Rwy'n cyfnod i chi i mi yn clywed siaradau'r Sfodd Cymru yn 2017. Ac mae'n gwael i chi'n ddweud y pethau场en diolch i ddechu'r unig agonon oherwydd ym Mwgol yn ei ddymiadau, ac mae'n dechrau rheoli sportwyr na ffilm oedd o gweithio ar gyfer oedau'r ffotoилаidd. Edych chi eu gwir yn i ddigon nhw i amddangos yn cyflau hwnnw i seisiol gyda Hi-of-in-glaswr yn Ieuniedaeth, soedd yn Ieuneddaeth, hasiolfaid, Ruth Glasbrough, director of safety and improvement, and Dr Brian Robson, director of health and healthcare improvement Scotland. I think that Denise Ewing would give us an opening statement. That's great. Thank you very much. My apologies. I've got a dreadful cold, so if I splutter at you a bit, apologies. Thank you very much, convener, for allowing us to make some opening remarks on the work of healthcare improvement Scotland. This is a really welcome opportunity to demonstrate to you the way our organisation is making a difference, and we really welcome your scrutiny of our organisation. When we begin a piece of work, we ask a fundamental question. How can we best help our partners from health boards to the new integration authorities provide the very best care possible each and every time for each and every person they support? By doing this work in healthcare improvement Scotland, how can we best help patients or people receiving care to have a good experience of care and a better experience of care? To fulfil the show, his is uniquely positioned as a provider of three things. We provide firstly improvement support, which can be tailored depending on our partner circumstances. We provide evidence for improvement, and that includes clinical guidelines and advice on best practice, and we provide public assurance on the quality of services that are provided. I can't emphasise enough the value of having improvement, evidence and assurance, along with the public voice, all in one organisation. It's a simpler and more effective organisational structure to improve the quality of care and we should be proud of it in Scotland, and many other countries are now seeking to move to that and adopt our way of working. I want to bring to life for you the breadth and variety and scope of our work, because in the complex and changing environment we work in, there's no single easy solution, and I think we all have to remember this. Our own healthcare improvement Scotland ranges from supporting people to have their say on the design and delivery of services, to approving new medicines for routine use in the NHS, we inspect hospitals and other services to drive improvement, and we help our partners design solutions to the challenges that they face. As an organisation, we work with a wide range of partners and other organisations, and we get to see and understand the full picture of health and social care delivery, and that has helped to support improvement in a range of areas. It's our knowledge and overall understanding that gives us value, but you don't want to hear about processes of what we do. I think you'll want to hear about the impact and how we measure the value of our work. For example, the first phase of our patient safety programme has helped to deliver a 17% reduction in hospital mortality, supporting the staff in our hospitals to save more lives. The one I'm most proud of is that the safety programme has helped to drive a 21% reduction in 30-day mortality for sepsis and blood poisoning, and again saving lives, especially young lives, across Scotland. On mental health, the safety programme has supported improvements at ward level, where there have been examples of reductions of up to 70% in the number of patients who self-harm, 57% in the incidence of physical restraint having to be used, and 78% in the incidence of physical violence on the wards. These figures come from some of our most disturbed wards in Scotland, where staff have been working with mental health patient groups and patients from the wards to deliver these outcomes. I think personally when you start fixing mental health, you know that you live in a civilised society. We are also expanding into new areas to reflect the integration of health and social care, which puts people right at the heart of delivery of services. Our new improvement hub is a key part of this, and we are forming new partnerships across the public sector, with organisations like the Scottish Federation of Housing Associations. An example of the impact of focusing on housing can be found in work that was originally led by the joint improvement team and now sits within Healthcare Improvement Scotland's improvement hub. Support was provided to the Western Isles to improve the service that provides equipment and adaptations to individuals' homes. The service keeps people in the community and enables timely discharge from hospital, and in addition to enabling people to live independently, the work has also delivered efficiency savings by significantly increasing the level of recycled equipment. In 2012, under £10,000 of housing equipment to help people live at home was recycled. In 2015, that had risen to £400,000. A high-profile element of our work is around assurance, and we conduct unannounced, in-depth, robust inspections. At its core, that means that you can read our inspection reports and know how well services are performing, from how clean your hospital is to how well it cares for older people. We have processes in place to escalate concerns directly to ministers, but it is more than just about inspection. Instead, we use the inspection process to drive improvement and share good practice and areas for improvement. For example, the number of requirements that are contained in our HEI reports has reduced by 50 per cent. That means that our hospitals are being kept cleaner by staff that are better trained and informed. To take a specific example, our HEI inspection of St John's hospital in Lothian in 2010 resulted in seven requirements and two recommendations, while our latest report in 2016 shows there were no requirements or recommendations. So far, I have described the impact of some of our work, but it is through the combination of our roles that we can deliver the most sustained and substantial improvement. To illustrate this, it is worth considering how our combined role works around the quality of care for older people. In collaboration with partners, our work ensures that older people can expect to receive firstly better designed care based on the latest evidence in our clear sets of standards, more reliable care through our support of implementing improvements in, for example, frailty and delirium, and be assured that care is of the highest and consistent quality through rigorous independent inspection. For example, we worked with NHS Ayrshire and Arran to reduce the number of older people over 65 who needed to be readmitted into hospital from 16.3 per cent to 11.6 per cent. This means more older people are cared for in their own homes with all the benefits that brings. I believe our wide range of functions puts his in a unique position. We are able to work across our powers to support improvement in a comprehensive and strategic way. It may be useful to compare that to other organisations and systems where you might only be able to see one part of the jigsaw, not how it all fits together. It is clear that there is still very much for us all to do. We know that we need to keep on improving and adapting. Health and social care services do remarkable things every minute of the day, but as an organisation that exists to support these services to improve even further, we do acknowledge the pressures they face. In these challenging times, and they are challenging times, with rising demands for services, and most importantly the competing demands between acute and chronic care, Healthcare Improvement Scotland has a crucial role in supporting these services to remain sustainable for the future. I look forward to his continuing to make a real difference for people across Scotland. Thank you very much. We would all commend you on the positive things that you have just explained in your statement. When the fact could begin, the core aim of Health Improvement Scotland is to improve the quality of healthcare and to increase the effectiveness and value derived from it. That appears to be your core aim. Given that the NHS in Scotland misses seven out of eight of its key national performance targets, would you say that you are succeeding or failing in that core aim? I think what we are trying to look at is the overall picture, and I think you are aware that there is a review of the targets at the moment. I think there are definitely challenging times ahead, and we have certainly started to look and address some of that. Robbie, I do not know if you want to pick up on some of that. Yes, very directly. Clearly in terms of the Audit Scotland report, which was quite stark in terms of the challenges facing health and social care in Scotland, has set out the performance. One of the key things for us as an organisation, increasingly, is to look at the totality of the quality of care provided in Scotland. For instance, one of the things that we look at now, increasingly, is about the leadership, the workforce and how sustainable services are. That is not a place that we have necessarily been before in Health Improvement Scotland, and increasingly we are going to be looking at the many dimensions that impact on the quality of care and of which the workforce will be a fundamental part of that. We have an important role to play in shining a bright light in terms of the quality of care in Scotland, and I think the demonstration of the openness of our reports, for instance, that we can demonstrate a very independent and objective approach in terms of our contribution to that. Thank you very much. One of the things that I would say is targets hit acute care, and I think one of the things I ended with in my talk is this real tension about the pathways of care and the management of really quite chronic conditions in the community. I think one of the issues that we have to ensure going forward, taking a whole picture around things, is how do we actually work upstream a bit more to actually prevent some of the pressures that are coming into acute care. Brian, I think you wanted to come in on some of that. If you don't mind, you mentioned Harry Burns review, Sir Harry Burns review of targets and indicators, and Harry has spoken to this committee. We are actively involved in that review of targets and indicators. All of the work that we are involved in as Healthcare Improvement Scotland focuses on outcomes, so we have measures and indicators around our work. So we're feeding some of those examples into Sir Harry to make sure that the areas that he's looking at, and I understand that we're now looking at a broad set of indicators and targets, looking at population health, quality of care and value in healthcare, as well as the staff and patient experience. So our work contributes to that, and we'd like to see much more of our work evidenced in some of the main targets and indicators. So how do we then know what you're doing is impacting on improvement or not, if we have seven out of eight of the main performance standards not being met? Would it be eight out of eight if you weren't there? I think that I would actually continue to push the whole principle of improving targets by pushing a lot of work upstream, and I think that Ruth would like to probably answer that, because I think that the important thing to get at with targets is if we keep doing the same things that we're continuing to do at the moment, the way we run acute care and chronic care, we're going to continue failing. We have to change the way we run healthcare in Scotland, and I think that's part of the work we're beginning to do at the moment. So if I could just talk the committee through briefly our work around living well in communities. So this is work to help the system to make the changes to reduce admissions into hospital and to support earlier discharge from hospital. And our approach around our improvement support offering focuses on helping the system to understand their local opportunities for improvement, to design or redesign services to address those opportunities. We support them practically with implementation, and then we support evaluation by collecting local measures to see if the changes are making a difference. With living well in communities we identified using the evidence base and our evidence arm, a number of areas where we know there are real opportunities to make changes. And one of those areas is around anticipatory care planning. So to take a very practical example of Glasgow partnership, what we've done with the Glasgow partnership is we've worked with them, we've worked with the data so that they've been able to understand where are their real local opportunities for improvement. On the back of that they have identified a number of areas of work, and one of those is around the anticipatory care planning work. And the support that we provide includes then looking at practically what can we do that helps that local system to implement anticipatory care plans. We know they make a big difference in terms of admission to hospital. We know that between 5% to 6% of the population has complex needs that would benefit. We know that the evidence shows that if you have the right information available in the system, you can reduce admissions by up to 30% to 50%. We know there's a big variation across Scotland around who has ACPs. And some of the very practical work we are doing has been around supporting the design of templates to make sure that systems are collecting the right information. We've done work with the electronic key information summary nationally so that that information is available electronically when somebody presents at A&E. In 2016 we saw a 20% increase in the number of ACPs on that electronic system. We've also been raising awareness across Scotland around the importance of ACPs, working with partnerships and boards, producing practical things such as video and practical toolkits. So it's all about supporting the system to make those very practical improvements. And if I can take it right down to a patient level, because I think that's quite important in terms of the impact. So these are two real life stories of two individuals. One was Margaret, she had an anticipatory care plan, and the other was Jean, who did not have an anticipatory care plan. Their circumstances were very similar. Their conditions were very similar. And actually Margaret, who had the anticipatory care plan, she spent much less time in hospital. She managed to die at home because this information was available to everybody supporting her about what her needs and wishes are. And Jean, who didn't have one, she had a number of admissions to hospital with all of the costs that incurred and she eventually died in hospital. So it is working right through from the national level, right through to the very practical impact for patients and individuals using services. So how do we find that out then? How do we go and find out what you're doing, what impact it's on? So we have information available on our website. We have information in our annual report. One of the areas that we're looking to strengthen at the moment is how do we make this information much more accessible? Because we have various communities, a practice site. We have various case studies that are open to clinicians and practitioners doing the work of improvement. And I think one of the issues for us at the moment is about that's available to the clinicians doing the work. It's available to the managers. How do we get more information out into the public domain about this kind of work? There's another way of measuring it, though, as well. Because the bottom line with that practical example is that the new Glasgow City IGB has had a budget allocated to it. We are responsible for quality assuring their commissioning plans. So we would expect to see in those commissioning plans that they have actually put the resource into anticipatory care planning because the Queen Elizabeth Hospital in Glasgow to reduce the amount of people coming in through A&E department, it requires Glasgow City and the other integrated bodies that have been set up in the west of Scotland to actually use the resource they've been given to actually deliver anticipatory care planning. Cymru, dwi'n anod o'r syniad hwnnw, yn respective outcomes and impact in terms of the £25 million that's spent in healthcare improvement Scotland. We publish in our board papers a measuring our progress report, excuse me, which sets out very much the demonstration of increasingly linking our investment in terms of our budget against impact. I'll give you a very practical example of that beyond improvement support. For instance, in Scotland, there's a very high technological procedure in cardiac care called a transniotic valve implantation, which is an alternative to cardiac surgery. We provided the evidence base to support its use in Scotland in a way which was more focused than would otherwise have been the case, and that saved the NHS in Scotland £2.6 million. So we need to demonstrate as an organisation in terms of that investment from a healthcare improvement Scotland outshare in the return on that investment as a public body. Colin. Thanks very much, convener. Can I just touch on issues around the governance arrangements that you have in place? It's always quite a complex process and particularly the oversight you have on your various constituent parts. Last week we obviously took evidence from the Scottish Health Council, and I think it's fair to say there were a number of concerns raised by members of the committee, which I think reflect public concerns over the performance and the role of the Scottish Health Council. So can I ask, first of all, how independently does the Scottish Health Council and the other constituent parts operate from yourselves and what performance management do you actually undertake over the various parts? I think we can both answer that, actually. I think the governance arrangements in terms of healthcare improvement Scotland are relatively straightforward in that we have a board, which I chair, that provides governance. More recently and importantly, we have to provide governance arrangements across local government as well, because we're working right across the public sector now, so that's a much more complex arrangement. We have governance committees, and for example, one of those governance committees is related to the iHUB and improvement. Now, that governance committee has to have an advisory board on it, which has representation from local government, social work, housing and the third sector. We have to have, in terms of our improvement work, governance arrangements inside healthcare improvement Scotland that feed up to our board that actually have participants from all of the third sector. Because of that change to working across health and social care and the sector, I have reconfigured my own board at the top to reflect that by having members from the third sector and from having individuals from local government on that board. The Scottish Health Council is a governance committee of healthcare improvement Scotland, and therefore is managed by healthcare improvement Scotland and performance managed, and is answerable. The director of the health council is answerable to the chief exec. We have commissioned a review of the health council because we feel that the work of getting the public voice and public representation can't be contained particularly within one area. It now has to extend right across both quality assurance improvement and evidence. In fact, our public partners work across all of these areas. Our review of the Scottish health council, which is due to be published, I think Robbie May might want to talk us through that. Okay, thank you. In terms of the, I'll come back to that point in a moment, but in terms of the governance arrangements, the accountability runs to myself as obviously the accountable officer for healthcare improvement Scotland. But the other thing I would add into the mix is that the Scottish health council has its own identity and legislation in the public service reformat. So there's a bit of history there which needs to be recognised as well. In terms of the review of the Scottish health council, it is to do all the things that Denise has referred to. But I think importantly, and I think we touched on this last week, in the context of the integration of health and social care, that we need to think more broadly about not just patients, but about citizens and how they engage with services. So that review will be ready in late February, early March. And I think that will be the opportunity to look at some options for the future and then we'll take these recommendations back. And indeed this committee is expressing interest in making sure that its voice is heard into that review. So if a member of the public has a complaint about the health council, you effectively deal with that complaint. Is that the case? Is that not an example of effectively marking your own homework, so to speak? If they are part effectively of the same organisation, but a complaint about them basically goes to yourself? Well, can I tease out two issues? One is about accountability and one is about independence in terms of accountability. Obviously I'm accountable for the overall performance of the Scottish health council, but I've also got a responsibility to ensure that it has credibility and remains independent. I've got an accountability in terms of its performance and any complaints that come in, I need to assess and respond to. So I think that's a very clear governance and accountability line. But you're effectively responsible for the performance, though. So if somebody complains about the performance, you then make a determination as to whether that's a valid complaint. Is that not a conflict? No, I don't believe it's a conflict. I think it's upholding the independence of the Scottish health council as much as I uphold the independence of our inspections. And it's important that it's part of that whole performance thing about the credibility and independence. There's an accountability there which I need to deal with and that's through, for instance, you should refer to complaints. So if they are independent, what is the point of them being part of your wider structure? Well, I think... Well, I think there's a number of opportunities which Denise referred to. We have an opportunity in Scotland, in healthcare improvements Scotland, to do something quite unique. And bringing together evidence, quality improvement, quality assurance, and increasingly importantly, the citizens voice. And that mix and that blend is a really important ambition for us as an organisation in telling the whole story about the experience of care. And I think that embedding of that together within one organisation allows us to take, from the bedside, the patient opinion, the experience of individuals, all the way up to the boardroom in terms of the quality of care delivered by the leadership in NHS Scotland. So can I ask just a general point of the panel at HIS, therefore currently content with the voice of patients within the NHS? Well, I can certainly answer that. No, is the answer to that? Absolutely not. I think actually we've got a long, long way to go with that. Because in terms of when we have inspections, we have patients on inspections with us. And they talk to members of the public and they hear people's views and they reflect them back. And they also write parts of our inspection reports for us. But we're in a learning process of how to do that. The public are involved in new medicines and the public are involved in all our evidence guidelines. The increasingly they're starting to drive the selection of guidelines because there have been problems in the past where people and particularly clinicians, no offence to the clinician at the end here, but decided to write a guideline about what their pet subject is or what they've got the most evidence in. Whereas members of the public would say, we actually need some evidence about something that really matters to us. So a big one at the moment for us with the public is they would genuinely like to know what new services that the integrated bodies can develop that will actually make a substantial difference and stop them having to go into hospital for things. Now, we don't know the evidence base for that at the moment. So we've had to ask our colleagues in knowledge and evidence about can you start to look at some of the evidence that actually matters for things for the public. So we'll still continue to do really worthwhile things like the asthma guidelines and everything, but we do need to actually involve the public in discussing that. So when you ask, is the public voice heard? No, it's not. It's not heard around that. It's also not heard in genuine adult discussions because when I did my opening statement about acute care and chronic care and the tension between the two, the NHS and social care in Scotland has got a fine-out budget that's really a problematic. We are going to have to decide in Scotland, it's a public debate about how much we're going to spend on state-of-the-art techie acute care and how much we're going to have to spend on chronic care that shouldn't be in hospital and should be out in communities and we need to know how to shift these budgets. But for the public to have that truly genuine debate, they have to have the facts and knowledge at their fingertips about what decisions people want to make about that. So when you asked about the Scottish Health Council, at the moment in our review, we would like to see the public voice far more through all our work in healthcare improvement Scotland so that they can genuinely say, well, we actually don't think this is a great idea and we have a constituency body. Now, the citizens panels that we've set up are beginning to start to do that, but you can only ask them one question at a time. And I think that what I would like to see in Scotland is a far more honest debate about do we want to spend the money more on chronic care or do we want to continue to have the seriously high-tech acute care because it just gets more and more expensive and if we're going to be the best in the world and acute, then we need to spend the money on it. But that's a public debate. Sorry for a rant about things. I don't want to separate the two issues because that's a wider health debate. What I want to look at specifically, though, is your current, effectively enforcement of the current role of the health council. It seems to me if you're unhappy with the role that's being carried out at the moment, you're not really enforcing changes on the health council at the moment. You haven't made significant improvements to the work of the health council despite the fact you obviously have that performance framework role. Well, I think I want to recognise that, as Denise said, this is an evolution here. How do we strengthen the voices that this is in terms of making some big choices about the future priorities of health and social care in Scotland? I think there are a number of things so that the health council is already doing, which should be given credit for. So you've had the Scottish Public Service Ombudsman here talking about the complaints process and how the Scottish Health Council suggested a more robust and earlier engagement in terms of the management of complaints. That is a demonstration of the work of the Scottish Health Council in building a more, I suppose, responsive and a less defensive complaint system. So there's really good work already under way in the Scottish Health Council. What we want to do is to build on that and to think about, then, how do we strengthen the citizens' voice in decision making and make sure it's a genuine debate? Sorry, I want to find a question. Are you the right body to do that? If I'm highlighting the fact that there's widespread concern over what's already happened in terms of the patient's voice and you haven't made significant changes for what I can tell, are you the right organisation to basically enforce those changes? Well, I believe we are the right organisation to do it and the reason we're the right organisation to do it is because increasingly we're looking at the totality of the quality of care. And if we're going to do that in a way which isn't just about the clinical experts given their view and we want the voice of the citizens, well, it's fundamental that we have that voice and right in there from the start. And I think, actually, your point is that if we didn't have the Scottish Health Council within us, for example, we would have to create something else to get that voice because we can't start to look at overviews of services and support the redesign of services without having the public voice in. So we would have to actually recreate it and that's why we've actually set up the review of the Scottish Health Council is to look how we're actually going to do that better. Okay, Alex. Thank you, convener. Good morning to the panel. Thank you, Denise, for a very comprehensive explanation of what healthcare improvement Scotland does and thank you for coming out to my constituency and meeting with me personally to go through it. I'd like to follow on from Colin's questions in particular in relation to some of the evidence we got last week about the work of the Scottish Health Council, which obviously sits in your stable. Now, I'm looking at the website of the Health Council here and I think it sounds like an organisation, as you just said, Denise, that if it didn't exist, we'd have to invent something like it and I'm glad that it's there if it's delivering this role. And it says, and I read from the council website, our aim is to improve how the NHS listens to you, values your views and experience, respects you as an individual and involves you in planning and developing health services. Good stuff. It also then has a big colourful graphic which says, working together to improve health and social care, your voice. So it strikes me that that then gives the Health Council two roles, that's one of quality, but you've talked about, and in terms of eliciting the views of patients. We learned last week that despite 2.3 million pounds a year, 14 bases, the Health Council elicited the views of only 1,100 people, or thereabouts. That's less than 100 per base, if my maths is right. I'm also anxious that when we talked about the views on major and minor service redesigns, particularly in major service redesigns, we're averaging about one a year view offered by the Health Council. It strikes me that this is a conduit that patients have to influence change within the NHS. That is stifled at best. Can you tell me, well, firstly offer me your reflections on those views? Okay, thank you. In terms of the number that was shared and which you've just expressed again in terms of the 1,188, that was in relation to a particular initiative by the Scottish Health Council. One initiative in terms of engaging with communities about stronger voice. How did it get a stronger voice? That was just one initiative. In terms of 2016 though, just short of 13,000 people is the number that the Scottish Health Council has engaged with directly over the course of the year. The number to engage to the website or social media is tens of thousands more than that. So just giving an assurance that that number is in that context was a particular initiative by the Scottish Health Council. In terms of the wider point, in terms of the policy versus engagement, I think one of the things that we were teasing out last week was about the role of the Scottish Health Council in that is a lot about policy, a lot about informing policy. But one of the things I think that has got a bit stuck in terms of the conversation is that threshold between major and non-major. And I think that's where I think some of the debate has got in. One of the big things I guess around our voice and strengthening our voice is about how to make sure all change is seen as just as relevant as the major stuff. I'm glad if I had to hear that and thank you for the clarification on the numbers. On that, in terms of the distinction between minor and major service redesign, I think that's a very crucial distinction because obviously what the SHC decide is minor, for example, the closure of the CIC, is very major to some people. Now, I want to ask about the quality assurance role that you have here because I understand that you don't quality assure minor service change. In fact, I have a quote from a letter to a patient campaigner, Catherine Hughes, from Healthcare Improvement Scotland, who was writing, I think, about the CIC and particularly around the decision making that led to this minor service change as the SHC decided. However, the SHC does not have a formal quality assurance role in this process, the letter says, and it would be the Scottish Health Council's role to halt the process. It would not be the Scottish Health Council's role to halt the process of NHS board engagement once a need for change had been identified. Why does the SHC not have that quality assurance role over minor service redesign? So that's a matter of history in terms of the guidance around major service change which came out five or six years ago, and what it sets out is the role of the Scottish Health Council. In twofold, one is about the engagement around the quality of individual boards as engaging across totality of service change. The role of the Scottish Health Council is at that point, but it becomes in that guidance major service change to quality assurance the process and ultimately the maximum of three months consultation, that's an important point, but in terms of the role itself, it's not expressed at the present in terms of beyond major in the quality assurance role. I'm not going to pre-empt the outcome of the review in terms of the Scottish Health Council, but one of the things that we wish to get into is just about that broader role in terms of giving confidence that every bit of changing health and social care in Scotland is as consistent and as good quality as the stuff that reaches the major threshold. Well, that's, again, gratifying to hear. I think we would all endorse that, but for me, then, that means that the critical point in this journey is the decision by the SHC as to whether that service redesign is major or minor. And obviously, if that's a subjective process, then for many people, particularly CICs, a great example, they would not see that as a minor service redesign. Can you just explain how that process happens? Well, just for clarity, confirmed that the Scottish Health Council role is not to decide in respect to what's major. That's ultimately for ministers to decide. The Scottish Health Council offers a view and that is in terms of the process, the right thing to do. Now, in the current process, so the position in respect to major service change and the designation of it rests with ministers. Could I raise just to stand back from all of that minute because I think it's an important point you raise about the CIC without getting into the CIC. But it's back to what my statement again about this tension because one of the things that people are really concerned about is that often they have chronic illnesses and the response of the health service is to deal with the acute part of it. So Lyme's disease is a classic example of that where you get a month's worth of treatment on your antibiotics and then you're sent off with no treatment whatsoever to cope with your headaches, your fatigue and everything else. And centres like CIC provide some support and care for that. And I think the discussion and the debate in Scotland has to be about when we have disorders that you go past the first month of acute treatment, but people are really disabled for the rest of their lives and I picked Lyme's disease because it's the hidden one actually in Scotland at the moment and its prevalence is growing and it's really appalling that we're not doing more for these people. But where do they go? So they look at the CIC as a place to go and I suppose my argument would be surely in the body of the whole of the NHS in Scotland where we could provide far more support and recognition of chronic illness and we should be offering that as part of the routine of everything. And for me, that's the big anxiety at the moment because I don't hear that conversation going on anywhere at present. Well, I think I'm really keen for this not to be dominated by the Scottish Health Council, there are other issues, but I'm surprised it's taken a week for us to find out that actually they contacted 13,000 people rather than 1,000 and I wonder why no one was able to correct that last week, but I'll leave that sitting there. Donald. Thank you to the panel for coming and just picking up on your point about Lyme disease as a member for the Highlands and Islands, I'm very glad to hear that's on your radar because it's a very significant issue. Can I ask about the independence of HIS from government? I think we all accept that you are a non-territorial board, but you do report to government, to ministers. And I was also going to ask about your role in inspecting hospitals. You can be called in by government, as you were, for example, to Crosshouse Hospital last November to carry out an inquiry or an inspection. Leaving aside your role in terms of infection control, can I understand to what extent HIS instigates of its own accord inquiries or inspections into NHS hospitals? I'll pick up the broader issue of independence and then I think Robbie will pick up on the others. I think it's really important about who do we have to be independent of? So I think it's really important that we have an independence from central government, but also now we have to have an independence in a new relationship from local government as well. And we also need to be independent from a lot of vested interests that can come knocking on our doorstep. I firmly believe as a chair you have to build independence. I don't think it just happens. I think you can appoint who you like and think, well, that's you've got an independent board or whatever. But having the right people in post, I don't think makes you independent. I think you really have to work at being independent. So for me, that's got two things. One is I think it's personal. As a chair and as a board, I think we have to maintain our principles. I think we have to be apolitical. I think we have to be fair. I think we have to be truthful. And I think we have to be compassionate because the best care is not always the best treatment section. I'm sure Dr Robson would say that to you. And importantly, I think we have to be free from financial incentives. So I think we have to grow a board that actually is based on principles. But then you have to demonstrate your independence. And I think we're starting to begin to do that through our reviews and Robbie will talk about those in a minute. I think we're demonstrating it through sometimes difficult decisions and difficult things we have to say. And I think also we're starting to demonstrate it by highlighting the challenges to government. So I think, Robbie, if you want to pick up on the quality assurance bit of how that works. Thank you. In terms of the specifics of our independence to act and inspections, it's entirely independent. So our inspections around the care of older people is informed by intelligence about where we go and announce in the care of older people inspections. And that's the same for our HEI inspections. Sorry to press that. If, for example, there is an issue with a maternity unit in any hospital unit or any hospital in Scotland and you get intelligence, are you of your own accord able to go in and inspect and inquire and report back? Absolutely. So in terms of how we've evolved as an organisation, our independence has increased in terms of how we exercise our independence and it's increasingly informed by intelligence. So, for instance, we were in the Beatson in 2015 with concerns about the quality of cancer care at the Beatson. Now, there are a number of reasons why we were there, but it was prompted by specific concerns raised by the General Medical Council. We did not wait for permission to go there. We went and we produced a report within a matter of months. Can I follow up? You don't deal with complaints. You have limited enforcement powers and all that being true and the fact that you ultimately report to government, do you agree with what is a wide body of opinion that what we need in Scotland is a truly independent health regulator comparable to the CQC in England? Well, if I can answer that, I think that I would be very cautious about introducing a regulatory regime to the National Health Service in Scotland. If you think about the accountability of the National Health Service at present, the accountable officers for NHS board are personally accountable to Parliament. The accounting officer for the NHS is accountable to Parliament and obviously comes to his committee as it's Paul Gray. If you introduce a regulatory regime, you introduce a different set of relationships and accountabilities and a different set of sanctions. Now, I would be cautious about that because I think the reason that we have healthcare improvement in Scotland is because we recognise that inspection alone will not drive improvement. There's a mix of approaches from evidence, through improvement support and increasingly getting the voice of citizens. And I believe that in one organisation in healthcare improvement in Scotland, we have something unique and it's how we exercise our independence and our existing powers. So our powers have increased. We have now the ability to sanction the closure awards. That did not exist before. So I think we have, in terms of our view, is we believe we have sufficient powers. We will keep them under review, but I'll be extremely cautious about going down the regulatory route in Scotland. Brian, did you want to... Yeah, just to say, I mean, this is an international discussion. All over the world, healthcare systems are considering does regulation help? How does regulation fit in? One of the things that healthcare improvement in Scotland does is we connect in across the world and we take advice from across the world. So Don Berwick, an international expert in quality improvement, has made his views and regulation very clear in his English review after the mid-staffiture incident. He's made it very clear that regulation has a role, if done correctly, but regulation from the outside does not sustainably improve care. And that's the evidence that we're now seeing across England. And the CQC and others have been up to meet with us in Scotland to see how we combine the roles of improvement and external inspection at the same time in one organisation. And we're in fact meeting this afternoon with Health Quality Ontario, who are meeting with us later on this afternoon, who are again interested in how we do this. There is no perfect way of doing this, but regulation from the outside, the stronger that regulation gets, the more concerning the results. NHS, we have very strong relationships with NHS Improvement England. And we're doing quite a lot of work with them and a number of other organisations. They struggle because they have a separate organisation in the CQC, so they don't have access. And they do have access because they meet, but they don't have direct access within their organisation to be able to use data. And I think Ruth could give you some examples of where that's really important. That's really where you're going to answer that. In terms of the procedure, so if there's an inspection occurs in a report you're in, what happens to that? Is that shared with the hospital or the care home before it's published? Is it shared with the government before it's published? How does that work? In terms of inspection reports, there is a draft issued for factual accuracy, and it is for factual accuracy to the board ahead of publication. The Scottish Government see the draft report, the final version before it's published, a few days before publication. So there's a very robust... Do they request changes? Sorry, do they request changes? No, no, it's Scottish Government absolutely not. This is an independent inspection. And indeed for the NHS boards, when they can come back with factual accuracy, it is simply about factual accuracy. Could I ask then if the government doesn't request any changes, then what's the point of sharing with them beforehand? Well, give them beforehand for a number of reasons. One is to give them advanced information in terms of what is coming into the public domain, and they may wish to prepare lines in response to that. But also reflects the fact that there is an accountability relationship between the accountable chief execs and the accounting officer in terms of the director general for the NHS. Would that work better if you're an independent body? Would that not be better just being published and then everybody gets it at the same time? It would slow it all up. I mean, Grampian, I think it's a classic example of that, where there was major issues, and I suppose back to your point about people complaining, at that point we did. We do triangulate information, where in Grampian it was the general medical council, the consultants themselves, patient groups who were coming to us and we met with them in Grampian. And in that time and when the report was published, it was shared with government, not for any changes whatsoever, but so that there was action taken about some of the serious problems in Grampian. So that was the value of it because you would have added another month on to and slowed it down. I suppose I think it would be important to talk about the value of the two of scrutiny and improvement together in a very practical way. Because this is background to our belief that you don't drive improvement in health and social care by inspection alone. It's really important to provide the practical support then, to act on the issues that have been identified through the inspection process. So as a very practical example, we know that there were issues in our acute hospitals around the management of delirium. We could have just consistently kept calling the problem out, but that would have had limited impact. So what we did as an organisation was we then pulled our improvement resources together and looked at how we worked with the clinical experts. We looked at how we worked with the patients and the families because they were involved in this work. We developed very practical assessment tools because one of the issues was that people with delirium admitted to an acute hospital weren't being identified. So how can we support clinicians to actually give them the tools to enable them to be identified? Another issue that was identified was that once people were identified, they weren't getting the appropriate management. So we then worked again with clinicians and with individuals and their families to put together bundles of checklists. So if somebody's identified with delirium, this is what you should do. And we provided practical support across Scotland for the rollout of that work. They're working very closely with our clinical communities. We brought individuals together. We do a lot of work around networking across Scotland so that what's working well in one hospital can be shared with another hospital. And on the back of that, we have seen again some significant improvements and just to give you a couple of pieces of data, the mean length of stay reduced from 22 days to eight days in Grampiam. We saw a 50% decrease in falls in two of the older people's wards in Greater Glasgow and Clyde. Unidentified and treated delirium can often result in people falling. If that then results in, in some instances, a hip fracture with all of the impact that then has on the individual and the costs. So reducing falls by 50% is really quite significant. And we also saw reduction in re-attendance at an emergency department for patients age 65 or over from 26% to 8% in one hospital. And that was around our work around both delirium and the work we also did across Scotland around frailty. So our belief is if you provide practical support because most of our clinicians, most of our managers, and when I say most, I mean 99% have come into the role to do a really good job. And part of our approach is how can we support them practically to make those improvements. Ivan. Thanks again and thanks for coming on to talk to us. I'm not from a health background, but I'm from a process improvement background. I'd just like to explore about more some of those areas and how you operate there. It was very reassuring to hear you talk with data, which is one of the cardinal rules when you're talking about process improvement. There's perhaps an issue how it all joins up because, as you mentioned, there's a targets indicator review going on and there's perhaps an issue about what you're measuring, what it's going to measure at top level, but leaving that to one side for the moment. I suppose I'm interested in it drilling down a bit more into, first of all, the process you use to decide what areas you're going to focus on because, classically, you would pre-tod that in terms of what was the biggest impact financially or whatever and what's got the biggest impact on the preventive agenda. So I'm interested in finding out how you tackle that. And then secondly, how you go through the process improvements themselves. And then, on the back of that, I'm interested in exploring to what extent the health boards play ball, if you like, to what extent they engage, to what extent do you get resistance. And then finally, I want to go on and talk about some of the financials round about that, but we'll come to that. So if we can maybe pick off the first two or three of those, I'd be very interested to hear that. So again, perhaps I can use Living Well in communities as an example of how we decided which areas to focus on. And it was the combination of looking at the evidence space. So what does the evidence tell us are the key areas where if we focus, we'll reduce hospital admissions and help people to live well at home. We also looked at the data. So we had quite an extensive piece of work looking at the data and pulling that in and we pulled together expert opinion as well. And it was the combination of those three factors that then led us to say there are these key issues, anticipatory care planning, palliative care, intermediate care and reablement that we need to focus on across the system. Then translating that to a local level, we have this piece of work which is around high resource users. So these are the 2% of our population who use up to 50% of hospital and community prescribing resources. And we support partnerships then to do their local analysis to see who their 2% are and then provide practical support on the back of that to say on the basis of that understanding where are you going to target your redesign work. In terms of the very practical approaches that we use, you'll recognise them. They're all the standard approaches around continuous quality improvement. So, as an example, the work in Glasgow at the moment, on the back of that high resource individual work, they have identified palliative care as one of the pathways that they want to focus on because the data shows that that's where they could have a significant impact. We have helped them to map their palliative care system across health, social care, third sector and independent care sector. And we produce these summary visual maps. Be very happy to forward one to you if you're interested. They're great because they allow people to look at the system and see it as a whole in one go. We then help them to overlay data onto that map to understand where the key problems are. And as part of the work we've been doing in Glasgow, we've developed a questionnaire whereby we have surveyed a whole range of different staff working across the whole system to get their views on where the key opportunities are. And one of the next steps is to then also work with the individuals using services to get their views on the key opportunities. On the back of that, we then work practically with an area to say, now you understand where are the high impact areas where you can intervene. We then provide practical support then around what we know works in other areas to address those issues. We also work very closely with NHS Education for Scotland who provide training because we know that it's really important that improvement work is led by people who work in the partnerships in the board, clinicians, managers, practitioners. So we both commission training and we help to deliver training. And Brian might want to say a bit more in particular about the work we've done with clinicians around training and given them practical skills around quality improvement. For course we're in time to match it. I mean, we could have a whole conversation about this, but let me just give you one further example of how we use data and how we use the evidence base. So Scotland has some of the best data around diabetes of any country in the world. And I'm sure the committee have heard from experts in the field in Scotland. However, one of the things that came through that evidence base was where we identifying patients who were admitted to hospital whose blood sugar had gone too low. Now the data tell us that one in six hospital admissions is a patient with diabetes. The majority are not admitted because of their diabetes. However, 30% to 40% of those have insulin as part of their treatment. And what we were finding that in less than 25% of the time, a low blood sugar, a high-po-glycemae was being recognized. Now a low blood sugar is one of the most terrifying situations diabetic patients tell us the experience.  We studied the processes. We actually watched what happened and we'd processed mapping and we identified a series of failures within that. But as you would recognize in the field of engineering, sometimes the simplest things are the things that make the biggest difference. So they looked around the world and we saw there's this thing called a hypo box. So a hypo box is simply all of the things that you need to assess and treat a patient if they develop hypo-glycemae. So when I went to see the hypo box, the hypo box is a Tupperware container. It's a simple Tupperware container with all of the equipment that you require to make it easy for the staff to do the right thing. And as a result, in wards in Glasgow, we're now seeing more than 80% of the appropriate response in the appropriate time. This is dramatic improvement by process mapping and by applying simple methods. I'll just touch briefly on the fact that we're engaging clinicians in the improvement journey. We work very closely with NHS Education Scotland and we now have almost 190 Scottish patient safety or Scottish quality and safety fellows now trained through the training programme over the last seven or eight years. One of the important things to note there is that six other countries join that training programme because it is so good. So we have input from Denmark, from Ireland, from Republic of Ireland, from Wales, from Norway and from Sweden. So we have input from across the world now looking to see how you actually improve care through the eyes of clinicians because as Ruth says, clinicians and managers come to work to do a good job. But if you don't help them to understand improvement, they find it very difficult to do improvement. I'd like to hear that. If you do this stuff right, in my experience, what tends to happen is the cost starts to fall away and before you know it, you're amazed by how much progress you can make in how much money you're saving, which clearly is what the whole preventative agenda is all about, you start to see light at the end of that tunnel. So I should have finished off that story about the Think Check Act because Think Check Act, although driven by the evidence and driven by the patient's experience of low blood sugar, one of the things that we're measuring there is length of stay in hospital. And we're seeing reductions of between one and two days per length of stay, per incident of hypoglycemia. So Stuart Ritchie, who's a clinician here in Lothian, Debbie Voight, who's a clinician in Tayside, have been leading this work along with Thomas Monaghan in our organisation. So they're looking for that sort of data. And that's another thing that clinicians previously were not interested in that sort of data. They didn't think that money was important. Money is critically important, whether it's in drugs or treatments or some of the fancy stuff that we can now do. So clinicians are now interested in how you can actually reduce waste and invest money better. So anyway, we get to focus on outcomes rather than inputs and stop this sterile debate about the amount of money we're putting in and start worrying about what's happening in the process. Just my final question is exactly on that. Your budget has gone up from £15 million to £25 million. I just wanted to kind of project a wee bit on that and see if there was some logic behind that. Yes, we can. The basis for the budget increasing is of around £9 million for 1617 is at a number of layers. The principal layer of the extra money around £6 million is from our new responsibilities for improvement support and the transfer of responsibilities from the joint improvement team, JIT, and Elements of Quest, which is a Scottish Government support team. So that was a large chunk of it. Another chunk of it was the £2.5 million extra we're getting for integrated improvement resource support as well from Scottish Government. Another piece of the increase is the £1.3 million that we now have in our budget for the death certification review service. So it's a combination of things. One is about extra funding for us to fulfil our roles, transfer of budgets, but I think one of the key benefits we now have is an integrated stream of income from Scottish Government in a way that we haven't had before, which is great news for this organisation. Alison. Thank you, convener. I'd like to discuss the issue of standards for a moment, if I may.  So I wonder if you could tell us how often you update your standards, how you assess an NHS board against those standards, and what happens if a board is simply isn't meeting them. OK, in terms of the neurological standards, you can come back to the committee on that specific, in terms of where we are with the refresh updates and their approach to that. In terms of the broader point about standards, we need to recognise as an organisation that standards are an important part of our work. The work that we do, for instance, in HAI, we use HAI standards, when we assess the quality of the clientliness within our hospitals. We have older people's standards, when we assess the quality of care afforded to older people in our acute hospitals through our inspections. Now, one of the things that we are doing as an organisation is reflecting the fact that we need to update our standards. And we're doing that in a broader context, though, in respect of health and social care standards, which have obviously now been subject to consultation, and we will be using these new standards in a relationship with the care inspector, for instance, looking at the quality of care. Can I just come back to... My question was, how often do you update your standards? Is there a concise? There is a process for reviewing them, and it varies according to the different standards that we're looking at. So, for instance, in terms of the standards around breast screening, and as an example where technology has moved on, where the approach to breast screening has moved on, and the need for those standards to be updated. So, it varies according to the different standards. And there isn't a set review time period, and we need to keep them under review all the time. And what action do you take if an NHS board simply isn't meeting standards? Well, in terms of, if we take, for instance, our HAI standards, we have a robust process. The conclusion of an inspection, we set out requirements and recommendations, and requirements are basically categorised in terms of whether it's high or medium in terms of the risks, and for the high risk, we expect the board to have dealt with it within one month. And we revisit. We carry out unannounced follow-up inspections for HAI, for instance. If we are not content with the sustainability or progress or the responsiveness of that board, we can escalate to Scottish Government, and I think that just emphasises the point in terms of that accountability mechanism which exists within the NHS in Scotland. OK. I think that standards are obviously key to quality and safety. And in 2014, you outlined plans to, for more comprehensive quality and safety assessments, including examining staffing and leadership. Have you implemented that approach and how do you rate current staffing and leadership levels within the NHS? Can I touch on the approach that we set out in 2014? We are now in a phased implementation of that, what we call our quality of care reviews. And the reason that we are taking forward that whole approach is that we recognise that the workforce, the leadership, the effectiveness of care, the responsiveness of it are all dimensions of quality that we need to look at. So that takes us from the boardroom, the leadership at the very top of these organisations, right through to the experience of individual patients within wards, for instance. So that works already under way and you'll see examples of where that is already happening. So, for instance, we carried out a review of hospital-based complex clinical care in Lothian and we published that last year and that touched on issues of workforce and the leadership for that particular service. We are piloting and testing the quality of care reviews with the Child and Adolescent Mentor Health Services in Lothian and we're also doing work with our NHS Grampian as well. So in terms of quality of care reviews, we're building a momentum that will take us into a more complex, a more comprehensive assessment of the quality of care. In terms of workforce, I think you used the second part of the question, is we recognise the real challenges in the workforce and one of the things that we recognise from our inspections is commenting on the quality of care is important, but we need to increasingly comment about the system and the challenges within that system. A lot's about workforce and attracting people into demanding roles. There's issues in terms of training and development. So we need to increasingly look in inverted commas at the supply of the workforce coming in and to do it in a much more rounded way in assessing the totality of the workforce and the challenges on that. You wouldn't hesitate to comment if you thought that the workforce and any deficiencies were impacting. Absolutely, and so if you take, for instance, the work that we did in Aberdeen-Roll infirmary review, where we looked specifically at the emergency department and the concerns about the quality of care and the workforce issues, we commented on it very directly. Can I just add to that? The workforce, as Robbie says, is not just about numbers. It is about mix, it's about training, it's about staff experience, as you would well know. One of the groups that we run along with Nez is what's called the Sharing Intelligence Group, where we bring together six external agencies in Scotland. We bring together Healthcare Improvement Scotland, NHS Education Scotland, NSS or ISD, Mental Welfare Commission, the Care Inspectorate and Audit Scotland. We meet and we review every, currently every NHS board every year looking at all the data, including data around workforce. So workforce and workforce experience forms part of our assessment of every single board. And increasingly, in over the last six months, we've started looking at IGBs as well. But the workforce experience, for instance, through the General Medical Council Trainee Survey, to see how junior doctors are experiencing safe, supported training environments are a core part of that evidence base that we use. Thank you. Richard. Thank you. Can I touch on the intelligence gathering system as a Lanarkshire MSP? I remember in 2014 there were reports of higher than expected mortality rates in acute hospitals in NHS Lanarkshire. His committee to establish a health intelligence review group bring in basically Care Inspectorate, Public Ombudsman, Audit Scotland. The intention was to bring together intelligence, what's happening on the ground. What is happening with that group? Where are you with this group at this moment? I'll get Brian to say a little bit more about that. But just in terms of the background to the group, the reason that the group was set up because of a reflection on the deficiencies in England highlighted by Ms Staffordshire that the failure of national organisations to share intelligence, to respond to intelligence, to act on intelligence was a key aspect of the Francis Inquiry recommendation. So we were on the front foot in Scotland through Healthcare Improvement Scotland in addressing that. Convener, if I'm made, Brian, we will still elaborate. Yes, thanks. So in fact, that's the group I've just referred to. We didn't call it what we were going to call it. We now call it the Sharing Intelligence Group. And these six... It's a bit like the CIA. Eh, well... I don't know. If it wants to make best use of intelligence, maybe the CIA does or maybe it doesn't. Anyway, so these six agencies, we literally come together every two months and we consider, well, in Monday, we're actually considering four health boards as coming Monday. But it's not just the data that are in those reports. It's actually the conversation around the table and such themes as culture, such themes as leadership, such themes as management grip, those sorts of things are the areas that we get as a result of sharing conversations around the table. Now, I should say that when all the agencies, these six agencies, come together around the table, we have our own governance arrangements. So if there are any issues that need to be taken forward or accelerated by, for instance, Audit Scotland, then the Audit Scotland representative round that table takes that back to Audit Scotland and engages with the chief executive and other officers of the board. Taking important clarification that Robbie Pearson made, have there been any examples of the new intelligence gathering approach to pick up any problems that are coming along? I think that, let Robbie speak in a minute, I think one of the things we're trying to achieve with that group exactly is to get to amber warning systems because at the moment we are operating in a red zone the whole time and what we'd like in Scotland is to use that group to pick up amber warnings, which we certainly are doing and Robbie can talk about that in a minute. Ultimately, what we would like boards and IJBs to do is we send out self-assessments and we would like them to tell the truth to themselves and then we would quality assure that. Now we're not anywhere near that stage at the moment. At the moment we're moving from red to amber, if you like, but ultimately that should be our aspiration is to move to each board and integrated joint board doing self-assessments. Do you maybe want to talk about the amber? Yeah, so amber zone, as Denise described, is really important in terms of being there sooner and with the appropriate intervention and I think some of the examples we've seen in the past have been at that moment when it's frankly crisis and an intervention from healthcare improvement Scotland. So getting there is going to be crucially important in the sharing of intelligence and one of the key aspects of that is about the quality of the training environment for junior doctors. We now have a wealth of data from the GMC and NHS Education for Scotland survey of the quality of training. The quality of training is a good indicator about the quality of care. Therefore we now use that intelligence away which I think is much more sophisticated. But Brian may wish to elaborate in terms of how we're actually using it in practice. So in addition to the amber warning and getting advance notice of anything that could go wrong, we also look for bright spots. We look for areas of very good practice that are happening and of course we come across them in every report. There are good things happening across NHS Scotland and in the integration of health and social care. We meet following the meeting, we meet with the chief executive and the other officers to discuss with them what we find. In fact, we met with NHS Lanarkshire just last week and not only did the full executive team turn out but also the chief officer from North Lanarkshire and officers from South Lanarkshire integration joint board were there. And so we had a very rounded discussion around the areas both of good practice but also areas that we wanted them to just be alerted to. So now to hold the meeting up. Can I ask where do you get this intelligence? From whom do you get it? Is it patients, doctors, staff, reports, a flag up an intimate of whatever or Twitter? Where do you get this? All of the above and each of these agencies have ways of both their formal inspection or formal review of services from staff experience, from patient experience and particularly from the mental welfare commission from relatives experience of the care of their loved ones. Thank you, Careers. Yeah, patient opinion is part of the information we look at as well. Thank you. Mary. Thank you. As a health professional, I might be biased because I was involved in writing some sign guidance but I do think it's excellent quality. And certainly I became involved in writing sign guidance because I was involved in contributing to the perinatal mental health guidance. And the reason I wanted to be involved was because the first one was practice changing. And I just wondered if you could explain to colleagues what the need, I mean there's an awful lot of bodies producing clinical guidance now in these. Why does Scotland need to produce its own? So why does Scotland have to produce its own? Because we can and because we can get the appropriate focus, the appropriate priorities. The Scottish Intercollegiate Guidelines Network, Sign Guidelines has now been in operation for 22 years. And over that time, we've managed to agree what the priorities are based on evidence, based on patient experience, based on good Scottish data from the services. And as you'll have experienced yourself, it's literally a collegiate approach. You have patients, you have expert clinicians, you have jobbing clinicians who just want to go around and do the work, who can tell you what it's really like and how difficult it is to put everything into practice. So you have all of these people round the table and what sign does and John Canceler, who's the current chair of sign, is making a very clear statement that actually the evidence base is as important now as it's ever been. However, the products have to change. The sign guideline, I don't know how big your sign guideline was, but the diabetes sign guideline, the sign guideline around cardiovascular care is about an inch to two inches thick. So what do I do? I'm a general practitioner. When I'm seeing patients on a Friday, that's not much use to me. And as a patient with diabetes, that's not much use to you. So what sign have done over the past few years has been to change their products, make it more simple, simple messages, both for patients and also for clinicians. Now, if we just linked in with all the other guidelines producers across the world, would we get as good a service as detailed and as bespoke for Scotland? We would not. However, we do link in with all of those networks and the somewhat humorously titled GIN, which is the guidelines international network, meets regularly and sign has a key role in that to learn from others. But the products are changing and John Cancelha and our team in sign are fully prepared for the products changing. Indeed, and in fact, the sign guidance that I contributed to was one of the first to produce a patient version, which meant that there was a plain English version to help people to make these very difficult decisions about taking drugs during pregnancy and breastfeeding. So I was personally delighted with that outcome. I don't think we should ever underestimate in Scotland the amazing generosity of staff and the public to contribute to these things because these are unpaid posts in their spare time and I'm sure you did that as well on evenings and everything else. And I think that's a major advantage in Scotland that we have that people will give their time up because they genuinely want something to be improved. And I think it's going to turn into a bit of a lovin because we actually see the improvement come out at the other end. It does encourage us to contribute. I said the reason I got involved the first time was because it was a practice changing guideline first time. So we pushed the boundaries again with the second one. So really it was a good experience for me and it does contribute to clinical improvement on the ground because I am a jobbing clinician. I worked as a pharmacist in mental health and went to call that good practice back to where I worked. The other thing I wanted to ask about was the patient safety improvement programme which again has been, as a jobbing clinician, a very, very positive experience to get involved with. So we have felt empowered to make changes in a way that we haven't in the past. We are doing stuff like medicine's reconciliation. I worked in mental health in an area where it's very difficult to get change because the risks are huge and it was a very positive experience. I wonder if you could talk a little bit more about what's happening on the ground in mental health, for example. I know there's a number of patient safety improvement programmes in the hospital that I worked in right up until last May. So to take the mental health patient safety programme as an example, we have focused in our initial work on acute inpatient wards and we've had very clear aims around reducing levels of restraint, reducing levels of physical violence, reducing levels of self-harm. I think our chair talked about some of the data from that across Scotland where we have seen on wards really quite significant reductions and the key to us has been that this has been about working with local clinicians, involving the service user patient voice as part of it. I think we're particularly proud in the mental health work about the extent to which the service user voice has been weaved in. We have developed in Scotland the first ever service user assessed safety climate tool. So we have a tool where we can actually ask patients on the ward how safe do you feel and ask a number of questions and on the back of that we're able to identify areas to focus improvement work. And I think just looking for some of the data in terms of the impact of that work, it's been improvements in rates of reduction of violence up to 78%, restraint up to 57% and individual self-harm in up to 70%. So this is significant improvements for some of our most vulnerable individuals. We've got a big challenge though because we've been giving money on for CAMH services to start to look at the child and adolescent services. And I think one of the huge issues that we've got in Scotland is the time you wait at the top end for very specialist services. And I think at the moment our challenge is to start to look more at pathways. And so looking at in the integrated space, what kind of pathways can we put in for children that they don't have to constantly access the most specialist care in child and adolescent psychiatry? So I think that's going to be, we're just beginning this work and I think we've got huge challenges to start to move that forward. Do you have a patient voice involved in setting that agenda and driving it forward? Yes, although one of the irritations, we have a board member who is very vocal about children because as she constantly points out to us that we don't have any children on the board. So we're still working on that one, but it's an area that's, it's difficult. We've focused on older people. Now we need to focus on children and, Brian, if you wanted to... Are you going to talk about children? No, I'm not going to talk about children. So I'll just do an example. You do it in the evening. Yeah, okay. So just an example of how the patient voice is being linked into that CAMH's work and this is working in Grampian where they've actually developed a young ambassador peer support model as part of their child and adolescent mental health services. And that's where a young person in recovery from a mental health issue actually joins the clinician at the point of the first assessment with the young person coming in. So it's a really innovative model and we are watching closely in terms of the impact of that and then we'll be sharing the learning from that across Scotland. I just wanted to say just one thing about another evidence base, which is to your field of medicines. But actually, of course, medicines are not much to do with pharmacists. Actually, it's most to do with patients and prescribers in terms of doctors. But we've produced all sorts of now... It's all sorts of leaflets and material so that the public better understand both the advantages of the medicines but also when things could be coming unsafe with the medicines. So in fact, from Highland itself you invented the work around... Leading the way in all sorts of... Leading the way around giving cards out to family members to stop medications when you're having diarrhea or vomiting or you're particularly unwell. And that's making a big difference to acute kidney injury, one of the biggest issues that we now face in modern healthcare. And another just a wonderful example that we're now just working through the Ada Drugs and Therapeutics Committee is this just not sure, just ask about starting new medicines. So this has come from Tayside and one of our roles in healthcare improvement Scotland is to share best practice. So this is now being circulated and distributed out through pharmacies, through GP practice, through the libraries and other outlets near you. Miles. Thank you, convener. The panel. I wanted to follow up on Alison Johnson's questions specifically with regards to senior management in the health service. Do you think we've got the right people in place? Do you think they have the right skills and the past and experience to actually take forward what is going to be a period of major reform in our health service? And specifically around the recruitment process in Scotland, how do you think the pool of people we recruit towards senior management is that wide enough? And actually that sometimes is key to taking forward that reform in the health service to have that leadership and do you have concerns around that? I can kick off at least in terms of the context. It is changing. So the traditional NHS Scotland where a simple line from an NHS board all the way up to St Andrew's house is now obviously changing in the context of health and social care. So there's a much greater diversity of participants contributing to the leadership of health and social care that never existed before. So to answer your questions slightly indirectly, I think it's about what the skills we now need for the future. They are less about command and control, frankly. If ever that was effective. It's now about influencing. It's about negotiation. It's working with a much wider range of partners with different perspectives, different cultures and different history. And that will require a different approach to leadership. But that was just a general sort of reaction to the question. I think just to add to that, I mean I think we need to start looking at and certainly people are starting to look at how we train leaders across the whole public sector because the skills we're looking for in Achieve Ezek and the Health Board now are really about transformational change, strategic planning. And that doesn't always require a health background and the same in education. And so I think we should be looking much more in the public sector at leadership development across that. Everywhere you go across the UK everyone is struggling with succession, planning and recruitment. And I think we've got the similar kind of headaches here. But I think the easiest way to resolve it at the moment is actually about trying to grow some of our own within Scotland. And I think that that's going to have to be the way forward. I don't know, Brian, you're involved in. Yeah, so maybe Ruth might want to say something about the development programme for the non-executives. Is that a relief? Yeah, sure. So maybe I could just make a point that the management of the NHS, the management of any healthcare system is extremely complex. The partnership between managers and clinicians is critically important. If you look at all the failings that's happened in the NHS in the UK, there's been a breakdown in management and clinician relationships. So one of the areas that we are focusing on is that arrangement. And if you look to, for instance, NHS Lanarkshire now, there's a very clear tripartite model running, for instance, the hospitals with a chief nurse, a chief medic and a chief manager. You know who's in charge. They work very closely together and they're responsible for the care. Can I come back? Just another point, which since I was elected in MSP in May, one of the factors I've been incredibly concerned about is what seems to be a postcode lottery across Scotland for health services and one which I believe is ever increasing. And so in terms of your experience of our health service, would you say that you'd back up that that actually we're seeing a postcode lottery with many services? Some health boards doing really well, others certainly not in some key areas. The expert variation, aren't you? We certainly see a level of variation across Scotland. What's important is to understand what sits behind that variation. Because sometimes the variation is based on differences in local needs. It can be based in differences in local population profiles. And in that case, it's good variation. Part of what we're trying to do now is to really get better data around the variation and then support our system to understand what sits behind it. And how are you driving that forward though? Because I think one thing which when we have FOIs come back when we ask parliamentary questions is you see over years a worsening situation and that postcode lottery sometimes getting worse. And as we've heard already today, sometimes key individuals in a health board can drive real improvement in some area where they have specific interest. So how are you as an organisation making sure that every health board starts to improve in that way and we share knowledge because we keep hearing as a committee that we have lots of pilot studies going on but they don't get beyond pilot study. So there's a number of things we're doing. Firstly, key to this is transparency around the data and we're working very closely with our colleagues at ISD. We have a new programme that we're getting up and running called the effective care programme and its focus is on reducing unwarranted variation in clinical processes or clinical interventions. It starts from the point of saying what is the data telling us about where the key variations are and then working with the health boards with the clinicians around the skills to then understand what's at the root cause of that variation and where it is unacceptable differences in practice that we then work with them to address that and that also then pulls in the evidence guidelines as well. Do you have any cases of that then where you've specifically made an improvement? So I think specific improvements through the patient safety work because a lot of that patient safety work was around identifying areas where there were inappropriate variation in practice across the system and certainly the work and Brian could talk to this about on the acute side around the BAPs. So the initial work was around the ventilator associated pneumonia and just highlighting that actually if you really concentrate on patients who are on ventilators you can eradicate this fatal condition. 50% of people that got a ventilator associated pneumonia died. So we studied that in Tayside. We then rolled that out by sharing experience. So part of our opportunity here in Scotland is to share best practice. And it is commonly a phrase that's commonly used elsewhere in the world is that we have the best care however we don't have the best care everywhere. And I see a commitment in the delivery plan to develop an atlas of variation and atlases of variation have been things that have significantly driven widespread change in other countries and we are certainly very keen to work with ISD and Scottish Government around atlas of variation. Clare. Thank you, convener. I'll pick up a little bit on what you were talking about there and what Marie Todd was talking about. Again, I need to declare an interest on my mental health nurse and certainly have used sign guidelines to improve my clinical practice and hopefully improve the outcomes for the patients that I treated. We have heard at this committee that there have been lots of pilots run in lots of health boards and lots of IJBs which produce great outcomes and great patient satisfaction rates and clinicians are really pleased with them, but concerned that those are seen in silos and that that practice isn't rolled out and you've touched a little bit on that, perhaps you could maybe tell us about how you scoop up all that good practice and make sure that it is disseminated across the country. You weren't talking about spread, actually, because it's such a difficult problem. So there are a range of approaches that we use to spreading the good practice. A part of it is around networking and pulling individuals together who are working on these issues. We increasingly produce tools and guidance to support implementation at a local level. The use of data is really important in terms of highlighting areas where it's working well and then we pull together case studies and share those across the system. So it is a range of methods that we use. I think the challenge is, in improvement work, that you can't just take something from one area and transplant it into another area because context really matters and the key is to understand what was it about the area that delivered the improvements that led to that improvement and then supporting the translation of that practice into another area and being appropriately adapted into that context. Again, we are studying those that are trying to do this around the world. We run a webinar series called QI Connect. Every month we bring together 48 different countries, more than 500 organisations for a one-hour webinar and we've run that now for three years. I would say that easily half of those webinars talk about the point you're just raising. How do you move beyond pilots? How do you, why don't good things spread? What we're doing is not just studying that in an academic way, we're actually putting it into practice, as Ruth says. The more that we can get leadership and management and professional bodies around the table with us, the more that they can feel responsible for actually having consistent practice where the evidence is there, the better. That's certainly something that we are studying along with many others around the world. Can I also ask briefly, convener? I know we're out of time. The Scottish patient safety programme worked particularly well, I think, because it was bottom-up rather than top-down. You're talking about leadership and, yes, leadership is really important and we need to know who's in charge and who's accountable. But how are you capturing some of that good practice from at the co-faith clinicians and using that to drive some of the improvements that you're seeking? I would completely agree that importance of the bottom-up. We talk about one of the challenges of spread, is that we're trying to spread solutions to problems that people don't know they have. So it's absolutely crucial at that local level to do the work to diagnose what their key quality improvement issues are and then to support them to make the changes. And part of what we do across a range of our improvement programmes is work with local areas to capture case studies, to share those. We are increasingly using videos now, so you can go online and watch a range of short video stories that capture what's been done and the improvements that have been delivered. As I say, we do the networking events. We do a lot, actually, just through the individual discussions. So we will go into an area, they may face a challenge and we'll say, actually, we know that that board just next to you has already faced this and solved it. So we'll connect individuals together and enable them to learn from each other. That's why quality assurance and improvement are important together. Because we have the authority to say in an area, this is what's working well for you, these are the areas you could improve on. And I think that that's the way you can then say that with authority that drives the improvement. Whereas I think regulation for regulations' sake just won't drive that improvement. I'll just add very briefly to say that every one of our programmes that's dealing with a clinical area has a national clinical lead. So we now have 53 or 54 national clinical leads across our programme. These are people who work for us one day a week or two days a week, but the rest of the time they're in practice. And that's a whole range from nursing staff to medical staff, pharmacists, AHPs who are involved in our work. The final brief things, if we get you back in a year, what will be your big achievement? Well, I think actually our big achievement would be that we've actually convinced you that having an amazing organisation that does quality insurance and improvement works better than anything else you've seen in the rest of the world in driving improvement in healthcare. And when we come back, we would give you a lot more data to actually support that. Okay, and finally, Denise, you said that we need an open and honest debate about funding the future of health service. You also said that people need to tell the truth to themselves and that you're an independent organisation. So maybe in the spirit of independence, telling the truth and open on this debate, I wonder if you could give us your view on whether you see cuts to services happening in NHS and social care field across Scotland. Well, I think you said it's about funding. I think it's about how we use our funding. I think for us as an organisation, we have to live with the reality across the Western world at the moment that funding is going to be tight whatever we do. I think that... That's not the question I asked. I don't think that's the question. I think the question is not really about cuts to services. I think it's about changing services. No, but could you answer the question that I asked? You're seeing health and social care across Scotland. You're probably one of the best people that we can ask this question to. And actually, it's not about cuts to services. I would reiterate that, actually. It's about people actually shifting resource. And in fact, in some areas, it's about taking some money out of areas and putting not even the whole amount back. So it's not particularly about cuts. I think it's definitely about shifting resource and also deciding as the public in Scotland what we actually want to spend our money on. So I think it's about... I think we could drive ourselves down a negative ragabit toll by saying it's about cuts. I think what we need to say is actually we can do a lot better with the money we actually have at the moment. So there aren't any cuts happening? I'm not discussing that. I'm talking about doing better with the money we have at the moment. So, you know, I was hoping that the words you used to describe your organisation would come across, but I've asked you a question that I would hope you would give us a straightforward answer, but unfortunately that's... I think that's a straightforward answer. I think that's a straightforward answer. Anyway, thank you very much. Thank you all very much for this morning. That's been very helpful and we will suspend briefly for a change of panel. Hi, the second item on the agenda is evidence session on the transplantation, authorisation of removal of organs, et cetera. Scotland Bill and we're going to hear from Mark Griffin who's in charge of the draft proposal and Andrew Milne, the clerking team to the non-government bills unit in the Scottish Parliament. Mark, who invite you to give an opening statement? Thanks, convener. Good morning, everyone. Thanks very much for having me along that committee today. Today you'll have in front of me of you my proposal for a member's bill on a soft up to process for organ donation and the statement of reasons that goes along with it as to why I think that I shouldn't have to go to consultation again before introducing a final proposal. The reason that I've brought forward a member's bill proposal, my own personal reasons were that my father, when I was 12, was diagnosed with a heart condition and was told that he needed a heart transplant. Waited 10 years for a transplant, got one, but wasn't strong enough after 10 years of the decline that his body went through. I have to be done the relevant drugs and everything else that he wasn't strong enough to make it through that operation and died when I was 22. So I've really strong personal reasons behind this bill and members around the table, Richard Lyle amongst others, will know exactly the situation that my family and I were in and why I've brought this proposal today. I feel that, aside from the policy behind the proposal that there is already a wealth of information out there, a wealth of research, a number of consultation exercises that have already gone ahead. It means anything that I do won't add anything new and would actually might even be counterproductive. We might be in a situation where people are being over consulted and they're almost getting fed up of being consulted and actually just want us to get on and decide whether we're going to do something or not. And Ann McTaggart, who had the previous proposal, she went out to consultation in 2014. The previous committee had a consultation on the issue in October 2015, and the government themselves are running their consultation which started in 2016, and that's three consultations in three years. I really don't see the need to have a fourth consultation of my own in that same space of time. I've seen the list of the organisations and individuals that the government have gone out to consultation with, and I think that's a fantastic list. I wouldn't be adding to that list, and I wouldn't be getting any more information than I think the government have or will already have received and be in the process of receiving. If the committee were to approve a statement of reasons, that would give me permission to lodge a final proposal within Parliament, but I don't think that would be appropriate and that I wouldn't lodge any proposal until the government have concluded their own consultation and decided whether or not they would take forward any legislation. So I hope to be informed by the government's consultation as well, rather than trying to short-circuit that process. I'm happy to take questions from the convener on the statement of reasons today. OK, thank you very much Mark. Any questions from members? Alex? Thank you very much indeed for your presentation. I think that none of us can fail to have been moved by your personal reasons for bringing the bill forward. You rightly pointed out that we've had or will have had three consultations in as many years. In terms of the first two, was there much variance in terms of what came back from the public? In both consultations, Anne's consultation had almost 600 responses and the committee's consultation had individual responses and a survey of almost 900 responses. Those came back broadly in favour of the proposal. Public opinion, there have been a number of polls conducted by the British Heart Foundation, which have all come back in favour of a move towards an opt-out system. Today we're talking about whether there's a need for another consultation or not. Exactly. I think another one would be. I think it would be counterproductive. I'm certainly of a mind with you on that. I think that you rightly pointed out particularly in the very moving case of your father how important time is in this entire agenda and I think that anything that delays the possible legislative change will be measured out in human lives. I'm very much minded to support your case here. Should there be no further questions, I would like to move that we back you on this. Colin. That's very much convenient. You touched on the fact that there were three consultations, two that have already been conducted and one that's planned by the Government. Is there any organisation or any person within those three consultations, in particular the one that's planned by the Government, that you think is not being consulted? No, I think that there have been three extensive consultations. In fact, a private member's bill by virtue of it being my own private office, is that if I was to get to consultation with just the resources of my own office compared to the office of the Government in the range of civil service advisers, the publicity budgets that they have, I can't see any consultation that I would carry out having as big a reach as the Government's one, so I think it would inevitably be a smaller, far less reaching consultation which wouldn't give as much, as many responses and as much information as the Government would already. Richard, do you? Mark, I personally know your personal reasons behind it. I was actually a good friend of your dad's, as you know, and had to go through the same pain that your family had to go through at the time. But can I ask for the record, when did you launch your bill and did you know at the time that the Scottish Government was also tabling a consultation on this? Yep, I lodged my bill in December, 19 December. I lodged the proposal along with the statement of reasons and I did know that the Government were carrying out a consultation. Now, I hope and I believe that the Government will bring forward legislation on opt-out and they'll have my full support for doing that. What I'm doing, the reason I'm doing this and what I hope doesn't happen is that after the Government carries through a consultation that they decide not to proceed with legislation. And I'm going through this process so that if at the end of that process the Government decide not... This isn't right, we've decided not to take us forward that I'll be in a position to pick up the ball and to move forward with my own proposal. In the previous session I had a bill on British Sign Language and I introduced that in my first year after being elected and it took four years to get from first introducing to passing that legislation. So if the Government were to decide not to and I was to pick up a private member's bill fresh already over a year into the parliamentary session, then maybe there'd be difficulty with the timetable and getting that passed in this individual session. So I decided to run that in tandem and like I said, if the Government's consultation concludes and they decide to bring forward their own legislation, fantastically have my full support. But if not, and I'll give them the time to come to their own conclusion. But if not, then this process is to run in tandem so that I'm ready to take forward my own proposal if they decide not to. The greatest respect to a number of members on this committee now, I was on the health committee in the last session and basically we went through this and I actually travelled along with Duncan McNeill to Madrid to see the Spanish system. And there were quite a lot of concerns about Ann Taggart's bill and Ann Taggart again I would say I was a very nice lady. But unfortunately during the time that the vote was held, the basically the Government did give the commitment that they would bring forward the bill. So knowing that and knowing, sorry, time of the pain again, but knowing your personal history and we are father. Why did you feel you had to pick it up as it mainly because you agree and the point that we are father and I do apologise for actually it that way. But basically I'm interested to know because the Government did give a commitment in the last session that they would bring forward a bill in this session and they have tabled basically a consultation and just to finish off convener, you said can you reiterate, you basically saying that if the Government carry forward this, you will hold back and wait until they table a bill and then you will move and work along with the Government to get that bill because quite honestly Mark, we all want it. I want it, you want it, sure everybody sitting in this room wants it, but with a great suspect and targets bill the last time was flawed and that's why I didn't vote for it and I'm totally agreeing with carrying this bill on but that's why I didn't vote for it in the last session. Well, in the previous session the Government made a commitment to go out to consultation and that's what they've done. I'm not aware that the Government actually made a consultation to legislate for an opt-out system if they do and they table their own bill, like you said, I'll say fantastic, I'll get right behind it. That'll lend any involvement from me in a private members bill perspective and I'll support them in any way that I can. This is purely, almost as a safeguard that if the Government decide not to take forward legislation that I'll come in with my own private members bill but I hope that they do and they'll have my full support if they do so. Thank you and sorry for putting you through that. Some points, Alec, briefly. Just on that, irrespective of whether the Government made a commitment to consult or to legislate, I've fully endorsed Mark's position as a stopping block for that because in 2012, and do the right thing, the report to the UNCRC about the implementation of children's rights in Scotland, then Minister for Children made a commitment to legislate the age of criminal responsibility in the last Parliament and yet that didn't happen. So I think it's absolutely right that in a kind of built-in braces fashion that Mark takes this twin-track approach but in good faith that the Scottish Government will make good on that commitment and will work alongside them. So I'm absolutely endorsed the position today. Thank you, Mark, for coming along today and thanks for explaining the why now, which was one of my questions, was the why now. I'd like to ask you a little bit about you. You're saying that there's sufficient evidence already or sufficient consultation and it's just a bit about some of the consultation that's already been done. Also, the Scottish Government's out-of-consultation at the moment, so we can't use that as evidence that we don't need consultation for your private member's bill. And I'm looking at this from a purely health professional point of view. So there were two previous consultations. Is that what you were saying? There was the one for Ann McTaggart's bill? Ann McTaggart carried out a consultation on the health committee and out their own consultation. Well, the health committee carried out, from what I can see there, it was an online survey, a self-selecting online survey of about 900 people. With the online survey, from the information that I can see there, from the health and sport committee at the time, was very much, it was promoted by organisations who were actively campaigning for an opt-out bill. And the previous private member's bill consultation, there was 559 respondents, is that right? Of which there were 529 individuals and 30 organisations, and from my reading there of the consultation, the organisations which were very church organisations, professional bodies, those actually involved in transplantation were quite split over the consultation that was there. Can you maybe give me a bit of a flavour of your rationale for why you feel those consultations are sufficient not for you not to have to go back and consult with the public? The proposal that I've tabled is the same as Ann's proposal, so I've begun out to consultation with the same people, with the same proposal, and in all likelihood getting the same responses. The committee did have an online survey, which you could say was self-selecting, but any consultation, the government's consultation, it'll be a self-selecting audience. They did have organisations respond to that call for evidence by committee at six health boards, the general medical council, UK donations, ethics committee, Scottish donation and transplant group, no-field council and bioethics, so it wasn't just individuals, there's some pretty big organisations who have a lot of experience in the field. If you would be putting out the same questions that then resulted in a flawed bill, I can't quite find or follow the logic in that. Would you not look at trying to explore other areas? I just think there's been advances in medical technology since 2015 in terms of tissue transplant, transplant of limbs, things like that. Would you not look at covering some of those areas as well in a consultation if you had to go and do that? The consultation, the proposal that I've tabled is a one-line proposal, and just because the one-line proposal was the same as Ann's doesn't mean that the bill at the end that would be introduced would be the same as Ann's. Certainly, obviously, I would look to take advice from the committee and the evidence that committee received at the last session, the debate that we had in Parliament, already in discussion with the Government and talk about the particular issues that they had around Ann's bill and look to introduce a different bill that certainly wouldn't be the same bill that would be introduced again. My apologies, I thought that's what you had said, so the information would be the same. I think that this is something that we need to get 100 per cent right. I think that we need to ensure that any bill that's placed before Parliament has to be 100 per cent right, because it's too important not to get it right, and we need to get it right the first time. Thank you, convener. Who is next? Alison. Thank you, convener. Can I, just for clarification, formally, if the committee votes against your proposal today, we would actually be asking you to carry out a further consultation. So we would then have, well, there seems to be some discussion here, whether two or three consultations have already been carried out, so we would in effect be asking for a fourth consultation. While you have very reasonably, I would suggest, said that you're very happy to absorb the Government's ongoing consultation at the moment. That's correct. Technically, if the committee doesn't agree, then they would ask me, I would have two months to go out to consultation and go through the normal member's bill procedure. I wouldn't conclude that consultation by the time the Government had already concluded their own, so yet four, it would be the fourth consultation in three years. I would probably suggest that there be some repetition there, duplication and clearly a delay to progress. I think that what concerns me is that Minister Eileen Campbell says in her letter to the convener that the Scottish Government intends subject to the outcome of the consultation to bring forward legislation, so there is no guarantee. So it is the case that if members of this committee are determined that they would like to see great progress here or guaranteed progress, then we should support your proposal today. Certainly, there is no guarantee with the Government consultation. I'm saying that I guarantee that I will bring forward legislation at some point if the Government do not, so yet if the committee were minded to see legislation on opt-out, then the only way to guarantee that is through this process. Okay, thank you very much. Thank you very much for coming along this morning, Mark. I think that we all sympathise and commend you for your aims in bringing this forward. Just firstly and for the record, can you categorically guarantee that you will not make a lodgy formal proposal until not only has the Scottish Government consultation been completed but they have published their results and analysis? 100 per cent. The Government consultation is due to end in March. I would expect a month, maybe two months until the provided responses. The language was when the consultation closed, which is in the 14th of March. I want to clarify, is it when the consultation closes or when the results are published by the Government? I would actually not plan to lodge anything until even later than that, until the Government come to affirm a decision as to whether they will bring forward legislation or not. Thank you, I just wanted to clear that point up. A second point I want to ask is if the consultation isn't specifically on an opt-out system or not, it's about how we increase organ donation and it obviously includes as Parliament mandated to do in February of last year to have a broad consultation, including a consideration of opt-out. Were the consultation to come back in the evidence and analysis to suggest that actually your proposal would not in the view of the response of the consultation and the Government lead to an increase in organ donation? That's ultimately what this is about, it's about increasing organ donation. If the consultation were to suggest that that would not be the case, would you still bring forward your member's bill? Yep, there will be consultation responses which support the system, an opt-out system, there will be consultation responses against, on a similar basis to Anne's consultation, the committee's consultation. I'm of the personal view that an opt-out system would increase the number of organs available for transplantations at which would save lives and I'm committed to taking forward legislation in this Parliament on that basis. I appreciate that, it's just that in your statement of reasons you cite a consultation and for what you've said that you've indicated that, regardless of the outcome of that consultation and the results, you're going to proceed. Yep, the Government on the same basis, the Government will take a view at the end of that consultation as to the merit, how much weight they apply to each submission and they'll decide what they do on the basis, they'll agree and disagree with some responses and they'll plot a course from there and I'll be in the same position, I'll agree and disagree with some of the consultation responses and I've already said I'll plot a course to introduce legislation if the Government doesn't. I do appreciate that, but it seems that you're prejudged in the consultation and in fact you're already going to, the only reason you've suggested that you would not lodge a final proposal would be where the Government to indicate that they were going to legislate. You've not stated that, where this consultation to and the analysis to demonstrate that this is not the best way to proceed, you would withdraw, which suggests that if you're citing the consultation as evidence for your bill, but you're not going to use the consultation because you've already taken this decision, is that really adequate for a statement of reasons? The point I'm making really clearly, the process has been prejudged. Well, the statement of reason relies on consultation that's already been carried out by Ann and the committee, simply pointing out that asking me to consult on at the same time as the Government's consultation. Point I want to come back to then because if we're going to accept that the consultation is going to be getting carried out simultaneously, the Government consultation is under way, the results of that are ultimately only going to be used if it's supported with the proposition. It then comes back to the existing consultation that Ann McTarger had in the previous session, which led to a bill that was flawed, which was a view of both this committee and Parliament. And I only ask these questions because I share exactly the same aims. I just want to make sure we get this absolutely right. And I want to know why it is we've been asked to waive a consultation. And if you're citing things such as the Scottish Government consultation, which isn't actually going to have an impact on what are you deciding to proceed with this or not? The process for a private member's bill is that a member will have a particular view on whether legislation is needed to change a situation. They'll then go out to consultation to ask what the public view is, where there's a public view for a particular mechanism, whether particular avenues are appropriate or not. But at the end of the day, the member in charge will still be of the opinion that legislation is needed in their consultation. It's on the mechanism, so I think almost every single consultation, every single private member's exercise in the history of the Parliament, will have almost been prejudged because the Memberhood tables believe strongly in that course of action and they go out to consultation to consult on the mechanisms for doing so. I appreciate that. My way that time has been going on, I'll rest on that point. It's the final point I wanted to inquire on was your explanation for having lodged a draft proposal was to, I think, expedite the process for a Belt and Races approach, is Alex Cole-Hampton now. That was in the 19th of December at the end of January and it's already before committee. And if this committee accepts your statement of reasons, you will then be free to go ahead and lodge the final proposal. That's taken factoring in recess a matter of weeks. Why did you choose to lodge that proposal before Christmas and not wait until the Government had concluded its consultation where you would have all that evidence available and analysis? You would have an indication from the Government whether or not it wished to legislate. Why not wait until then to lodge the proposal? Actually, I came back after the election with the intention of lodging a proposal straight away and I would have done so except I put a call for a meeting with the Minister. I didn't want to table anything and take anything forward without speaking to the Minister first because I wanted to basically see what the lie of the land was with the Government if there's any way that we could work together. So actually, I didn't get that meeting with the Minister until November. So we sat down, we talked through where we felt things could have been changed with Anne's Bill, how broadly supportive the Government was. So the reason that a proposal wasn't tabled actually in May or June before summer recess was that I thought the best thing to do was actually to sit down with the Government first and the timing of this proposal has simply been waiting to meet with the Minister and then going ahead after that discussion. Thank you, another question. Thank you, convener, and thank you, Mark, for coming to see us today. I think it's worth putting on record the work which Anne McTaggart did do, although the bill wasn't successful around this. Specifically, I wanted to ask, you've said that you've received no assurance from the Minister that the Government would take forward a bill and I think that's concerning, but do you feel that there's been any delay from the Government with regards to this and also, secondly, how do you see your work and that of the Scottish Government going on at the same time together will actually help eventually deliver a really strong bill which can be supported across the parties in Parliament? Well, the Government have come back after the election, they've taken the time to pull together a consultation document and gone out to consultation within the year since we've come back, still within that calendar year, so they've taken the time to get it right. That's appropriate, I hope. That's what they'll do right through the process. They'll take the time to get it right and they'll bring forward good, strong proposals on an opt-out system. I think the Minister has said in a recent article that they have a presumption in favour of introducing legislation after the consultation, which is excellent. If the Government decide to take it forward, they'll have the full weight of the civil service behind them, much more resources than I ever would in my private office and I'll simply say to the Minister whatever I can do to help, give me a call and let me know, and that would be the extent of my support, supporting as much as I could as a backbencher. Marie. Can I just ask? Thank you very much for your evidence so far today. I wanted to ask specifically about the process of consultation and what the purpose of it is. I'm conscious that the last bill failed and I would imagine that there was an opportunity in a new round of consultation to look at the specific areas on which the last bill failed to hopefully inform the development of a new bill which was stronger and more robust and less likely to fail, more likely to succeed. Is that not the purpose of consultation? Well, I wouldn't be going out to consultation on a bill so there wouldn't be a bill ready to go out and for people to say, I agree with section one, I don't agree with section two, I could amend part of section three. The consultation would simply be on that one-line proposal and I think the committee and government have already said that they commended the Aims of Anne's Bill which is effectively that one-line proposal. So the meaningful discussion on actually the content of the bill happened in here and committee and in the chamber when there was debate around a specifics of a bill and at this stage without having a bill drafted to go out to consultation that you just wouldn't generate that same level of discussion, it would be a consultation purely on that one-line proposal which would generate much similar response to what we've already had. So there wouldn't be any opportunity to drill down into the particular feelings of the last bill at all? Not until you had, I mean you could have pre-legisl of discussion with government and civil service but the way the bill process works is that you would lodge a one-line proposal to go out to consultation and you would come back after that consultation, have an analysis of the consultation and then send away a policy document to legal draftsman who would then draft a bill for introduction to Parliament. I just wonder if it's worth, I mean I didn't look at the particular consultation that occurred in Wales and whether it was a more robust process than that but I was struck by the numbers. So our consultation last time around got 500 and something responses. Wales, which has a smaller population, got nearly 3,000 responses and to me that strikes me as a much more robust consultation and that might just be why their legislation passed in Wales. That's my concern and if everyone around the table has agreed that what we want is for a successful bill to be tabled, is there something that we could look at there? I would agree and I think the reason the Welsh Bill and the Welsh consultation has so many responses was because it was a government bill so it had the full weight of government, it had a PR department and a budget for publication to get so many responses. If I was going out to consultation, I would be using the exact same resources you have in terms of two or three members of staff, maybe posts on Facebook, social media to try and get out there but with the best of all in the world, I'm just not going to reach as many people as the government will do. And that's another reason I think that the government consultation will be better placed to seek a much wider range of responses. That's why I wouldn't do anything until that exercise is concluded and the government have taken a decision as to whether they carry go forward with legislation. Thank you. Okay. Thanks. Oh, sorry, Ivan, yes. It's your question round about procedure and timing so I don't know if you can answer it or it may require the committee clerks to comment. My understanding is that the stage you are at the moment, you're bringing forward the proposal and then you bring forward the final proposal after that and then a clock starts ticking, I think, for a month. But you've undertaken not to do that until such times as the government's consultation is finished and they've commented on that. Given that, my understanding therefore is that if you want to proceed at this stage, even if the committee was to agree at this stage to what you're proposing, then there's no time lost because you're going to be sitting waiting anyway. Is there an option that, given some of the concerns that have been raised in your commitment not to proceed until the consultation comes back with the fair at this stage and you come back later in March when the consultation is finished with the same proposal for us to move forward or not, is that an option or procedurally is that an option? And I think, and maybe the collapse would connect me if I'm wrong, but I think procedurally the committee has to make a decision within a certain timescale and I think that timescale passes at the February recess and so as to make a decision before recess whether you ask me to go out to consultation or not. I mean, you could ask me to go out to consultation again. I would go out and carry out that consultation exercise, but as Marie Todd points out that the government consultation that is running at the same time will have a much wider reach and a much bigger budget and I would expect a much higher response rate than I would be able to generate through my own private office, so running both at the same time, I think, probably... No, that's the answer. Thanks for the clarification. OK, Mark. Thanks very much, Andrew. Thank you very much for coming along. As agreed, we'll now take the next item in private.