I am an introvert. I love people, but I have my limits. I don't recharge in groups. I don't recharge at social events.


Hello everyone, welcome back to another session in Dentistry and more today we have a topic from Epidemology or public health industry that is screening for disease. So screening is nothing but actively searching a Disease in an apparently healthy people or a population So hope you remember the concept of causation and iceberg phenomena Where the iceberg represents the cases? But the tip of the iceberg is a symptomatic cases that is only what we see So these tip of the iceberg or the disease people with symptoms who goes to Doctors for the treatment, but the majority there is a 90 percentage of the disease people This 90 percentage are asymptomatic, but they still have disease They are below the water level They don't know they have the disease so they don't go to doctors for the treatment. So screening works in that section of the disease Population that is the asymptomatic cases. So screening is nothing but actively searching Cases in an asymptomatic population or apparently healthy people So uses of screening the first one is a prescriptive screening that is for our own benefit So the doctors or healthcare person do screening in order to find out a disease in a healthy people Okay, so screening procedures which is prescriptive in nature for the case detection Whereas a prospective screening here the Benefit is for the others not for the person because we are protecting these people In order not to spread the disease. It is very common nowadays because the COVID-19 disease where we quarantine People with disease because they don't spread to others It is actually benefiting the other people Because they don't get the disease from the person that is prospective screening screening for immigrants from infectious disease Now for the research purpose that is to estimate the prevalence and incidence which can help the research people and also to educate or to create awareness for lifestyle diseases such as diabetes or to Detect the disease so early so that the intervention can be done so early So the complications or mortality will be very less So what are the types of screening they are mass screening high risk screening Then the multi-phase screening mass screening is nothing but it is done on a mass of people irrespective of any high risk group or a particular risk Just like the tuberculosis which is very prevalent in third-world countries like India by 60 to 70 percentage are Having disease but majority are asymptomatic or carriers So in order to find the disease from such a huge population with 70 percentage of prevalence We need to do mass screening. We just cannot exclude any group Because the disease is so prevalent. So in such cases mass screening is the only strategy The second one that is high risk or selective screening where only a particular group can be Involved such as if for diabetes We can just use people with 40 plus or people's parents with diabetes history And if for breast cancer the women group of 40 plus can be particularly used Because majority of the cases will be in that sentence so we can just reduce our cost workflows or time whereas this Multi-phase screening it is done on different phases for any disease The first it starts with questionnaire then clinical examination and then there will be investigation which can be a blood investigation or The radiographic investigation because it is having many layers of investigation to find out the disease but it is Not having much benefit. It is showing increased cost So what are the criteria of screening tests? The three criteria is Acceptability repeatability and validity. Acceptability is nothing but it should be very acceptable for the people Repeatability is consistency and validity is accuracy Acceptability it should not be painful, discomforting or embarrassed for the people Repeatability is nothing but the reproducibility or the consistency. It should give the test should give consistent results when repeated more than once So there are three factors which involves in the repeatability The first one is observer variation then the subject variation and technical Here is observer variation We have two things that is intra-observer and Inter-observer intra means within the same person the same observer if I'm doing the examination I should be doing it two or three times so that I can minimize the error by taking average Whereas inter-observation is a little more complicated because there are two people involved so The proper training or the intensive training or the standardization of procedures only can minimize the error because Both person has to record the result accurately or consistently so We need to train the examiners very well or we need to standardize the procedure Whereas these errors are common in cases of x-ray, ECGs, blood pressure or histopathological specimen But it cannot be eliminated completely that is there Now the biological variation it can be due to the changes in parameters Or radiation in perceiving the symptoms And technical errors could be the defective instruments the faulty reagents But this is the most important thing and the Screening test that is a validity how valid how accurate the test in Finding out the disease. So what extent test accurately measures which it intends to measure The test which is to identify the HIV patients or test to identify the corona patient. So how accurately it detects the Person worth disease. Let's take the RT-PCR its accuracy is around 95 percentage means if population with 100 people With COVID-19 disease the RT-PCR would be able to detect 95 out of 100 still It is not able to detect five people with disease So that is the accuracy or validity what extent the test can measure what Intense to measure so it distinguish those who have disease from those who do not We can say glycosurus is a screening test for diabetes but GTT glucose tolerance test is a more valid just like the antigen test is a screening test Whereas the RT-PCR is a confirmatory test or more accurate test So validity has two components that is a sensitivity and specificity So this is a picture you need to visualize when thinking about sensitivity and specificity before that The validity means nothing but accuracy so how accurate The result of the test to its true value how accurate it is giving the The test is to its true value if 100 people are having disease how accurately it is reproducing the test result Whereas the reliability is precision how close are the results of a test on reputation? That is reliability Now we have some mathematical test for the evaluation of screening test One is a sensitivity specificity then positive predictive value negative predictive value percentage of false positive and percentage of false negative So before moving on you need to keep in mind that positive means case negative means healthy people false positive means false case that is healthy person false negative means false healthy that is actually a case So sensitivity it is the ability of a test to identify correctly all those with disease that is true positive 90% is sensitivity means 95 90% of the disease people are screened and they give the positive result and ten percentage will be false negative that means if a population of 100 people and we are having a test and the test giving 90 positive result that is 100 disease people and this test is saying that out of 190 are having disease So what about the ten percentage this test is saying actually they are false negative They are saying there is no disease, but they are actually having disease, right? Because all 100 people are having disease, but this test is able to detect only 90 out of those 100 The remaining turn is false negative that is sensitivity ability to detect the correctly detect the disease cases Whereas specificity Identifying correctly those who do not have the disease that is true negative Before it was true positive true positive means case true negative means healthy So 90% specificity means 90 by 90% of this non-disease people will be true negative Then percentage will be false first day that is if 100 people we take and nobody's having disease Okay, this test after this test this test is saying that 90% is true negative. That means 90% is not having disease, but it is saying that 10% is having disease But actually they do not have any disease So this is a error of this test This is able to give only 90% of the specificity that is the 10% of the population This test is giving wrong information So that is sensitivity and specificity any test any test is Mature in this two value sensitivity and specificity to take any test will be measured They'll be mentioning about its sensitivity and specificity So the perfect test is 100% is sensitive and 100% is specific. That is very rare So let's take these all things into a mathematical table that is A, B, C and D A is true positive that is it is actually a disease and and test also it is giving positive Actually it is disease, but in test it is giving negative that is false negative. Okay Actually, there is no decision, but it test it is giving positive. That is false positive Actually, it is no no disease and test also giving negative that is true negative. So this is A, B, C and D So total positive cases are A plus B. It also includes false positive. Total negative cases are C plus D It also includes false negative. Total cases are A plus C and Total Healthy or not disease are B plus D or without people without disease So sensitivity is this is persons with positive test divided by all persons in population with disease. So this is the Denominator all persons with disease A plus C That is total case. So it will be This is person with positive test A by A plus C whereas specificity is a non-disease person with negative test that is D divided by all persons in population without disease that is B plus D. So sensitivity is A by A plus C Specificity is D by B plus D. So never learn this A by B C by D A plus B C plus D because it is very confusing So you need to be Be very thorough with this concept. What is true positive? What is false positive? What is false negative and false true negatives? next we have Positive predictive value and negative predictive value.  A plus B is the total positives and A is the actual diseases from the total positives Whereas the negative test is a proportion of Patients who test negative who are actually free of disease So D is the actual people without disease by the test giving that is C plus D is the total negative by the test So this is just horizontal A by A plus B D by C plus D whereas the sensitivity is A by A plus C or D by B plus D That is specificity Now let's take an example where the total population is thousand Out of them 100 is having disease 900 is not having disease. Okay So we have done a test in that 80 has given positives So 20 is Negative. This is a test result. Okay. Actually 100 is having disease So true positive is 80 then The false negative is 20 True negative 800 This is what the test has given and 100 is false positive But actually 900 is a total negative or healthy 100 is a Total cases, but the test is able to give only 80 out of 100 and 800 out of 900 cases and healthy respectively So total positive is 180 and total negative is 820 and total. So let's see one by one What is sensitivity? Sensitivity is nothing but A by A plus C that is 80 by 80 plus 20 100 that is 80 percentage and specificity is a D by B plus D That is 800 by 800 plus 100 that is 800 by 900 89 percentage So this particular test is able to detect 80 cases out of 100 cases and this test is able to detect 89 healthy people out of 100 healthy people So its sensitivity is 80 percentage and specificity is 189 percentage So now let's see the positive predictive value. It is a proportion of people with positive among the total positive that is 80 by A by A plus B 80 by 80 plus 100 that is 80 by 180 44 percent. This is a proportion of the Positively tested among the total positive or the cases among the total positives. This is a healthy people among the total negatives it is 800 by 800 plus 20 that is 98 percentage is an 80 predictive value and 44 percentage is a positive predictive value Now we have the percentage of false negative and percentage of false positive. That is C by A plus C and B by B plus D. It gives a percentage of false negative and false positive First false positive is B and false negative is C. So just take the denominator of disease and non-desist So this is an example you can try it out I have the answer with me So we need to find out the sensitivity, specificity, positive predictive value and anti-predictive value And this percentage of false negative and false positive. So sensitivity will be 40 by 140 Specificity will be 9840 by 9860 Then the positive predictive value will be 40 by 60 then negative predictive value will be 840 by 9 940 So here you have the answer. Sensitivity 40 by 140 specificity 9 840 by 9 860 false negative is 100 by 140 false positive by 20 by 9 100860 positive predictive value is 40 by 60 and this and 100840 by 9000 So this is a mathematical evaluation of any test Ideally speaking sensitivity and specificity should be 100 or close to 100 Okay, so less than 90% age won't be much accepted So That is all about a screening The only thing is you need to be very thorough with these false positive and false negative True positive and true negative and nothing but the cases and healthy people and how we calculate the sensitivity specificity And never learn this A, B, C, D Always try to understand the concept and Then apply it. So you won't remember you won't forget it for a very long period So if you understood this topic of screening, I'll come up with a new topic in dentistry and more. Thank you


The conflict between Zelensky and Zeluznyi has split the Ukrainian army into two parts. President Volodymyr Zelensky is allegedly bypassing commander-in-chief Valery Zeluznyi in communication with some military commanders, complicating the latter's ability to fully command Ukraine's armed forces. Ukrenska Pravda reported, citing anonymous sources. The report comes amid speculation in Western and Ukrainian media about alleged disagreements between Zelensky and Zeluznyi. The alleged dispute came to the public eye following Zeluznyi's up-ed for the economist in which he offered a sobering view on the war. Instead of directly communicating with Zeluznyi, the president maintains parallel communication lines with chiefs of some military branches, such as ground forces commander Oleksandr Sirysky or Air Force commander Mikhail Oleschchuk. Sources told the news outlet. Zeluznyi allegedly receives information from his subordinates only at the Supreme Commander-in-Chief's headquarters meetings. There is an impression that Zelensky has divided the armed forces into two groups. The good one commanded by Sirysky and other favourites and the bad one subordinate to Zeluznyi, a person from Zeluznyi's inner circle, told Ukrenska Pravda. This greatly demotivates the commander-in-chief and, most importantly, prevents him from commanding the entire military. Ukrenska Pravda's sources claim that Zelensky sometimes makes decisions in military matters guided by political reasons.


Hello everybody and welcome to another hobby cheating video and today it's time to get dirty down The strict technomancer that is Vinci V. Let us get to the technique and learn it Vinci V style Yes today, we're gonna be talking about dirty down weathering products specifically We're going to be looking at rust Vertigree and moss so these are the three original products that they launched with they do have some others now But these are the three that I know really well today We're gonna take you through how to use these products how to get the most out of them and most importantly some advanced techniques Where we combine them with some other traditional miniature paints and products to really achieve some awesome effects So let's head over to the desk. Let's get rusty All right, so we're gonna hit as I said three dirty down products rust vertigree and moss We're gonna do them in that order all three of these are really really fun products And I really like the way they integrate in first word of warning You have to shake the living bejeezees out of these before you start I use my mixer, but a really really good shake Second piece of advice is use like a dry well palette something like that and get it out to work on It'll just make your life a lot easier than trying to dip your brush in that bottle so Each of these actually works a little differently. Let's talk about rust first So with the rust so this is the brown rust. They also have a yellow rust which I haven't I haven't tested yet So I can't speak to that one, but with the brown rust You really want to get in there and get some pretty heavy applications as per always with these you want to focus your attention on the things where Where rust would naturally gather so here? I'm working around rivets and in places where like the lower sides of these circular things where water would naturally run to and then build up and oxidize the metal so recesses rivets All these kinds of places right Anywhere where their oxidation would naturally occur And you just kind of let it be you have to kind of glop it on there pretty heavy And then just kind of spread it around a little bit Now let's watch it dry. This is a pretty magical process Because as it dries over Let's say about two minutes. I think of time this actually represents Over this period as it dries it really does turn into this wonderfully natural looking rust But the thicker it is the more sort of it becomes the problem is that's not how rust works It isn't just like some You don't have like perfect steel on one side and then it immediately becomes full rust And I see people mess this up, but we don't have to this stuff is water-soluble It's not meant to be applied like that and then you stop so instead. I have a clean dry brush Just some water and then I'm sweeping it around working picking at the edges and By doing that. I kind of spread it off soften the edges. You kind of feather it out once it's dry And that's what's really awesome about this product It stays workable really for quite a long amount of time after you applied it And so you can remove it you can weaken it you can feather it and With the the brown rust that's a very powerful tool because it effectively is gonna tint the rest of the metal I can get it wet I can wipe with my finger if I want to clear something away good to go now vertigris Vertigris is a little bit different when you first put it on and when you see It here as I'm as I'm applying it you're probably like what in the heck is this that is not vertigris That looks like Christmas green color okay With the rust you want to go on pretty heavy With the vertigris it actually behooves you to kind of go on fairly light You can do a heavy application, but then it'll look a little older a little darker If you're looking for that sort of traditional light Vertigris color you actually want a relatively light application of the vertigris So you can see here again Let's let it dry over time and you can see how as it dries naturally over time What you end up getting is where it's quite thin You will get that very light blue green color Of the vertigris emerge quite naturally where it's quite thick and It'll be much much darker So my advice to you is think about the type of vertigris you're gonna have what additional steps you're going to utilize and so on Now you can also reapply it with light touches over top like if you just kind of dab around Afterward it will then lighten up and you'll get some lighter versions of the thing Unlike rust the vertigris won't as easily sort of spread out Is what I would say It will tend to be a little less. It's a little less reactive to this kind of feathering technique like you can do with the rust You can still lighten it up. You can still erase it. That all works. All right, lastly the moss I'm just gonna use his feet. I don't have a base here. Normally moss abuse and something like base But we'll assume he's just been walking through a jungle and his feet are all mossy You know, that's why not right the moss effect. I really love it's a very natural moss effect And and this one just really combines with a lot of other things for bases and stuff like that If you want to ever have sort of naturalistic vegetation in scale I actually think this is one of the best products around to create that on rocks and stone and basing and stuff like that But I just wanted to show you here what it looks like and then once again Let's just let it dry you can see it goes on this one goes on the tone is relatively correct in the green But as it dries it really lightens up Quite a bit And and becomes very very matte and it just really has this very natural mossy like appearance So there we go the moss all dry on the feet We've got some nice rusts spread out and feathered all over the rest of the leg And you can see now how the rest of the vertigris dried and we get that very natural nice effect there With all this set. I really do like how this looks. I think you're good at base All right, so now you can see that just with the product alone and then the reactivation and using regular water We can achieve some really cool things. However, we can do a lot more the simple fact is by combining this very powerful weathering product with other Traditional things we use for weathering. So this would be pigments or acrylic normal acrylic paints or even Contrast paints we can achieve some really cool effects So now we're going to look at how we can sort of mesh these two things together and how awesome we can make our minis look All right, now let's have some fun Let's get crazy. So here. I just have some dry pigment This is from Vallejo and I'm just smashing it all around into the cracks and into crannies and again places where rust would naturally gather and water would Deposit and oxidation would occur Rivets and recesses are always your guide I've talked before about how you can take pigment and then just swoosh it around with water But this time instead of using water, I just blew that's just blowing off the excess off camera We're going to use the dirty down and I'm going to lay it straight over there this is actually a fun way to add even more texture and Sort of additional mass to it. You can go heavier than I did you can mix the pigment directly into it As long as you don't if you put in too much, you'll stop the effect So you got to be really careful there, but you can sprinkle a little bit in and that's fine So if you actually want physical texture, this is a great way to add that and make the rust even heavier This leg we're going to do real rusty. So once again the same thing as you're swooping it around You will get into that pigment that's still hidden there and reactivate it and it'll get all mixed up and Tint all of the surface So if you're going for sort of a heavier rusted thing some, you know, Nurgle or chaos Just junked out machine or some rusted hunk on the on your base. This is a great way to go So the other thing we can do here Is we can reapply multiple steps.  I want to be really really rusty I can then go back feather and sweep the edges of that again and once and you know get a good effect But by building it up layer over layer You can actually get these areas of really really intense rust where it looks like the the steel or whatever material is Just you know, it's a complete it's oxidized all the way through Now contrast paints here, I'm using agarose dunes I don't know how to say that word but you can use any of the contrast paints any of the browns or oranges and stuff like that Will work really well. So instead of feathering it out with just water I'm going to reactivate it and feather it with the contrast paint This is my favorite way to make something really really rusty Because then it mixes with that and you get these really natural transitions between The actual dirty down heavy rust and then what feels like the patina of the light rust and you can do this over a couple different applications You can you know sort of contrast over the things smooth it out feather the edge go back in apply a little more contrast over the whole area Reactivate and smooth again apply a little more dirty down like this really works Well, and it's sort of like back and forth and once again once you've reactivated it with the contrast paint You can still wipe with your finger wipe with a brush and so on Now we can also go a little heavier. I apologize this part fell just slightly out of focus I had to re-record all of this multiple times it kept failing and was really making me angry But here I'm just going to use Rhinox hide and instead of smoothing out the rust I can Reinforce the rust so in the areas of heavy rust I can stipple and dab stipple and dab some Rhinox hide into there to show areas of really dark brown rust in the same way I can then grab some orange paint so some like rusty orange paint and I can then fill that out where it's Yeah, super duper heavily rusted so right along edges on the actual rivets themselves On any of those edges again where water would gather I can do the same thing with the vertigree color grabbing a lighter color vertigree and Then just sort of dabbing along the edges along recesses where the vertigree would be more intense or heavier To reinforce that effect so in either case you don't have to stop With just what that effect gives you you can paint around it drawing the color out Or you can paint on top of it to intensify the effect whether it's additional orange or additional vertigree I can then also smooth the connection by doing streaks very light streaks with the vertigree So whether it's the rust color or the vertigree color or anything like that You can also just run simple streaks and use this as a streaking medium either way you get an awesome effect So there you go you can see how no matter what you're going for whether it's Light rust up to you know something. That's a truly Nurgleized rusted hunk of junk Using these various techniques and these products can be really really really a great tool in your arsenal I have to say the dirty down products. They are a little expensive, but I do think they're really awesome The effect you get is rather unique. It's super matte It's super credible and in my mind it really really combines well with everything else we already use To make really really awesome looking weathered rusted Beat up Miniatures. It's also great for things like bases and stuff like that too So don't sleep on those opportunities today. We focused mostly on the miniature But of course when you're doing mossy bases or old things that are sitting out and ruined under your miniatures This can be an excellent product for that as well So thank you very much. I hope you enjoyed this if you did hey give it a like Subscribe for additional hobby cheating in the future. We have new videos here every Saturday If you want to support the channel, it's as easy as sharing it with someone telling someone about it I really appreciate that but you can also click the link down below. There's a merch store where you can buy products There's also a patreon that patreon is focused on review and feedback and taking your next step on your hobby journey as Always though, I thank you so much for watching this one and we'll see you next time


Tyler, one one here today, how do you sum that one up? Disappointing, was expecting to get three points at home, these are the games we shall be winning really. So yeah we're very disappointed tonight, walkway over point but it's not really ideal, we need the three but we'll move on to the weekend. It certainly is a frustrated feeling address for you, two points dropped rather than one game? Yeah massively, the first half killed us a bit. We stuck in there and managed to walkway over point but like I said before it's not ideal. But if you're not going to win the game at least don't lose it and that's what we've done so.  Yeah good, I've always been ready keeping, make sure I'm ready when my chance comes again. So yeah I was ready tonight and thankfully I got a goal. Talk about when your chance came, came tonight and you took it pretty well I think. How would you under top us through that? Yeah and I've seen Chappy out wide and I just thought like this is me, get across the centre off and that's what happened. You put it across and there left foot goal. I work on them day in day out in training so I know if I was there in them positions it's a good chance I'm going to score. And how nice is it to see that hard work pay off and be proven in the game? Yeah it's always pleasing for the hard work to be paying off with the goals hit in the back of the net. So yeah like I said on a personal note I was happy to get a goal and rescue up point but we needed the free but we'll keep it moving. Quick turnaround game again on Saturday, how important is it to use that frustration and try and push us on to get the three points? Yeah massive we need to go there and get three points. We need to put the wrongs today right on the weekend and make sure we're on our game and walkway over three points.


Long queues are now being noticed in a few filling stations in Accra, the Undosted Capital. While many filling stations are under lock and key, are still not dispensing petrol. Plus TV correspondent Akim Lawal guarded that the scarcity was caused by a power tussle among members of Newpeng and has now left residents groaning as the scarcity has grounded social and economic activities. The federal government has urged the federal government to please find a lasting solution to the perennial fuel scarcity. People have been here as early as 5.30 in the morning, trying to buy fuel and the queue is still long. Many people are still trying to get fuel. Many don't even have hope. Now, some other filling stations that you still get, like one filling station, I would like to mention them yesterday, they sold for 200. I've been here since morning, so since now I've never collected any fuel. So, what I've said earlier is that I want, I will appeal to the government to do something. You know, people are suffering now.  Many people are supposed to be at the same, I mean, in their working places now. But now, they are in the filling station. They are telling people here, they have light, they just went and put it off. We're just even telling them what is happening and they have fuel here. This is the serious problem in this country. So we are begging the government to come and intervene to those people now, to come and see what is happening here. Two grandmany queues here, people are, they are ready to work now. These are the people, they are ready to work, to feed their family. Nothing to do. Nothing will happen. It's very, very unfair. So please appeal to the authority people to come and visit those people right now. So you get notified about fresh news updates.


Have you ever thought I want to become a healthcare professional, but I don't even know where to begin? If so, then this series is for you. I'm going to be starting a new series called Who Wants To Be. In that series, I'm going to be going over various different healthcare professions, and you know, I'm doing this because there's oh so many of them. There's a ton of healthcare professions beyond just becoming a physician, a PA, or a nurse. So hopefully throughout this series, you'll learn about each of those professions and then you can make the best decision on which profession is right for you. So let's get into the video right now. So if you guys sit down and welcome back to my channel, if you're new to my channel, I'm a healthcare professional, I'm a physician assistant, and I work currently in trauma and acute care surgery. Since becoming a healthcare professional, I've realized that there are so many aspects of the healthcare world in terms of different jobs and careers that you can get into, and it was crazy because I was pretty tunnel vision and I was like, oh, I want to be a doctor, right? Or I knew nurses, and you know, I met a couple PAs, but I didn't realize all of the other professions that are in healthcare. And sometimes, you know, being a doctor or a nurse or PA is not right for you. And so that is what this new series is going to help you determine which profession is right for you. So the first profession I want to talk about is becoming a physical therapist. In this series, I'm going to be answering five simple questions for you. That is, what is the profession? What do they do? How do you become a part of this profession? How long does it take? And of course, how much do they make? All right. So let's get into the video, okay? If you haven't already answered it, take a look around. If you like what you see, go ahead and subscribe. So what's a physical therapist? Physical therapists are health professionals who help patients live a healthy and active life. They're kind of described as experts in movement because they help patients through prescribing exercises, hands-on care, and patient education. So what exactly do physical therapists do? So physical therapists work in tandem with other members of the healthcare model. So for instance, myself as a trauma PA, I work on a consistent basis with physical therapists in the hospital. A lot of our patients come in from traumatic situations where they have broken bones or they have traumatic brain injuries. And therefore, a lot of their function is either debilitated or lost. Because of that, we work with the physical therapists to help in the assessment and creation of a treatment plan that will work for what will help our patient get back to an assemblance of what they used to be. Now, sometimes that may need more physical therapy, right? So they may have to go to a rehab. They may not be able to do this at home, and they may not get all of the care that they need at the hospital, because it may be greater than the level of care that we're able to provide on a consistent basis. That is where the PT comes in to understand and to help us understand and to make suggestions on, hey, do they need to go to a acute care rehab or a subacute rehab or a long-term care facility, or can they do this at home? So essentially, physical therapists develop this plan to help improve the ability of our patients to move, increase their range of motion, reduce and manage any pain that they may be feeling, and then, of course, either restore function or restore some aspect of the function that they may have lost to help prevent any further disability. So how do you become a physical therapist? So to become a physical therapist, you have to have a bachelor's degree at first and then go to graduate school. A GRE is required for the majority of programs, but again, you have to look at each individual program to determine what their prerequisite requirements are. With that being said, it is important for you to go to PT CAS, because that is their central application site. It will have all the list of their participating programs and then through there, you can click on each program to figure out what the various different prerequisite requirements are. PT school is typically three years. It is a doctorate's degree, so you will become a doctor of physical therapy. There are bridge programs where you can do a three-in-three. So six-year program, you'll do three years of undergrad and then three years in your physical therapy program. In school, you'll have didactic year where you're just doing learning. You're learning about the body. You're learning anatomy. You're learning how the body moves. So like kinesiology, you're going to be learning all of those things in your didactic year and then you're going to be able to put it into practice in your clinical year. As I stated before, it takes about three years to get your degree in physical therapy, but there are various different program models. So you just have to go to their website. So that is apta.org or PT CAS, which is the application website to get a list of the programs that you're interested in so that you can see specifically how long their programs are and what you have to expect in terms of prerequisite requirements. Now let's get down to the money. So how much do PTs make? So according to U.S. news, the average salary of a physical therapist in 2020 was 91,000. Now that, right? I think that that is actually a pretty decent salary. Obviously, there are people who make more and physical therapists that make less depending on if you're inpatient, outpatient, private practice or part of a group, but ultimately the decision is yours in terms of if this is the right career for you. So who wants to be a physical therapist? Leave me a comment in the comment section below and let me know if you're ready to become a PT. If not, obviously there's still so many more careers that we have to cover. If you haven't already answered like this video, follow me on Instagram and on the PA and on Instagram at Get That to University. Thank you guys so much for watching and let me know what career you would like to see yet. Next, I'm thinking of doing respiratory therapists or even like occupational therapists or a nurse midwife. There's so many others guys, so let me know in the comment section below. Thank you guys so much for watching. I will talk to you guys next time.


Nitrates, concentrated in green leafy vegetables and beets, underwent a great makeover a few years ago from inert substances to having profound effects on the power plants within all of our cells, reducing the oxygen costs during exercise, meaning we can bust out the same amount of work with less oxygen. So one little shot of beet juice allows freedivers to hold their breath for over 4 minutes, they get about a half minute longer. For others, this improved muscle efficiency allows athletes to exercise a higher power output or running speed for the same amount of breath. I profiled this discovery in an unprecedented 17-part video series, the longest I think I've ever done. It's just so fascinating. But that was back in 2012. What's happened since? Well, this all led to many athletes, elite and amateur alike, consuming beetroot juice prior to competition. Well, what does the new science say? Well, most of the studies were done on men. It turns out it works on women too, even African American women, and even more neglected research demographic. Same workload power outputs using significantly less oxygen after drinking beet juice. But forget beet juice, what about whole beets? Cheaper, healthier, can find them in any produce aisle. But there had never been any studies on actual beets until now. Whole beetroot consumption acutely improves running performance. They gave physically fit men and women a cup a half of baked beets, which is equivalent to about a can of beets, 7 to 5 minutes before running a 5K. They started out the same, but during the last mile of the 5K race, the beet group pulled ahead, compared to the placebo group who were given berries instead. Though they were running faster, their heart rate wasn't any higher. So if anything, the beet group reported less exertion.  But if nitrates are so good, why not just take them in a pill? Nitrate supplements with names like Hellfire. Although they can work, their long-term safety is questionable. Non-vegetable sources of nitrates may have detrimental health effects. If we want to improve our performance, we should really ideally obtain nitrates from whole vegetables. The industry knows this. Instead, the market's an array of nitric oxide-stimulating supplements. However, there's little or no evidence of the performance improvement following supplementation with these so-called NO boosters. The evidence is with the vegetables. How much money can companies make selling beets, though? So how about a novel beetroot-enriched bread product? We've tried to get people to eat their fruits and veggies, and where has that gotten us?  And indeed, it worked. Red beet bread bought down blood pressures. Improved the ability of arteries to relax and dilate naturally? Bread, therefore, may be an effective vehicle to increase vegetable consumption without significant dietary changes because heavens forbid people should have to change their diet to improve their health.


I'm Chaplain Paul Guzman. I'm a priest of the Archdiocese of Chicago and I'm a reservist and I'm here today to bring the good news of Christ in Christmas to the men and women here on the USS Essex. With you and the unity of the Holy Spirit, God forever and ever. And it's a pleasure to do that. Our Lord has told us that we are supposed to go out to bring the good news to all peoples and all places and that even includes the high seas.  I'm here from Camp La Mignée and this is the least we can do for our sailors and men and women in the military and I'm here to bring them God's love and blessing. And Merry Christmas to everyone back home. I'm just a humble parish priest who was given the opportunity to come out here to serve our men and women in the military and it's a great honor to do that.


In this presentation, we will take a look at budgetary controls and reporting. In a prior course, in prior presentations, we took a look at the creation of the master budget, a static budget, and the components of the master budget. Here we're going to be focusing more on the flexible budget, but we want to review some of the components of the budgeting process and then go into those components more in depth concentrating on the flexible budget. For the budgeting process, we'll start off with the creation of the budget. We're going to have to compare the actual numbers to the budgeted numbers. So we're going to create the budget, of course, then we'll have the actual period we'll run by, the time period, the month, the year, then we'll do the comparison. What did we expect to happen in the budget? What actually happened? What are the actual numbers? We'll do that comparison, then we'll analyze the differences and then we'll strategize. We'll look at the differences, of course, the variances, and then we'll strategize.


It's an honor to speak with you all and to give God thanks for the blessings of freedom and to the heroes who really have this tremendous courage that you do to defend us and to defend freedom. So we want to thank you all very much, very, very special people.


So We're gonna do a high definition high quality Cartoon here only using the mouse in the mouse pad So without further ado, let's jump right into this video First thing you want to do You want to find a picture you want to use You want to drag and drop that thing drop the opacity down We got it down just good enough we can See all the detail Say about right there, then you want to lock that layer create your new layer right above it Now to keep from making this a super long video I'ma just show you guys the technique I use first and then I'm a time lapse the video So what you want to use is You want to come over here to your brush?  So I'm gonna just stretch it out to it. Give me some sharp looking points make sure This is locked with this black color to the top and make sure the bottom one is locked Okay, we're gonna zoom in a little closer. So why this is still selected You want to come over here To this drop down menu Then you want to click new brush Then you want to click art brush. Do you want to hit okay? And now you want to come down here. Do you want to click okay again? Come back to your brush tool and now we just got this brush we just created You know what I'm saying So that's the brush we made for our mouse Another thing you want to do You want to double click onto the brush? Then you want to bring your smoothness all the way up. Do you want to hit okay? I was gonna zoom in on our picture And what you do is with a steady hand You try to go as slow as you can so you get more control Then you just want to follow the line As good as possible And instead of trying to start right here like that We're gonna overshoot our lines I'm gonna wait. I want to bring the size down on this first.  Let's try to get as best as we can See it's a little more time consuming when you're using your mouse But it can be done and now that we overshoot these lines. I'm gonna show you why we did that Let's highlight all the lines together expand appearance Then on your pathfinder you want to click divide So now We can go to this white selection tool And we can delete The lines we overshot just by hitting delete twice Just help this Make some clean sharp line work. You feel me So we're just gonna do that process throughout the line work. So now i'm finna Time-lapse this so we can speed it up a little bit let go And drag that color gray on top of our line work Then we're gonna right click the color gray and send to back Then we're gonna select everything together Then we're gonna click merge So we make the gray become one with the line work Right click the gray go to isolate select group all the gray we don't want Only place we're gonna keep it It's inside the eyes And what a hair supposed to be now we're gonna Sample this color black. I mean we just gonna click the gray my bad Select the gray By holding shift You select all the gray area All the gray Our dropper tool tired picture again We're gonna go to expand the pants and then we're gonna click Merge on our path find us or all that can become one line And what we finna do is go ahead and go to our Pencil tool double click onto your pencil tool make sure your settings Look like Move your smoothness all up on your all the way to the top on your pencil tool Make sure your color is at the top and the bottom on this lock Now we finna zoom in to find the detail. All you do is You try your best And just trace it try your best to trace it with your mouse You see how i'm tracing the outline of the eyebrows Now what we finna do is we finna make a copy Of the line work so you wouldn't want to drag it to this blank sheet of paper Lock the top copy Find you a base tone to start out with for the skin tone You want to right click the color go to arrange send to back You want to highlight everything? Then you want to click merge on your pathfinder Right click the color again go to isolate select group and now we get to Delete that outer color because we don't need it.  It's the color of the eyes White and we made a base color layer by dragging it to this blank sheet of paper Then you want to lock the bottom copy turn the eye off go to the copy in the center And hit this drop down menu You want to stroll down? Till you see the last black line work Lock all those layers Or the black line want to close it back Now what we're going to do we're going to delete the skin tone out of this layer But we're going to keep the eyes and the lip color So just delete the skin tone make sure We get all the colors It's trapped inside the hair that bottom color back color layer And the color layer with just the eyes you want to go to your pencil tool And i'ma i'ma shade this entire picture just using my pencil tool So all I do is I start with my dark shadows first And then I place all the dark shadows where I need to go And every time I go lighter with my shadows, I create a new layer And I the lighter I go I put that new layer under the the layer that's darker than the one that i'm adding So I start with my dark tone as I put all my dark tones on on the picture I go a little lighter And I I put every every time I go lighter.


Good morning and welcome to the 14th meeting of the Public Audit and Post Legislative Scrutiny Committee in 2019. We have received apologies from Anas Sarwar this morning. I would like to welcome David Stewart who is attending in his place. Item number one is the decision on taking business in private. Do members agree to take items three, four and five in private this morning? Thank you. Item number two is Audit Scotland planning for outcomes. I would like to welcome our witnesses to the meeting. Caroline Gardner, Auditor General for Scotland, Fraser McKinlay, controller of Audit and Director of Performance Audit and Best Value from Audits Scotland. The Auditor General won't be making an opening statement, so we're going to move straight to questions and I'm going to ask Alec Neill to open for the committee. Auditor General, can I start with a general question? I refer you to Exhibit 1 in your report on page 3. There are 11 national performance framework outcomes, which the public sector and its partners work towards. The first one is grow up loved, which then goes on to say safe and respected. The third one is creative and diverse cultures and so on. Let me take grow up loved. How on earth do we measure that? I think I should start, convener, by saying that clearly the national performance framework and the outcomes in it are owned by government itself. As the committee knows very well, it's not my job to comment on policy. My view is that it makes perfect sense for any government to be aiming to set more strategic, longer term outcomes for the services that they provide, for things that the Government can do rather than focusing on inputs from the number of nurses or police employed in public services. The Scottish Government has been notable for its ambition in the outcomes that it has set for itself over the past 12 years now since the original national performance framework in 2007. Having said all of that, you're right that it's important that not just setting outcomes is the be all and end all of the national performance framework but that the Government has a robust and consistent approach to planning for how it wants to improve those outcomes through its own actions, through those of other public bodies and through the other ways that it can influence and leverage things that will have an impact on the outcomes. The briefing paper before you today is called planning for outcomes because that's what I think our interest is in, whether we can look at what Government does and see a clear line of sight between the outcomes set out in the national performance framework and, for example, the strategies that it's developing, the legislation that it puts forward, the money that it's investing in both capital and running costs of public services and all the other things that Government do. The two that you've pulled out are the higher-level, more less tangible outcomes, if you like. The Government, I hope, will be in a position to articulate how it's doing that, and I'm sure that it would point to things like the care review for looked-after children as part of that. Our paper is setting out the challenges of making sure that its approach is more consistent and more embedded in everyday policymaking, resource allocation decisions, performance reporting and monitoring. Let's take the example of looked-after children. We can measure whether they are getting well-looked-after. We can measure particularly in later years what their destinations end up being to see if they're ending up in the employment market with as fair a chance in life as everyone else. We can measure their educational outcomes. We can measure their health outcomes. How do we measure whether they've been loved? You're right that some things are easier to measure than others. One of the things that we say in the paper is that an outcomes approach, particularly the way that the Scottish Government is implementing that, means that they need to be more innovative and perhaps take more risks in a managed way, not just in the ways that they plan to improve outcomes like the one that you've pointed to but also how they measure them. We talked towards the end of the paper about the importance of asking in this case children themselves what their experience is as part of the measurement framework. It's not the only part, but I think it is another part that's important, particularly for the sorts of outcomes that are included within the latest national performance framework. If you take children, for example, growing up and you want to audit whether the Government has achieved its aims and outcomes in the national performance framework, how do you measure them? I realise that one thing that you can look at is the opinion of children, but we don't. Children can't tell you if they're more loved than their predecessors or less loved than their predecessors, therefore we don't know if we're measuring progress or regress. How is an auditor, do you measure whether the Scottish Government can improve love? Our starting point is to look at whether the Scottish Government has set out for each of those outcomes, first of all, how it plans to improve them, and secondly, how it will know whether it's succeeding or not. As we say in the paper, that means that it needs to have some baseline information, it needs to understand what the gaps are in that and it needs to be going through that cycle of setting how it plans to measure what's improving or not, doing that and then tweaking its plans as needed. That performance framework is now 10, 11 years old, so surely in the last 10, 11 years they have defined how they measure whether they're achieving greater love or not? I think that that particular measure is a new one in the latest version of the national performance framework, which, as you know, is now set out in legislation. More broadly, as we say in the paper, we've seen some examples of good practice, but equally, we think that there is room for it to be much more embedded in policymaking and performance reporting and that, although there are examples of good practice, that's not consistent. Do you not agree that if you have meaningless guff like this, it's going to destroy any exercise of any credibility before you start? I completely agree that the value of having a national performance framework is not in setting the outcomes, but in doing the underlying work, which is about planning for how you expect to improve them and then monitoring whether that's happening or not. For some of those outcomes, it's definitely more challenging than for others. I'm going to bring in Willie Coffey.  Thanks, convener. It's sort of continuing in the same theme, and it's really to ask you, Caroline, who, if anyone, is doing any work to try to make sure that targets or outcomes are meaningful for us. It can be pretty aspirational on one side, and it can be very prescriptive on the other, where we demand that something is reduced by a thousand, by such and such at a time, no specific targets. Who's doing any work to see whether the targets will have given ourselves collectively are actually achieving anything for us and achieving the outcomes that we seek? Is there any work being done to try to review and refine this sort of process? Are you the person to do it, or should it be government? I think it's for government to do it, but Fraser's been involved in the work that's under way at the moment, and I'll ask him to pick that up. Thank you, Caroline. There's a lot of work going on at the moment, Mr Coffey. Indeed, last week saw the publication of this report, Scotland's Well, being delivering the national outcomes, which was the first report of its kind, which is trying to pull together not on individual outcomes but a broad sweep, if you like, of progress. It's being made against the national performance framework and the outcomes, taking Mr Neill's point that, in various iterations, that has been around now for some time. Particularly in this latest iteration, which was launched last June, a lot of work had gone into looking at not just the outcomes but the 81 measures that sit underneath those outcomes to make sure that they are meaningful and that they are telling us something. There's absolutely no doubt, just to pick up Mr Neill's point, that some of that stuff is difficult to measure. It's difficult to audit. It takes us into territory of hearing stories and personal testimony from people and recognising that as legitimate evidence, both for measuring progress but also for us as auditors. We have dipped our toe in that water. We did a report a couple of years ago on self-directed support, for example. A lot of that report was based on us going out and talking to people who were receiving services in their homes and getting a sense of how that was going. That, in itself, isn't enough for us. We would always need to, in the jargon, triangulate the evidence with more quantitative stuff. I do think that, bearing in mind that this is a joint Government and COSLA enterprise in its latest iteration, there's a lot of work going on to make sure that underpinning the 11 outcomes, which are, in a sense, a statement of intent, aspirational, as you say, that we can have some sense of progress. I think that our challenge, as Karen Lyon says, to Government and councils and all partners, is that too often we still find good and strong statements of intent and vision but not enough of a plan as to how they're actually going to get delivered. Take, for example, supposing a particular target isn't made—and I'm sure that we could come up with a view—does anyone look at the people who didn't reach the target or meet the target or get the thing delivered on time and so on and so forth to see whether there was a positive or a negative outcome for them who missed out on our target? That's what I mean by do we review what the targets actually mean for us, because if there was no negative outcome for people who didn't meet the particular target, why have we got the target? That kind of review process in outcomes and target setting is that what's contained in that piece of work to look back at whether the targets themselves are appropriate. Shall I pick that one up? It's an interesting question. When things aren't going as planned or targets are being missed in, yes, I think that most of those will be reviewed. I think that what is tricky to come to your point, and this is something that we mentioned in our briefing for you this morning, is that the accountability systems around that are quite difficult, because almost by definition those things need to be delivered by multiple organisations and multiple people. I genuinely think that the days of saying that you were responsible for the delivery of that target or that outcome solely is quite hard to do these days. That can be very frustrating for the public, for you as you're doing your scrutiny work on those kinds of things, because it can be quite difficult to point to a single person that's accountable for the delivery of that thing. I think that our accountability systems need to catch up with an outcomes-based approach, because I also don't think that it's acceptable to say, well, nobody's responsible for it. That hasn't worked, we've missed a target, therefore it's some kind of systemic thing. We need to be sharper than that. But there is a tension in there, because I also see the opposite effect, which is accountability systems that actually encourage and drive people in the public services to do things that actually aren't necessarily in the best interests of outcomes or in the interests of their individual organisation. So there is a tension there that I think we need to surface and grapple with. That's very helpful. If I can try and draw an example of the point that Mr Coffey raises. I think that Anas Sarwar raised a question when we were looking at children's mental health as well, and he asked very specifically if somebody had counted and there was evidence of suicides by people who were on a mental health waiting list. I think that that kind of example goes to the heart of Mr Coffey's question, are there terrible outcomes for people whose government's targets haven't been met? That's something that the committee has touched on in different evidence sessions. I'm going to bring in David Stewart. Thank you, convener. Other general, your report mentions the importance of meaningful engagement with public sector workers. Could you provide some best practice examples of that, and I would refer members to my register of interests from a member of Unison? I think that we see examples of that on a small scale in most of the performance audit work that we do. For almost all public services, I think that the quality of the service that's provided depends on the quality of the interaction between the person receiving the service and the person providing it. And we see repeatedly really good examples where public sector staff, workers of all sorts, are encouraged to listen to what's important to the person they're providing a service to and to look at meeting their needs. We published a report a couple of years ago on self-directed support and there were some very good examples where people would sit down with a person with disabilities, listen to what would make a difference to them in their early lives and really think how they could use the money and the other resources at their disposal to provide very tailored support that gave people the best outcomes and helped them to develop their own independence. We also saw people who either weren't being encouraged to do that, weren't trained to do it or didn't have the flexibility themselves to do more than provide the services that the council already had available and the difference between those for the groups of people affected was like chalk and cheese. That was one of the key recommendations in our report that councils needed to understand better the approach being taken locally and to make sure people were trained, supported and had the resources to do what was needed and to listen to the voices of people being affected. Very often though we sort of see it from the other end from third sector organisations that we're talking to as part of our work and we do a lot of that engagement ourselves. So we spent some time as a leadership team within Audit Scotland talking to people from the weekly group about the way their housing services have got a, I think, yes approach where they're looking to meet the needs of people locally and where they can do that through the flexibility of the housing service itself or things that they can easily put in place. That can work very well. We were told of an example of a gentleman with very severe hearing problems who had the television turned up loud enough to the extent where he was disturbing his neighbours and the housing officer was able simply to buy a pair of wireless headphones that meant that he could hear the TV and the neighbours weren't bothered. Equally we heard examples where what was actually needed was some involvement from the health service or from social care services and it was much harder for the housing officer in some circumstances to engage the local public services in saying what is it that this person needs and how can we best meet it and it's that kind of consistency and flexibility and innovation that I think is needed to make a reality of this which takes us back both to the culture and the ways of working that we talk about in the paper and the sorts of evaluation that Fraser was talking about about listening to people and whether what matters to them is being delivered. Nobody's saying this is easy, it's clearly complex but those are the things that can make a difference. I think that these are some excellent examples and I think that although it's simplistic perhaps for me to say that people in the front line sometimes know best, I think that this is a tourism across Europe. Certainly the criticism and sometimes I find that surgeries and talking to the public is that you politicians and the general criticism that you would have come out with policies but you're not really talking to people in the front line and without making a party political point which of course we're not doing. If you take issues such as workplace parking, there's clearly some controversy among public sector workers which I remember as you know about issues like that. While you cannot let the general talk about the policy per se, is this a kind of example where talking to front line workers in the public sector or indeed the private sector first before developing policy would be quite helpful? Without getting into the specifics of the workplace parking levy proposals, I think that in general Governments tend to come up with better policies by talking to the people affected by them consistently not as a one-off consultation. The Scottish Government has made some serious commitments to that through its membership of the open government partnership, through the community empowerment legislation, through the approach to public service reform which is built on participation as one of the four pillars going back to the Christie report in 2008. Again I think that it's an example of where it's not the aspiration which is in question, but it's the consistency of following that through. There are some examples in other countries such as in America about looking at townhouse forums to discuss policies. I think that Mike Russell is looking at some issues around citizen forums and so on. Is this a development that you've perhaps picked up from other European countries that we could look at more carefully in Scotland? As you say, the Government itself is investigating lots of that. Fraser can probably give you a picture of what we see from some of that from the work that he's been leading. We see it in lots of different guises, Mr Stewart. The whole citizen assembly thing is clearly one version of that and we see lots of good community engagement locally. The challenge is getting that engagement much earlier in the process. As you know, I do a lot of work in councils and a lot of councils are very good at engaging with communities and service users when they themselves have an idea of what they want that service to look like. The challenge is involving people much earlier in that process and I would include staff in that. Before decisions are made, before proposals are made for consultation and the earlier conversation that says actually what's important to you, what really matters to this community. My experience is that when organisations do that, they are very often surprised that it's not necessarily the thing that they thought was going to be the answer. I absolutely take your point about very often the answers lying as close as possible to the front line service delivery, if you like. All outcomes in the end are local and to some extent individual. That's where I think the whole community empowerment and engagement agenda is obviously headed and I think that's the next challenge, is to do that much earlier in the process. Colin Beattie. I would like to link between money and performance. In the 2017-18 report on Scottish Consolidated Accounts, you recommend that the Scottish Government prepares a performance report that clearly links the financial resources outlined in the consolidated accounts. The briefing does discuss this and it talks about the Scottish budget should be clear about how spending contributes to specific national outcomes and we've talked about some of the difficulties of defining the national outcomes. You may recall that when the committee raised this issue with the Scottish Government as part of its scrutiny of the consolidated accounts, the Government indicated that it would include brief material in the consolidated accounts and signpost individuals to more detailed sources of information. What's your view about that proposed approach? You'll be aware that all of this work is rooted in the recommendations of the budget process review group, recognising that making a reality of the national outcomes means investing money and other resources and that we need to be able to track how that's doing to either continue investing or reinvest somewhere else if it's not having the desired effect. We are very clear in Audit Scotland in line with the budget process review group recommendation that there needs to be a much clearer link at both the budget end of the cycle and the financial reporting end of the cycle with performance, with the outcomes that the Government's planning to achieve and how well it's doing in practice. We're also clear that that's not a simple thing to do. It's complicated for a number of reasons that we outline in the paper. I'd be very relaxed about the Government's signposting in its financial report to the information that is held somewhere else. It's always a challenge to make sure that financial reports are accessible to readers, that they're not overburdened with detail and that the high-level messages are clear and apparent to readers. My concern would be that the signposting was clear and that's easier to do these days with technology allowing you to make very direct links to different sources of information and that the information that it was linking to was fair and balanced and rounded. We give an example in this paper of where the Government's reporting of its performance can sometimes highlight the positives without highlighting the things that aren't working so well and that obviously has the effect of limiting parliamentary and public scrutiny and making it harder to stop doing the things that aren't working and reinvest in things that are more likely to have the desired effect on outcomes, but the approach that sounds fine to me is the detail of how you implement it to make it accessible and make sure that it is giving you the rounded picture that's needed. Just expanding on what you've been saying there, do you think that approach is sufficiently transparent on how spending is directly leading to improved outcomes? I think that it is as long as the other parts of the package are in place, so if the budget is very clear about which outcomes financial investment is intended to improve and how it's expected that that will happen, it's quite straightforward at the end of the financial reporting cycle to link back to that and say, this is what we expected to do and link forward to this is how it worked out in practice, but it does need to make that link across the whole budget cycle and, as I say, the information does need to be rounded rather than selective and simply pulling out the things that are working well. It needs to show the whole picture. Fraser McKinlay wants to come in on this. Thank you, convener. It's just on that point, Mr Beattie. I think that the budget process review group got a point of saying that trying to identify specific budgets for each of the 11 outcomes is a difficult and probably not terribly helpful task because of the interrelated nature of them, and I absolutely signed up to that. Having been involved in some work some years ago to try to do that is difficult. What isn't good enough, though, is that if you take the children and young people's mental health report that the convener mentioned earlier, we just don't know how much money is spent on that. We couldn't tell you, and that's just not good enough, it seems to me. It seems to me that we should, and I think that this is the direction of travel, rather than trying to do it as an abstract exercise of what's the budget and what are the outcomes, a more practical taking a plate, a thing like children and young people's mental health, figuring out what the collective resource is that's being applied to that, and you could pick any other numbers of topics that we've reported on over the last few years. I think that we had a similar discussion about economic growth and trying to figure out how much money was actually being invested in economic growth, and we just don't know. That, for me, is absolutely critical, because if you don't know—for example, this report that was published last week on delivering the national outcomes is a good report and gives a very good picture of progress—places that we're doing well, places that we're not doing so well, but money doesn't get a mention anywhere in this report. We need to be better at joining the two things up, for sure. I think that, as Caroline says, there are lots of different ways of doing that, and it is going to be difficult to get a single bit of paper that sets all that out for people, but it seems to me a big gap, because, apart from anything else, it's quite hard to make a judgment about, well, where should we be investing more money? Part of this conversation has to be about shifting resource from one place to another to make a bigger difference in the delivery of outcomes. I was actually about to come back to those comments previously about the complexity and the number of different elements that come in to achieving a particular outcome. Is it actually possible, in all cases, to be able to identify the stream of money that's going into that particular service or whatever to achieve that outcome when there are so many bodies looking at different aspects of it and putting money in in different areas? Would it not be a case that you get to the point where you're tying yourself and not trying to figure out where every pound is going? Yes, I think that you do get to that point eventually, but I guess that my point, Mr Beattie, is that we're miles away even from starting that process. There's somewhere in the middle, I think, between not really knowing and spending forever trying to tie down every individual pound and pence and where that came from and who's responsible for it. We're not expecting perfection in any of this, but I do think. As we say in the report, the money is a means to an end. It's about allowing Government and their partners to make decisions about where we should be investing the money and, in the absence of a decent understanding of how much we're spending on things in the first place, that's a very hard thing to do, it seems to me. Given the work that's being done by Orbit Scotland, would you say that it should be possible for the Government to identify at least the broad stream of money that's going into that particular area and to measure the outcomes directly against that, given the fact that there's anomalies and gaps where other entries and so on are spending money into that as well? So it'll always be a flawed process, but what we're looking for is just the general thrust. Is that crudely correct? Yes, in short. We find ourselves doing that quite often in our reports where, in the absence of available data about spend on a thing, we do some analysis. It's based on assumptions, and as long as the assumptions are reasonable, it gives you something to work with. Fraser McKinlay has touched on the point that I wanted to raise, so I'm going to come in with it now, but it's on the point about data. The committee has looked at this across a number of your reports, Auditor General, and I raised that with the First Minister at the convener's group with her just a couple of weeks ago. I think that the most stark example of this, Fraser McKinlay just said, was the children's mental health report, where we discovered that we had no idea about how much in total is spent on children's mental health. There was no data on the outcomes specifically, and there was no data on why referrals to children and adolescent mental health services were rejected. Where there was data, it didn't seem to be consistent across the 14 health boards. It didn't seem to be shared in any way. We've also discovered, in self-directed support, that there is a lack of data. Very worryingly, on the early years and childcare report, you told us that there was no business case made, despite the fact that there were huge amounts of public money going into the increase in hours for childcare, but no kind of sense from the Government of what that was expected to achieve in terms of outcomes. Those are three examples. I suppose that my question to you is, is it even more widespread than this? Given the era that we're living in of big data and evidence-based decisions, can you give us a sense of where the Scottish Government is in terms of making evidence-based decisions with our money? That's a really important question, convener, and very timely, given that the approach to information is moving away from the need to collect it as a separate thing to it being generated by the things that we do in our everyday lives. You can see that in the way that the unbuses trackers work. They know where the bus is, and you can tell when your bus is going to arrive. We don't seem to be using that approach in public services. I'd pull out one more very important example to the handful that you've given us. I've reported a number of times about the slow progress that is being made with the Government's 2020 vision for health and social care, of helping people to spend much more of their lives well cared for, healthy, happy at home rather than relying on acute hospitals for their care. However, most of the data that we've got about health and care is still about acute hospitals. Most of the political focus is on what's happening to the amount that we spend on the NHS and on waiting times for acute services. There are big gaps in some of the basics around health and care in the community. We're just finalising our work on the primary care workforce planning, and the Government doesn't have good information at all on the number of GPs around the country and the amount of care that they're able to provide. Without us knowing that, it's very hard to be able to genuinely plan for how you can avoid hospital being the first resort rather than the last resort for people who are just about coping in the community. Those gaps are things that ought to be relatively easy to capture. We ought to have better information about how long people are waiting for GP appointments, for how much primary care practices are able to avoid people being admitted to hospital unnecessarily or to get them back home again quickly. As part of making a reality of the outcomes approach, an important question for Government about how it is using data and digital capability in exactly the way that you describe to get more nuanced and more real-time data about what's happening across the country rather than relying on the old approach of quarterly data collection and publication, we can move well beyond that now, and that's not built into the outcomes approach well enough yet. Your report says that the Edinburgh Parallel Computing Centre and the Scottish Administrative Data Research Partnership are doing some work at the moment on data to see if we can match with the performance framework outcomes. Do you know how far advanced that work is? I think that Fraser can tell you a bit more about that, and it's worth noting that that's a big part of the Edinburgh city region deal is making it a digitally enabled area. There's work and way, Fraser. I'm not sure that I can tell you much more about it, if truth be told, but we can certainly follow up in writing convenient if that would be helpful. I guess that that's an example. There are others that Glasgow University has called the Urban Data Centre, which does similar kind of work. As well as the issue of the gaps in our data and understanding in some you would think pretty obvious places, it's also an issue of the data not being terribly well joined up and people having access to different sources of data and making sense of that at a level that they can really make a difference in terms of the outcomes. I know that that perhaps sounds a bit techie. I just think that it's such an important point. I think that in 20 years' time we're going to look back and think that we were just putting a finger in the air to decide how much money is spent on certain initiatives in the public sector without the evidence to back up. There's even a front page article in The Herald this morning on exactly this, that the EU commission has withdrawn money from our public services in Scotland and it said that Skills Development Scotland do not have rigorous enough controls over how the money is spent and what is achieved with it. I think that that goes right to the heart of the EU commission of obviously decided that there is no evidence of outcomes in the money that's being spent in Scotland so they've actually just taken it away. Would you like to address that point, Auditor General? The committee will be aware that we've reported on problems with the management of EU funds, both the structural funds and the agricultural funds in recent reports on the Scottish Government and we'll pick the detail of that up again in the report that's due to this committee in the autumn. In general terms you're absolutely right that that chain of money from Europe through to the Scottish Government and on to the bodies that spend it is very important in accountability terms and the money is there for a purpose, as all public spending is. I'd like to pull the frame back and say that we're not talking about just funding that comes from Europe for particular purposes or just new announcements from government, the money that's focused on reducing waiting times. We're talking about a budget of about £42 billion a year now and the way all of that money is spent is crucial to improving outcomes or not. What Fraser and I are saying is that we'd like to see a much clearer line of sight for how that's intended to improve outcomes and obviously we need the data for whether that's working or not so that we can find soon and make adjustments as needed. It's maybe a bit of a wake-up call for us that the EU commission has decided that Scotland's clearly so poor at evidencing how that money is contributing to outcomes that they've just decided to withdraw it altogether. It maybe gives us a wake-up call for that in the rest of our spending as well. In principle you're right, I think it's a bit more nuanced in the picture you've described. I think that the funding is in suspension and in interruption, which are technical terms that the EU uses until it receives the assurance that it needs, but absolutely in general terms Government, to make a reality of the national performance framework, needs to know what it intends to achieve with the funding that it provides and whether that's happening or not. It's really related to the same point and very briefly I would say that despite a commitment to an outcome-based approach that we're reading about, one of the things that comes from your report is that performance still seems to be measured on inputs an awful lot or certain areas of the public sector are measured on inputs rather than the outputs and the outcomes. Politically, is that going to change? A difficult question to ask us when it, I think, you're right that it is in some ways a very political, both small p and big p problem. I think that the Government's approach is the right one. I said in response to Mr Neil's first question that whatever you think of the individual outcomes in the national performance framework, it has to be right for Governments to be focusing on the big challenges that their countries, their societies face and how they intend to tackle them. Those challenges tend to be long-term things that require that joined-up strategic approach. There's widespread consensus that the approach is the right one and, as we say in the paper, there are real challenges to making that a reality. Making the commitment in some ways is the easy step, the hard one is doing the long-term difficult work of actually improving the things that the Government has set out as its aspirations. One of those challenges, no doubt, is politics. I think that if I sat down with every member around the table there would be broad agreement around most of the outcomes in the framework around people being healthy and active, around us being well educated and the things that lie in there. On a Thursday lunchtime at First Minister's Questions, the challenge is to come back to the short-term things that are not working well and will, under any Government of any complexion, rather than progress towards the longer-term things. I think that it would be better for everybody involved whether there is a clearer line of sight, a direction of travel between where we are today and where the outcomes are. I think that that would make it easier to focus on the long-term changes that the Government is looking to see as a country. Equally, there is a role for politicians to us themselves about where the balance of advantage lies between today's political advantage and the longer-term changes that individuals and parties are looking to see. Thanks for that. I appreciate that it is quite a difficult question for you to answer. It is just on the same point, because I think that people watching this will be asking themselves this question. In paragraph 12, you talk really in similar terms to that which you just have, Auditor General, about long-term outcomes that may bring difficult decisions into sharper focus. You give an example of health moving more to a community setting. Now, bluntly, that could hurt in the first instance. That is going to require some big decisions. It is going to require some brave decisions before the outcomes actually improve. The question that will be in people's minds is, is that ever going to happen? Is that realistic, given the political environment, the electoral cycle that we find ourselves in? Do you have any thought on that that you can share with us? I do, and I am sure that Fraser will as well in a moment. I think that there are two things. I do understand why this is so difficult. I have come out of a BBC studio on the morning of my report on the NHS that is published talking about the need for shifting care from hospitals into the community and then had an opposition spokesperson going in after me who will say quite frankly, we know that you are right, but we have to be criticising moves to downsize hospitals or close wars or whatever it might be. I understand why that is difficult, and it makes that shift harder. You know that as well as I do. Equally, I think to say that that means that it is never going to change as a council of despair really, but it is right in my view to be taking that longer-term view of what Government and what public services are for. One step in doing that is to set out the outcomes that Governments are looking to achieve, and I think that the thing that helps to move that along is putting more of the rigor underneath it about planning for how you want to improve the outcomes and being accountable for what is working and just as importantly what is not. There will be political knockabout going on in there. We all know that it is a rough old trade, and to an extent that is what politics is about—it is about making those sorts of disagreements public and accountable to the public. Having that longer-term picture in mind has to be one of the things that makes it more possible. Fraser, you will want to add to that. The only thing to add briefly, Mr Kerr, is why the stuff that we are saying here about engagement with communities is so critically important, because that is where the conversations really need to happen. That is not about Government or health boards or councils just going out and doing a sales job. That is about having an honest conversation with people in local communities that explain the rationale, the evidence base for a decision, why and what the alternatives might be to come back to Mr Stewart's point about the people locally knowing what the alternatives might be. That, I think, too often does not happen. I think that the first thing that communities hear about it too often is that our leisure centre is going to close. If that is the nature of the conversation, then of course people are going to be up in arms about that. It is about having the conversation much further upstream to explain what the challenges are, what the alternatives are going to be and therefore, in that context, those difficult decisions might be more palatable without recognising that any of that is easy. My final point, convener, would be at a national level, because I think that, interestingly, those same principles apply in very local places, as well as ultimately for Parliament, in making some big decisions about, for example, it looks like, by the end of this parliamentary term, something like 50 per cent of the Scottish budget will be spent on the NHS. At what point, as a country, do we think that that is okay or not? If we continue that trajectory, I think that we need to be talking about the impact that that might have on other places. I make no policy view about that, obviously, one way or the other, but it is the kind of, as you say in paragraph 12, that is the kind of big discussion and decision that needs to be taken and looked at by Government and ultimately by Parliament. Bill Bowman. Thank you, convener, morning. Just to go back to the beginning of what Alex Neil was saying about growing up, loved, safe and respected, so you realise your full potential now. I think that I have conventionally stopped growing up and probably grew up quite a long time ago, so a large proportion of the population probably did. Maybe a lot of us fall out of this, I do not know. However, how does the Scottish Government know if I have realised my full potential and how do you audit it? How do we know that Bill Bowman has reached his full potential? I think that I will resist the temptation to personalise that and instead talk about the outcome within the national performance framework, as it stated. I recognise the challenge that you and Mr Neil are putting to us. To a great extent, it is a challenge to Government rather than to us. It is for any Government to set its own policy. I think that it is a good thing that the Scottish Government is doing that in a longer term way, which is focused on outcomes. I think that what flows from that is a requirement that they can say how they will measure whether that is being achieved or not and upstream and how they intend to achieve it. If I turn it round a little bit and the discussion this morning, you can see perhaps clearly where some people have not met the outcomes and we put resource to try and help them. However, in the potential side of it, there could be a large amount of unrealised potential that we are missing out on by maybe focusing on the more obvious aspects. Are you in suggestions how we might tap into that? I think that one of the things that we say in this paper, which is a truism, is that there may be trade-offs between outcomes. If you make a decision to prioritise one set of things within society, by definition others are going to be less of a priority. For example, picking an example, we pick up here that there may be a trade-off between economic growth and sustainable development between emissions and the environmental impact of all that. What we are suggesting needs to be done is more surfacing of the trade-offs there and then more clarity about the way that the thing that takes priority is being pursued in terms of the investment of money and time and how progress will be tracked. The particulars in here are clearly a matter of government policy rather than something that I think we can defend for you. That is not our job. What we can say is that, if those are the policy that the Government has set, that is what we think needs to be in place in order for this committee and the Parliament to be able to do its job. In the report that came out last week, there is a whole series of indicators around realising the full potential thing, Mr Bowman. None of those in themselves will be able to tell you whether an individual has fulfilled his or her own potential. When you look across the suite of indicators, a lot of which are about inequalities. It is about inequalities between where you live, between your socioeconomic circumstances, whether you are a boy or a girl or a man or a woman, whether you are disabled or not disabled. All those things taken together can give you a picture of whether, broadly speaking, people have the opportunity to fulfil their potential or not. There is a wee bit of a leap of faith in all of this, I accept, but if you are narrowing those gaps of inequality across all those measures, you can argue that more people are more likely to be realising their full potential. I wonder if I could ask you about the performance improvement model that is in Exhibit 3 in the document. I tend to ask this question every time we meet. It shows a cyclic process for continual improvement there. The key part of it for me is the review part, the study part, after we have done a thing to see whether we have done it well and so on, and whether we have met targets, objectives and so on. Do you think that that has been consistently applied across the public sector? Is there enough evidence to support it and do you think that there needs to be a bit more, perhaps, requiring the public sector to demonstrate that they do this? I agree with you. I think that this is a quite simple but quite a powerful way of taking the next step from agreeing now in statute the national performance framework. We have in the paper here a couple of examples of where it has been used well. The most notable example is probably the patient safety framework, where there are real advances in some important things that affect and protect people's lives being achieved by disciplined application of this framework. We also say that it has not been consistently applied. The convener has highlighted two or three of our reports, where some of the early stages about being clear about the scale of the problem and how you will measure progress were not thought about at the beginning. If you do not do that, it is impossible to know what effect you are having in there for whether you should do more of it or try something else instead. It is that consistency and rigor that we are looking to see. In that part of the cycle process, the review part, do you think that in there should also be the bit that I was talking about earlier, thinking about the targets and objectives in outcomes that we set ourselves to see if they are in fact appropriate? Does anybody do that? I think that there is something for me about timing and all of that. Particularly in relation to outcomes, those are intergenerational things. Those can take 30, 40 or 50 years. I think that there is a risk in the discussion about outcomes that there is a general sense that we will wait 30 years and see if it has worked or not. Clearly that is not going to work. It certainly does not work for us as auditors. That cycle needs to work not exactly in real time, but what we do not see enough of, Mr Coffey, is that cycle, particularly the review bit that is happening as it is going. I think that it is not your point about whether the intended objectives were set in the first place. Again, that is sometimes when the politics comes into play, if I am honest. Sometimes that will require people to say that we thought that was what we were doing, but we are going to shift that a little bit. Trying to have that conversation in a way that it is not defined as a new turn or a kind of failure or something is quite tricky. However, that model is actually effectively step 3 of the three-step model that we describe in paragraph 19. So what is equally important is steps 1 and 2, which is really about setting out clearly what it is that you are trying to achieve. The second step that they talk about is creating the conditions for that to make sure that everything is in the right place. That is about operationalising it, and, as Caroline Lline said, not consistent enough would be our assessment of that. Thank you very much, both of you, for your evidence this morning. I now close the public part of the meeting as the committee moves into private.


Chad, a strategic partner to the West and the United States in the fight against violence extremism, is going through a turmoil politically. This is the latest. The coup in Chad was started basically in April 2021, when the long-term serving president three decades in power, it is Debbie who was killed in the front lines by a rebel movement. And just after that, his son, Muhammad Debbie, and a group of officers took control of the country and suspended the constitutions. As part of the 18-month transitions, they announced serious negotiations with multiple rebel groups. And a national dialogue that will define the content of the transition, including the Electoral Commission, Peace and Reconciliation Commission, and even the reform of the Army, and many other reforms. Despite the inclusive ambition of the national dialogue, major groups were left out. However, the dialogue proceeded and came out with some recommendations and resolutions, including a 24-month transition and the possibility of current, of leaders of the current political transition to run for office. And that was a major departure from the promise made by the military at the beginning of the transition, that they will not run for office. And that departure has created the tension, the political tension we witness today in the country, a political tension characterized by riots. One of those major riots in October 2020 led to the killing of more than 100 citizens and the jailing of more. In addition to doing research and informing policies from the get-go after the coup d'etat, we were invited and to the U.S. Embassy to engage with the civil society and the government to help them think through the national dialogue, giving our experience with national dialogue and the capability U.S. IP hires in that domain. So we had a series of meetings with the government and trainings with some institution, some organization in the civil society, and particularly women organizations as well. So we worked with women organizations, worked with the government to help them decide the national dialogue. We were not part of the decision-making in the national dialogue. And we continued to do research and develop policy options to inform the government in the transition as well as in the post-dialogue situation. Chad cannot afford to miss the mark. Peace, security of its citizens, of the sub-region of South Africa are at stake. So what is needed now is for the leaders of the transition to signal their commitment to democracy, peace, and prosperity in Chad. That will start, for example, by making sure that justice is done to the victims of the October 20th massacre. Number two, making sure that the civic space, they are not closing the civic space. That civic space is open and people can express, the Chadians can express themselves. It will be important to the international community, friends of Chad, to be with Chad as they go through this difficult journey.