NHS the biggest single thing I think is about reducing demand and whether and there are a variety of things for that so if what we're saying is that a population is growing our older population is growing people are living long enough now to now live with multiple conditions people are now living long enough to get cancer and then live with cancer for you know a long period because of advances in care and technology so if we're saying that's that's true and I think we are saying that is true more people more older people more people with longer term conditions all of which requiring medication care intervention etc and we're saying we think the working age population is reducing so therefore the workforce supply is not going to be keeping pace and we're saying that the money is looking pretty flat then the traditional response of the last 20 years has been to throw more and more and more money at the health service and employ more and more and more staff to do things ever increasingly faster and faster and faster so you know waiting times did used to be a maximum of 12 months then it was a maximum of 26 weeks then it was a maximum of 18 weeks now it's a maximum of 12 but you know there's a sort of there's a limit to how how you know that that can continue so I think the traditional response of saying so let's respond to growing demand in the way that the health service always has which is more cash more staff is just not an option and therefore our endeavour has to be around shifting demand so the sorts of things that we are doing which I think you know are coherent is for example unnecessary interventions that don't add value I think there's quite a lot of work around that I think the whole realistic medicine scenario around perhaps offering procedures because we can rather than because they actually will will lead to an improvement in the patient's condition demand for new medicines where the cost of new medicine vastly outstrips the very marginal population health improvement as a consequence of that people currently you know having to go to a GP in order to be referred to a podiatrist rather than just going straight to a podiatrist you know etc I think and what I said earlier about self-management of conditions you know people actually whether that's using digital technology to help them artificial intelligence you know everyone knows the google doctor who will you know help help them with their condition using community pharmacy rather than going to the GP to go on a waiting list for an outpatient you know referral etc so my personal view of this is that the new focus for us all whether that's politically service providers patients and carers etc is how we manage demand on the health service down I would agree with what Tim has said I think that we do need to think very carefully about how we're going to support citizens you know differently in their home and how we support individuals with long-term conditions and I think the technology going forward I think there's a lot more that we can do we've got some great examples but in small scale and and we need to be able to think about how we scale that but we need to also make sure that citizens are confident to use technology in the way that tests have shown can work very successfully and indeed I think doing that and we've seen examples in Ayrshire where and I'm sure colleagues will have examples in in their areas where it enhances the quality of an individual's life they're not having to go to hospital three four five six times for appointments they're able to self manage they're able to to work and look after their their own health more effectively because of anticipated care planning and knowing what to do if they have an exacerbation of a condition so I think technology is important I think realistic medicine in terms of I think that this has been a really important conversation that the chief medical officer has has started and realising realistic medicine and engaging differently with clinicians and with patients I think that will have an important part to play but I think what we have to do at the heart of this is we need to we need to have a dialogue with our communities about how these are positive changes that we can make and that they actually provide added benefit added quality of life to the individual and by using new technologies and having and not needing to turn up at hospital as often or to beat your GP and then that final point around the wider community resource you know being seen by the right person at the right time and that's not always the people we might traditionally think we need to see and again in in Ayrshire we've been doing some I think fairly good work around eye care services where we've been redirecting people from hospital from general practice to the high street optical services with with great success so I think things like that are what we should see at the heart of redesign. I could hear you. You see a significant shift really from acute hospital care into care within communities and in primary community care settings and I think what John was saying both about realistic medicine and I think that's about changing the conversation that clinicians have with patients and the notion that just because it can be done doesn't mean it's the best thing to do and helping people really to have a full understanding of what the condition is what the choices are to them and with that better sense of dialogue they might just make some different choices around it. I think the use of technology and really developing local community capacity so you know if you live in a remote community and you need to see a consultant for an outpatient department in one of the islands then the amount of travel and overnight stays to get a short appointment with a consultant you know can we use attend anywhere software that NHS 24 has developed to make sure that if you actually don't need hands-on care or if it's a return outpatient appointment you can actually have that done within your local community and using that kind of technology so I think we're going to see much more of a shift into local communities community resilience and then that team of multi professional team of different practitioners who can work within the community to support people with slightly different expectations about what their pathways of care are going to be in the future. I think the final point to make is that we also need to focus on prevention as well and that clearly goes much much more broadly than just looking at NHS Scotland that's that's something for the whole of the public sector and indeed Scottish society. Can I share with you an example? I mean this week in preparation for the meeting I visited one of my local practices and the lead practitioner leader was telling me that they get 2,000 visits a week and they'll get 13,000 on their books. That means that everybody is coming to see their GP seven or eight times a year. That is not sustainable and it's one of the main reasons why a lot of the GPs are feeling so stressed and so under pressure because of this huge volume of repeat visits by the patients. Now the patients are really valiant but I would suggest to you and colleagues that we cannot sustain that so we have to take patients on this journey with us and reach out. That's a partnership. The health service is held in very high regard but their expectations are huge and perhaps beyond getting beyond their ability to deliver that. How do we reach out to the patients, these 13,000 or so patients, to say to them that there are different ways? It's not a failure if you don't see your GP at your practice but many of them think that it is. I want to see my GP or else. You know there's still an attitude a bit like that. There's so many specialisms in GP practices now but have we failed to persuade the public that there is a better model there for their healthcare because at the minute I don't feel that they feel that. They feel that it's a failing that they can't see the person that they would wish to see in a particular day. I think that that's right. I think that we need to do more about communicating that the changes are for positive reasons. I used the example of eye care in Ayrshire so instead of going to see your GP, go and see your optician in the high street. We have seen that shift of behaviour, people going to those services in Ayrshire. It's been a pilot to begin with but that has evolved very successfully. However, I think that we need to be more explicit. I think that our communication needs to be better. We need to be clear about why we're saying this, not don't go and see your GP but you'd be better to go and see this practitioner. If you're referred to a nurse or a physiotherapist or another professional then it's because we believe that's the right person to support you in your care needs. It's not that we're saying that you shouldn't see a GP but it's that default position and I think that we just need to try and engage more effectively with our communities. Perhaps we need to think about that on a wider Scotland basis in terms of having some key messages about how our communities can work with us because I agree that it has to be a partnership. The communication is fundamental to—I'm sure that other members in the committee have so many engagements with constituents who don't really get the language that the NHS perhaps uses in its writing and communicating with them. There is a degree of suspicion with what they read while they're trying to pass me off to us. That's the perception that we really need to improve and embrace that direct engagement with patients. It is a better journey for them but it's a whole healthcare model that we're looking at for them. We're not just pushing them out the door because we're too busy and we're stressed. I feel that we've got a lot to do in that area and I would really appreciate if you would take that kind of message on board and see if we can improve that. Malcolm? I would very much agree with that. I think that this is something where local systems and government can really work hand in glove on it. Suddenly one of the local things we started winter planning a number of years ago was a know who to turn to campaign and where we're communicating with the public about these are the different types of practitioners and actually if you've got this it's maybe better to go to a pharmacist or this is what an optician can do, this is what a dentist can do and actually looking at the training that modern dentists have and optometrists have and pharmacists have, actually if you go in and have conversations there they've got the training to pick up things that maybe 10 years ago might not have been picked up and if they're working as part of a multi-professional team. So I think getting those messages over that it's not just about the GP. I think GPs bring a unique set of skills but there's a whole range of professionals that you can work with and I think for that messaging and narrative from government to support that I think would be really helpful. I don't know what the European experience is but do you get the impression that citizens and other jurisdictions are already having this kind of experience where they are moving around the health service and finding these different skills or are they relying on their GP in this traditional relationship with the one-to-one with their GP? Are things moving on in other jurisdictions do you think and do we need to catch up a wee bit there? There are very different models. Some European countries' citizens go directly to secondary care, directly to secondary care specialties and don't touch base with the GP so it's obviously a very fundamentally different system. The thing I was saying earlier in New Zealand for example which is in many ways a similar kind of demography to Scotland, citizens have to pay to go and see a GP, people pay, I think it's £30 or something equivalent to go and see a GP and that obviously has an implication in terms of people thinking about what they want to do so I mean I think there are different models. One of the things I was going to mention if I may would be that part of the reason that we haven't yet got the plan that is going to deliver all of this is that it requires fundamentally buy-in from not just citizens but also from our staff and not just from our current staff but our future projected staff so if I just take one example in Edinburgh where we have a practice in a very deprived part of Edinburgh where a few years ago they just simply were overwhelmed with demand you know a huge young population, a lot of substance misuse and alcohol misuse problems and quite a sort of chaotic population in many ways for the GPs to deal with and they were just overwhelmed they couldn't offer appointments within a week or 10 days because they were just so overwhelmed and the local GP there introduced a telephone triage system which said well not you can't just phone up and ask for an appointment we're going to say to our population you need to phone up and have a conversation with in fact a GP but latterly often not a GP as well but initially a GP to say okay what is it you want to come in for what is it about just tell me a little bit about what you want to know and that was really good to either signpost the person to say well actually I can deal with that with a repeat prescription don't need to come in and see me for that I can ask the pharmacist to do that you've got a musculoskeletal issue you should be seen by a physiotherapist quickly I can organise that doesn't require to come and see me or in fact where someone was having you know a major problem that sounded really complex the GP could say okay I will see you but I'm going to give you a 20 minute appointment rather than come in for a five minute appointment now they transformed the ability of the practice to respond the fact the day I visited the practice to chat to them about it they showed me their appointment book for that very day and there were still appointments vacant for that very day however when that practice stood up in front of 130 practices across Lothiad to describe their approach quite a few practices said we don't like that approach we think that primary care is all about an interpersonal long-term face-to-face relationship with our patients and whatever so the ability for us as leaders to try to rapidly implement what appears to me as a as a health service manager a fantastic solution that appears very patient-centered actually in the way that it's been described but quite a lot of other practitioners just don't don't don't like that model at all so we've we've got a job but where's why I said how big is this challenge well I think it is 10 that's not to say it can't be achieved it's just I don't think we should underestimate how tough it's going to be we've got so many stakeholders that we have to get in a line in order to implement a different way of responding to traditional demand it was a patient response to that new model oh fantastic yeah fantastic yeah thank you very much for that I know we're really pressed for yeah thank you just on that point willy thank you for pointing out we're getting very pressed for time so if we can go to very quick questions and very quick answers if you wouldn't mind bill bowman thank you convener I think everything I've heard this morning from all of our colleagues has been most interesting let me just give you a slightly different approach you put together a joint submission now if I can slightly deconstruct that a little bit and maybe ask you individually as senior executives in your own particular boards what are you doing well in workforce planning that others might benefit from or be interested to to hear today I'll start in Ayrshire there was there was a pause in Ayrshire I think there's a number of things that I would highlight and some of them have been referenced so reporting radiographers and looking to develop that beyond just plain film looking at biomedical scientists and pathology and extending roles when I look at the work we've done in Ayrshire over many years around advanced nurse practitioners and the scale and range of activities that our advanced nurse practitioners are now involved in I think that's something that we see positively and indeed on Cumbria the out of our service we talked about earlier is an advanced nurse practitioner delivered service and very successfully delivered I think in communities we're seeing some some good developments around the eye care service I've referred to so using other skills but also through multi-dipsy teams bringing in physios and pharmacists my part there when you talked about eye care I thought you were talking about I like me as in everything these days is I for now and you had a new system for people looking after themselves I understand apologies I'll just use one example which combines technology regional collaboration and a little bit of innovation so one of the boards in our region just could not recruit radiologists so therefore the reporting time for their film and their MRIs and their CTs and etc was extremely challenging in our region we agreed to create a single radiology reporting system with a with a single technological base that would allow an image taken anywhere in the region to be reported by a radiologist anywhere in the region so an image taken in five could be reported in borders an image taken in Edinburgh could be reported in five you know etc and that has allowed us to be able to respond to what was a workforce challenged by regional collaboration added to digital technology sorry I was just giving you an example of what I was doing others could perhaps learn from in that sense so I'm in a slightly different position because my board is a national board and it's part of our raison d'etre to support other boards but I guess if I was going to pull out one thing I think what we have done over the last few years is really improve our capacity and capability around digital and I think that's why we've got the axe to develop the platform and the whole point of that is making sure that that information about the workforce is available on a once-for-scotland basis to whoever needs to use that in terms of their planning so improving that whole planning process. I have very much support then I think what Caroline has done in terms of the tourist system and how to support boards in terms of education and training I think is absolutely spot on two three quick things and I'll be very quick I think the development of rules of clinical development fellows to plug some of the gaps and really taking doctors who want to step out the formal training programme for a period of time and actually giving them some experience before they get back on the training ladder. Physician associates have mentioned, advanced practitioners have mentioned and I think that's really struck me over the last two or three years when Grampian has been about the quality of medical and nursing and HP leadership so that professional leadership and team working and working together and working through issues I think we've seen lots of redesigned work going on in our surgical services and our operating theatres and that's progressed at a rate I've never seen before. In Aberdeen Shire and Murray we've seen a development called virtual ward which is led by GPs meet together with the practice team every morning and they look at the range of patients that are potentially could trip into a hospital admission and I think are these patients who are at risk who are vulnerable can we send a district nurse or a health visitor or whoever and make some intervention and support them in the home in order to avoid tripping into a hospital admission and that's one example that's actually been you know developed right the way across Aberdeen Shire and into parts of Murray and finally I think the collaborative work on delayed discharges I think has made a huge difference to the lives of many many patients but and also to the running of Aberdeen Ronan Firmoy. Very briefly Monica Lennon. Thank you, it was a supplementary to Willie Coffey's line of questioning. I suppose Willie was touching on how do we reduce demand and have fewer people going through the door of the doctor's surgery but the other side of the coin and this is something that concerns me is the people who don't access services, who don't get to the doctor or the pharmacist or the nurse and I'm thinking about Lanarkshire where I'm based and in particular Tim you touched on substance misuse and alcohol and drugs and I'm thinking about the the reduction in those kinds of services and the people who don't get help quickly enough and it just actually increases demands on the NHS further down the line so what if we're going to see a continuation of particularly at local council level some services being cut back is that just going to store up troubles for the future, how can we get these people who are quite hard to reach, how can we get them into services quicker? Well they're just going to store up problems for the future and I think it is a major problem and you know we talk about prevention and yet we also talk about the demand for improving treatment and you know the reality is the pressure on social care budgets has meant that you know you really need to be at critical need of a service before you get it now in social care as opposed to those at you know at an earlier stage where prevention would help I think there's a broad acknowledgement that is the case it's probably back to what I was saying earlier about you know we we need some macroeconomic choices to be made around this I mean if you pour all of the money available into you know elective waiting times then that money is not available for primary care if you put all the elective if you put all of the money into you know increasing staff numbers then the money is not available for new drugs if you put all the money into you know etc so at the minute the numbers just simply don't add up and therefore I think you know what we've got to do is have a a short medium and long-term thing I mean although austerity has been around for 10 years I mean I've been in health service for 34 years I've worked under every shade of government I've worked under times of plenty and times of great difficulty and what I suppose I would learn from that is that things do get better eventually and so I think although we are saying you know the financial outlook looks really bleak for the next three or four years which it does and that's a reality I think if you hear one thing from us it's about saying that we acknowledge that the short termism around workforce planning hasn't helped that we need to raise our gaze we need to plan beyond austerity and whether the whether the solutions are you know at a UK level at a Scottish Parliament level or whatever you know a growing population with growing health needs will cost more money frankly and that needs to be addressed fundamentally. Thank you. So just very briefly direct to Paul Gray I will hear from next week he currently has a dual role as NHS chief executive and director general of the Scottish Government I'm just interested in how that works in practice does in his capacity as NHS chief executive what is his relationship with the chief executives is he directive is he consensual how does it work I mean we we meet with Paul and his his directors formally on a on a monthly basis so there's a lot of conversation there's a lot of dialogue and he's very clear with us about the policy of the government about where the services is heading what the priorities are and we have those conversations and I think is one of the great things about working in in Scotland that people in our sorts of positions can have conversations with ministers with senior government officials and you know we kind of know where things are heading so you know it's challenging at times and I think you know in our conversations with with Paul I think we're very clear with Paul about what the challenges are that we are facing and he's very clear with us about what the priorities of of the government are but I think that's a useful constructive conversation thank you on that note if there are no further questions that concludes our evidence session so I'd like to thank very much the witne