I welcome to the 10th meeting of the Health and Sport Committee and the Scottish Parliament's 5th session. I ask everyone at the room to ensure that their mobile phones are silent and that it is acceptable to use mobile devices for social media, but please do not take photographs or phone proceedings. The first item on the agenda is an evidence session on the Audit Scotland report NHS in Scotland 2016. I welcome to the committee Shona Robison, the Cabinet Secretary for Health and Sport Paul Gray, director general health and social care and chief executive of NHS Scotland. Welcome to the committee. I invite the cabinet secretary to make a brief opening statement. Thank you very much, convener. As I made clear in my parliamentary statement last week, the Audit Scotland report has provided a balanced overview of the NHS and made several recommendations, which we accept in full. I welcome a further opportunity to discuss the report this morning. Our investments and achievements are recognised and the report funding is at a record high of close to £13 billion. Staffing is at its highest ever level, and health, patient safety and survival rates are all showing improvements. But, as I highlighted last week, to equip our health and social care services for the future, we must reform as well as invest. We recognise the demands and pressures, and that is why we will continue to drive forward our significant programme of transformational change. By the end of this year, we will set out a transformational change delivery plan for the integration of health and social care, the national clinical strategy, the public health strategy, realistic medicine, workforce recruitment, supporting population health and meeting the 2020 vision. Audit Scotland highlights that we need to make a real shift from relying on treating people in hospital to supporting people with better care in their own homes and communities. That is what we intend to do. Over the course of this Parliament, we will increase health spending by almost £2 billion, and we will invest an additional £500 million in primary care. That will let us see, for the first time ever, half of the health budget spent in the community delivering primary community and social care. The committee will also be aware that we are investing £200 million in elective and diagnostic treatment centres to address the changing demographics of our nation over the next 20 years, particularly in meeting the likely increase in our elderly population. It is important that we focus on outcomes for patients and that the mechanisms we use to measure performance better reflect those outcomes. Our arrangements for a review chaired by Sir Harry Burns will ensure that our targets and performance indicators lead to the best outcomes for people being cared for, whether in hospital primary care, community care or social care. Our Audit Scotland is supportive of our transformational change plan. It is now important that we work together across Parliament and with our colleagues in health boards and local government to make that happen. It is through this approach of continued investment and reform that we will set the basis for delivering the 2020 vision and our longer-term strategy up to 2030. That will ensure a safe, sustainable and person-centred NHS for the people of Scotland. Thank you very much. I could ask any of my colleagues if they wish to open the question. Yes, if I might start. Thank you Cabinet Secretary. The committee is aware of your proposal to present the plan to bring about this transformational change by the end of this year. The Audit Scotland report has said that it is not clear yet what number and levels of staff will be required until further work is done on testing new models and a clearer plan is in place. It points out that the workforce implementation plan that the Government has published is high level and does not outline the workforce requirements to deliver the 2020 vision. The National Clinical Strategy and the Committee recently heard from the Royal College of Midwives who said that the NHS is running a third test of its workforce planning tools for midwives and that if it is having a third test to run the tool, it cannot tell me that the tool is robust. The Royal College of Midwives also suggested that some previous workforce planning had been done in isolation by boards without getting the input from professionals on the ground. I would be grateful if the Cabinet Secretary could tell the committee what is happening at the moment to develop this workforce plan with all those that we have heard evidence from. I very much want to involve all the stakeholders that you mentioned and others in the development of both the regional and national workforce plan. Workforce planning has been a key part of the NHS for a long time, but it has tended to be at board level. We have obviously worked with boards to make sure that they land their workforce plans as accurately as possible. What we do recognise is that we need to take a regional and national approach to workforce planning in a way that we have not previously done. That is a new part. That, of course, cannot sit in isolation, which is why the delivery plan that I have talked about this morning and Audit Scotland talked about is that we have to bring all the strands together. We cannot just look at workforce in isolation, which has to be overlaid by the financial plan, the national clinical strategy and realistic medicine. It is about bringing all those elements together in a coherent way that will set out for the next five, 10 or 15 years what is required to make some of those changes. For example, in the workforce plan, a key part of that will be what is the primary care workforce that is going to be required to make that shift. That is not just about GPs, it is also about advanced nurse practitioners, it is about allied health professionals, bringing all of that together in order to make sure that the workforce, some of those which will be new roles, I suspect, as we go forward, is there in sufficient numbers as we move and shift the balance of care across. That is, I guess, what the new part of that is. It is almost as much of an art as a science to get workforce planning accurate, because things change and you may have a workforce plan aboard, you may have a workforce plan that it thought was robust, but then the needs of their local population can change and they can find that they need to make changes to that workforce plan, which is why the regional and national approach is right, because we can project as far as we can about what those changing needs are going to be and what the workforce requirements will be, particularly in primary care. Donald McCaskill, the chief executive of Scottish Care, told the committee that the vacancy level for social care nurses has now reached 28 per cent. I appreciate what you are saying about the Government perhaps having a wider vision about which professional vacancies we need to fill. Is it the case that there is going to be greater national direction on previously non-controlled subjects? I think that there will need to be greater national and regional direction than perhaps there was previously. Obviously, social care is, again, more complex, because in the case of care at home, you obviously have local government as the employer, so through our integrated plans, through the IJBs, that workforce requirements across health and social care will need to be integrated, so it is not just about health, it is about the social care dimension as well. In terms of nursing homes and the nursing component, I know that the RCN has raised concerns. It has always been a difficult area to recruit to for a variety of reasons. We are keen to work with the RCN to look at whether we can enhance the career opportunities that may exist for nurses working in nursing homes that could take advantage of training opportunities and career development within the NHS. We need to look at more imaginative ways of trying to encourage nurses into the nursing home sector, if we are going to stabilise that. Jill Vickerman of the BMA last week expressed concern about the way that vacancies are currently recorded. In order to fully understand what vacancies exist, would it not be more sensible to include posts that are currently being filled by locums or posts that have been advertised and no longer are? I think that Jill Vickerman made the point that if staff on award, for example, know that there are actually 10 vacancies but only three are currently being advertised, then that has an impact on morale. How can we possibly—I just think that a clearer system would be appreciated by all? I understand the point that Jill Vickerman is making. There's obviously been a standardised way of recording vacancies. I understand the point that she and others have made. In addition to the work on trying to fill vacancies, some of that is very challenging, not just a Scottish problem but some specialties that are very much a UK and international problem. A lot of work is going on to try and attract people to those posts, making the posts more attractive across more than one site and all of that work. However, what we're also doing is looking at whether or not posts that are continually filled through locum and agency can be dealt with in a different way or perhaps certainly in the case of agencies. Some of that is being dealt with through the work of the CNO and looking at converting some of that agency spend into substantive posts themselves rather than relying on agency and back nurses. If a shift rotor in a hospital is continually using a high level of agency nursing, then an analysis of that may determine that the better thing to do is to convert that into substantive posts. Those discussions are going on as well. That's more difficult in locum in terms of medical posts. We do have the medical bank, which tries to help with short-term vacancies, but that is a bit more challenging. However, again, we are happy to speak to Jill Wickham and others about how we take that forward in our workforce plans and we will listen to what they have to say. My question is really just as a supplementary to Alison Johnstone's on workforce planning. It is to ask what impact Brexit has had upon the deliberations in the work under way of workforce planning. In particular, given the UK Government's failure to assure the status of EU nationals and, indeed, describing EU nationals' bargaining chips, I wonder if any contingencies have been factored into workforce planning in the event that we have a hard-bred exit. Obviously, this afternoon's debate is going to look at those issues in more detail. There are concerns about the impact on, in particular, our medical nursing workforce and medical doctors. Currently, there is about 6.8 per cent of our EU status, which means that, if we weren't able to retain those doctors working here in Scotland, that would be a significant dent in the workforce. We want them to continue to work here, as well as the nurses and the social care workforce that have come to train and work here in Scotland. We value them very much. One of the things that we have made a commitment to is to reassure the students who are already studying and those who are about to begin their studies here and those who are applying to study here from 2017-18 that they will continue to enjoy free tuition for the duration of their studies at our medical and dental schools. Unfortunately, the bit that we cannot provide assurance on is about the future rights to remain here to train and work. This could impact on their future career decisions when they are deciding where it is that they want to go. It is an important issue. It is part of the negotiations. We will have more to say about that later today. I think that it is important that the key message is to be very much valued, the contribution that they already make within our health and care services. Good morning, Cabinet Secretary. Thank you for coming to us this morning. The Audit Scotland report was quite uncomfortable reading for all of us who have a stake in the healthcare profession. The Government did meet one target, and that was in the treatment of drug and alcohol cases, particularly at the acute end, and I congratulate it for that. However, I would suggest that perhaps this is a case of what the Government gives with one hand that takes away with the other. We heard last month from Robin McCulloch Graham, who is the chair of the Integrated Joint Board of Edinburgh, that the impact of the 22 per cent cut to alcohol and drug partnership funding in the last Scottish Government budget would be measured out as a £1.3 million year-on-year loss to services in the drug and alcohol field in Edinburgh alone. That is, to my mind, a fire sale, and we will see the impact of that over not just years but decades in not just Edinburgh but everywhere in Scotland where drug and alcohol misuses a problem. We have seen a measurable rise in HIV cases in Glasgow already. I want to ask the cabinet secretary to give us her reflections on the Audit Scotland report and the fact that, although we may be meeting the acute treatment targets on drug and alcohol misuse, we will be missing out on the end game. If I could make a overall comment about the targets, it is important to say that the 31-day cancer target was only missed by about 0.1 per cent, which still are people. There are about eight patients in total, and we have to strive to do better than that, but Audit Scotland put that in some context. We also recognise that we have a challenge on outpatients, and that is why we are bringing forward an additional investment in outpatients, but, importantly, a transformation programme about patients, because we need to better manage the outpatient capacity. On alcohol and drug partnership funding, you will be aware that we also wrote to boards asking them to support the funding levels of ADPs. Some have, some haven't, and we will continue to work and discuss with those boards how we make sure that the outcomes of delivery of alcohol and drug outcomes continue to be as good as they are. In fact, many partnerships have well over-delivered what they were asked to deliver, which is a good thing. They have delivered a very high level of performance, and there has been a substantial investment in alcohol and drug funding. We have also said that we need to review the priorities and have a look at the performance more generally of ADPs and how we may want to discuss with ADPs some of the changes that they may wish to make and to focus on the outcomes for the next period of time. As I said in the committee before, we will continue to talk to boards about ADP funding, we will continue to look at what ADPs do, and we will continue to look at what the outcomes are and make sure that they are in a position to deliver those outcomes. I am grateful for your answer, and I am certainly encouraged to hear that this is still very much on your radar. However, 22 per cent, as a cut in the overall budget to alcohol and drug partnerships, can only lead to withdrawal of service in some areas, as we are seeing in Edinburgh. It is fine for you to go to the local health boards and the integrated joint boards and say, make this money up somehow. It is a very different thing to actually make that materialise on the ground. With that loss of service, we will undoubtedly see a proliferation, drug and alcohol misuse or long-term addictions going on treated, which I think will then have a material impact on those treatment targets that we see. If we see an increase in demand for acute treatment targets in treatment, then those targets will be missed in the future. Can the cabinet secretary explain to us the reasoning behind the original cut to the 22 per cent in ADP from the Scottish budget last time? The budget was a devalucation of health and justice funding, as I am sure you are aware. To put a bit of context, as a Government, we have invested over £630 million to tackle alcohol and drug use since 2008, so it has been a significant investment. We made it clear to boards that we expect the outcomes to still be met and that they will require to ensure that that happens. We suggested that boards should maintain the level of funding through their own resources. Of course, boards have been given above-inflation increases this financial year, but however they do it, we still will require ADPs with the support of boards to meet their outcomes. Part of that is the review. That review is under way with key stakeholders looking at how we support them to do that. There may be some need to focus some of the ADPs more around those outcomes. ADPs are very varied in what they do and how they operate. We need to bring a bit more of a standardisation to that, but the bottom line is that outcomes matter. The funding is important, but what matters is the outcomes for that funding. We have been clear that those outcomes still require to be delivered. That will either be through the level of funding that they have allocated. If they can do that with the funding that they have and deliver the same outcomes by doing things in a different way, we will look at that. If not, then we would require and expect boards to support the ADPs in delivering those outcomes, but the outcomes still require to be delivered. I think that everybody around this table would absolutely agree that the outcomes matter and the outcomes still need to be delivered, but this cabinet secretary has the feeling of a premiership football manager still telling its team to deliver the same result when three players have been sent off the pitch. That is what we are talking about here. We are talking about a 22 per cent loss in resources. I do not think with respect that you answered my question as to why the government felt that it was okay to withdraw that 22 per cent of funding. We have asked boards to support that funding at the same level as previously. The budget was an amalgamation of health and justice resources, and we have asked boards to supplement the funding. If you look at the outcomes, which are again the most important, the funding is important, but it is what is delivered for the funding. The waiting times have been hugely reduced, with 94 per cent of people now being seen within three weeks of being referred and routinely meeting the national 90 per cent within three weeks local delivery plan standard. Drug-taking in the general population is falling. I think that in the light of all that information, it is important that ADPs look at what they are delivering, their existing outcomes, and what the outcomes should be going forward. As part of the review of targets and indicators more generally, we think that ADPs should be focusing on over the next period of time. In the light of some of that shift in behaviour, there are still challenges, particularly among some of the older population. We need to make sure that substantial resources that are still going into drug and alcohol are delivering the right things and perhaps refocusing on where the biggest problems still remain in the light of some of that population behaviour change, which is a good thing. Cabinet Secretary, we have heard several times this morning that outcomes matter. According to the report, there is a funding crisis, there are workforce problems impacting on patient care, agency use up, vacancy rates up, and seven of the eight key targets or outcomes are being missed. If outcomes matter, we have a problem. How can it be if seven out of the eight targets are being missed, that further budget reductions are being regarded as efficiencies? I could direct it to Mr Gray first. Mr Gray is the senior official with NHS Scotland and, obviously, you are responsible along with the Cabinet Secretary for Accountability for this, so that is why I want to bring you in. Efficiency savings have been delivered year on year by the NHS in Scotland. That is not a new proposition. I am not clear just so that I answer your question appropriately, Mr Finlay. What are you referring to specifically as budget reductions that the budget has gone up each year? Well, if we look at different boards, they are telling us that they are making very significant. I do not want to always harp on about Lothian, but NHS Lothian is some 68 million this year of reductions. If you are missing seven out of eight targets already and you are required over the next four years to bring in another three to four hundred million, how on earth can they be called efficiencies? We look to boards to transform their services in order to deliver them more efficiently and to improve the outcomes that they deliver. NHS Lothian is from memory, and I will be happy to provide it with accuracy to the committee if I have made a mistake. NHS Lothian's uplift was 6.4 per cent, so it has a funding uplift. We have put in extra money to Lothian over the past two years to bring them closer to the end of that parity. I do not think that it is unreasonable for the public to expect that the NHS in Scotland becomes more efficient year on year, but that is why the programme of transformational change that we have in train is so important. The further detail that the cabinet secretary will provide to the Parliament by the end of the year, and I have also undertaken to write to the Audit Committee by the end of the year confirming our framework for change as requested in Audit Scotland's report on transforming models of health and social care. I do not think that it is unreasonable to ask boards to make efficiency savings and their budgets have not been cut. I am happy to say something about the eight targets if that would be helpful. We may come to that, but almost every witness that has come before us has raised issues about cuts to services. The only people that I hear of who are saying that there are no cuts to services are senior managers in the NHS. If we have the highest level of investment, as has been stated in the NHS, would you regard this report as a glowing endorsement of the management of that record investment? I am not after glowing endorsements, Mr Finlay. I think that this is a balanced report, as the cabinet secretary has said. As the cabinet secretary has also said, we have accepted its recommendations. Among those recommendations are the importance of sustained transformational change. I think that that is fundamental to delivering a safe person-centred and effective health service. What comment would you have to those patients who have been waiting longer for treatment than they should because seven out of those eight targets have been missed? I apologise to patients who wait longer than they should. I have done so in the past. I regard it as appropriate and proper that I should do so. It is not what we seek, that patients should wait longer than the targets that we have set. However, if I may say on the eight targets that we are, as far as I can determine, and I have done some research, we are the only country in the world that tries to meet all eight of those targets. I am happy to have stretch aims. I believe that it is part of our approach to improvement to have those aims and to be doing all that we can to transform in view of meeting the stretch aims that we have set ourselves. The cabinet secretary referred to Sir Harry Burns' review. It is the right point at which to review whether all of the targets that we have are delivering the outcomes that we want. However, in the meantime, if we are not achieving what we said, we would achieve them. I apologise to those who have not been seen within the time. Can I just make the point that, obviously, in the election that we were elected on a manifesto commitment to increase the health revenue budget by £500 million more than inflation by the end of this Parliament? That was higher than any other party put forward. No matter who is empowering this Government and putting forward a prospectus in this Parliament, it is against a backdrop of increasing funding but increasing demands. If you look at the outpatient demands, for example, increasing over the years, despite those huge increases in demands, most people are still being treated within the 12-week target for a first outpatient consultation. In terms of inpatient rates, 91.2 per cent of inpatients were treated within the 12-week treatment time guarantee for quarter to this year. That is not good enough. We want everybody to be treated quickly, but it is important to make the point that the vast majority of patients are still treated quickly within the NHS. We need to make sure that, through our transformation programme, we improve that performance in a sustainable way. Partly that will be done through, for example, our outpatient transformation work. Our outpatient system is not the most efficient that it could be. We need to make sure that the capacity is used as effectively as it can be. The work of Sir Harry Burns has been political consensus for many years around this. In fact, I think that the spokespeople of all the political parties over the years have at one point or another said that we need to make sure that what we measure in terms of patient outcomes more accurately reflects the patient experience. Sometimes our targets are more input-based than about outcomes. I accept that criticism, and that is why I have asked Sir Harry Burns to look at our whole system of what we measure and why, to more accurately capture what the patient experience is, and that is what we will be doing. We are short for time this morning, so I could ask for answers to be brief as possible. Can I return to the issue of workforce planning? We use the phrase workforce plan, workforce planning a lot. Is there a document or spreadsheet within NHS Scotland that is a master plan that shows, for example, the current levels of staffing across all disciplines, the current levels of vacancies, predicted vacancies going forward, recommended staffing levels in 2017-18? Does it actually exist physically? It does, in that each board has that level of information. We have that on a national basis, also ISD produces a lot of statistical information, so the information is there. I guess, though, the new bit of the regional and national workforce plan is bringing all that together, but not just in terms of what the picture is in the here and now, but projecting on a regional and national basis of what is required in a more granular detail. The fact that that is going to change the nature of the workforce and what it looks like is going to change probably more than we have ever seen. That requires us to make sure, for example, in the primary care workforce that it is not just about producing more nurses and more doctors in the specialties that we have and trying to land that as accurately as we can. Obviously, the nursing and medical workforce numbers, the training places all try to reflect what the needs of the service are going to be. This is different, though, because it is shifting the workforce into more primary and community care based services, which means that the workforce and what it looks like needs to change. That is quite new, and that is why we need to take a national perspective on that. What is not new, surely, is the fact that you need to project forward. You must have needed to project forward in 2010. You must have needed to project forward in 2015. You must have some idea of what you will need in 2017, 2018 and 2020. Of course, that is why we are able to project the number of nursing and midwifery training places, the number of medical training places. It is all based on what the analysis of the needs of the service are, but it is quite difficult to land that 100 per cent accurately. However, our workforce colleagues work very hard with boards to try to make sure that those are undergraduate places and training places that we land as accurately as possible and that the needs of the service are going forward. What I am saying is that we are in different territory going forward for the next five, 10, 15 years, because the nature of services is going to change so dramatically, particularly that shift to primary care. That requires us to look far more in a far more detailed way about how we create that new workforce in primary care. Richard Cullen. Thank you. Good morning, cabinet secretary. Mr Gray. You used the budget words, as I called them, this morning. Transformation programme, reconfiguring services, local services. Things move on, we have to change, we have to look at how we can do things better. Do local health boards actually do enough in explaining what they are doing and why they are reconfiguring services? Too often the Scottish Government gets thrown at it that it is concentrating services. When local boards make decisions that local politicians do not like, they then ask you to call in. I think that is what I call concentrating services. Do you think that there is a better way of informing the public why services are being reconfigured, moved, concentrated and improved? I think that some boards are better than others at different times with service change proposals over the years. You can see where some boards have gone out and consulted the public in a very good and meaningful way. Whether everybody always likes the changes proposed has been, in some cases, more accepting of those changes because there has been a proper consultation in other. There are other examples where that has not been handled quite so well. However, the point here is that boards will always be looking at the needs of the local population. Sometimes service changes happen quickly because of patient safety concerns or the inability to recruit key staff makes a service unsustainable. That has ever been so over the years. What is new is that we now have the national clinical strategy, which provides the framework and blueprint for the future of what the services need to look like. Those services are more specialised in nature and will perhaps have a more regional delivery focus through to what is reasonable to expect your local hospital to provide, which will still be the majority of services. What more can be done in primary care at the moment may well be done in secondary care, but it does not need to be done in secondary care. That is quite new. We have never had a blueprint for clinical services that lays out in that way what the vision should be. Obviously, we need boards to translate that locally and to make sure that what they do and the changes they make are in line with that national policy. What annoys me is that I belong to some of the information meetings that the local board in my area has and they tell us what they are doing. However, when it comes out in the paper, it is entirely different. The public perception is entirely different. What can they do, really, honestly, to improve this? Have more meetings, more social media, more adverts? All of those may be justified and relevant. Communication is key. Boards need to be able to set out not just why they are making the changes, but what a new service will look like. Sometimes that is the missing bit of describing and showing and demonstrating, which is not always easy, but trying to demonstrate what a new service will look like. Quite often, when you go back and talk to the public and patients once a change has happened, they think that the new service is better, but they might not have thought that when the change was being proposed. Change is difficult, and it will always be so. However, it is required. If we are going to invest the £500 million of additional resources in primary care and shift that resource, I do not know what people think shifting resources and shifting the balance of care means other than doing less in acute and more in primary care. That is what it means, and that means that things need to change and services need to change. Otherwise, someone perhaps on this table could tell me how else £500 million in primary care is going to be invested. That is how it is going to be done, but we need to make sure that the public are with us on that journey that they can hear about how much more can be done at their local health centre instead of them having to travel miles potentially to their local hospital or to a hospital much further away. I think that the public will get a better service out of that, but we need to explain that. Can I come back to the issue of efficiency savings? It touches on the point that Richard Lyle made about taking the public with us when it comes to transformational change. We have to be honest with the public when it comes to what is actually happening with regard to savings. The key message in the Audit Scotland report is that funding has not kept pace with rising demand. That is a fact that health boards are having to make, as the report says, unprecedented savings, £291 million in 2015-16, rising to £492 million in 2016-17. Are you seriously saying to the public that every single one of those savings that health boards will make is entirely efficiency savings? Well, I will hand over to you in a second, Paul. Just to say, though, that you will recognise that, as I said earlier in an answer, that all the parties put forward their perspective for funding into health. My party's commitment to the £500 million above inflation was the highest of any party. That went in front of the public and the public made their choices. The health service has now had a percentage uplift. Above inflation, obviously, boards are varied, but every board has had above inflation uplift. Efficiency savings have always been part of changing the way services are delivered. Every penny of those efficiency savings are reinvested into the front line. However, we expect boards to make sure that they are making those efficiency savings in the right way in order to free up resources to the front line. However, you are right about demand rising. That is why Audit Scotland's conclusions are that reform is what is required. Audit Scotland says that throwing more and more money at the NHS is not really the key answer. The key answer is reform and doing things differently. We agree with that. That is why, despite increasing levels of investment, that in itself is not enough. We have to change the way we do things, keeping people out of hospital and treating more people within primary and community services. I have not heard any other alternative plan to the one that we have put forward, and my plea would be that people get behind that. There are some things that we need to stop and want to stop. That is not about simply trying to make everything better and faster. I am sure that the chief medical officer would be happy to brief the committee on her approach to realistic medicine, which, if implemented effectively, will mean that certain procedures of limited value will be stopped. We will not do them anymore because they are of limited value. That is a discussion that needs to be had with the public, and clinicians are much better placed to have that discussion than I am. That is not about us saying that everything will simply continue as it is, but it will be a bit better and a bit faster. However, there are efficiency savings that we have made, which, for example, in NHS Fife, they have an efficiency programme to have greater compliance with the agreed drug formula. That is going to produce a saving of £8 million by getting 80 per cent compliance in NHS Fife. They have done work on the community respiratory team in Glasgow Health and Social Care to support patients with COPD. That has reduced in-patient admissions, reduced the length of staff when admitted and led to more efficient use of medicines and devices at home. I am not going to give a great long list, convener. I am conscious of time. Yes, there are things that will stop, but they will stop because they are not delivering value or because we have better techniques or because there are improved treatments or better drugs now on the market. Under no circumstances am I trying to suggest to the committee that everything will remain the same. As the cabinet secretary has said, it cannot remain the same and deliver what the people of Scotland need. The question was about all the savings, efficiency savings. Are you telling the committee today that not a single one of the £492 million pounds worth of savings at health boards will have to meet in 2016-17 will adversely impact on patient care, not a single penny of those savings? Every one of them is efficiency or changes to do things better. None of them are to do with balancing the books. None of them will impact adversely on patient care. It is important that the books are balanced, but it is important that patients get a good service. What we expect boards to do in the changes that they make is to make the services better, delivering them in a different way, but they can be delivered in a more efficient way. Paul Gray has just outlined a small number of examples of how that can happen. If we do not encourage boards and support boards to make those changes, nothing will change. We require to make sure that every penny and every pound is spent in the most efficient way. That is a prudent way to manage the finances of the health service. I do not think that anybody disagrees with that, but that was not the question. The reality is that if we are going to take the public with us when it comes to transformational change, we have to be honest with the public. I do not think that it is being honest if we say to them that not a single penny of the savings that health boards are making will adversely impact on their care. Staff see it every day, patients see it every day. Why do not we just be honest with the public and say, look, these are difficult decisions that will impact adversely because there is not sufficient funding there? It is not meeting the demand. Instead of simply dismissing funding, it is only an efficient saving. It is only change. You cannot take the public with you unless you be honest and say, yes, there will be cuts made by health boards that will adversely impact on patient care. All those efficiency savings are reinvested in services that patients want and need. If efficiency savings are there to help, drive, reform and change and reinvest in the front line, it is about doing things better and differently. Some of those decisions inevitably will be difficult because change is difficult, as I was saying earlier on. Of course we work with boards to make sure that the efficiency savings that they have identified are ones that are going to make those improvements. We are not just sitting back and saying to boards, going to do whatever you want. Of course that is a managed process and we require them to discuss with us the level of efficiency savings, what those efficiency savings are and, importantly, what they are going to deliver in terms of change. Can I just follow up one question on the funding that you mentioned in your manifesto comments, cabinet secretary? Can you tell me where in the manifesto you committed to reducing local government budgets by £450 million? Do you think that that has been a good thing when it comes to social care and preventative health or a bad thing? I think that the public made their choices based on the manifesto perspective that each of the parties put forward. We put forward a prospectus to increase health funding by £500 million more than inflation. The public made their choices and made their decision. I think that at the end of the day that is what elections and democracy are about. We were very clear about what our priorities for spend were. We have also of course transferred £250 million into social care because we believe that it is important that we look at the whole system and that health and care are inextricably linked. That is why the £250 million into social care is not just delivering extra capacity in social care, which can get people out of hospital and keep people out of hospital, but also delivering the living wage for 40,000 care workers, which is hopefully something that you would welcome. I certainly do welcome it because I did propose it several years ago. We have run over it because we started a wee bit late and I have three members of the committee who still want in. I have been then clear. I want to clarify and dig a wee bit deeper on some of the numbers on the budget. I understand this a wee bit better because there are people throwing stuff about about cuts this and cuts that. Is it true to say that the budget in 2015-16 was £12.2 billion and in 2016-17 is £12.9 billion, which is an increase in cash terms of £700 million? That is correct. Even taking into account inflation, the increase in real terms is 2.7 per cent. There is more money going into the health service. There is twice as much money extra going into the health service as you need to cover the inflation cost rise. That is the fact of what is going on. If you look at the page on the Audit Scotland report, it talks about £490 million in savings, but that is in the context of extra funds going in. Is it not then therefore true to identify that as being a redirection of resources within the health service because, effectively, you are taking money from one area and moving that £490 million along with the extra £700 million that has gone on top of that into other areas of the health service? Would that be a characterisation? That is correct. Without doing that, we would not be able to resource the shift in the balance in the investment in primary care and the changes that need to be made. You cannot do that just with new money alone. You have to also shift the existing resources, which is partly what the efficiency is. That is clear. People look at that and think that there is £492 million of cuts and, in actual fact, a £700 million increase in cash terms. Clearly, that comes down to what you deliver for that, but it is also true to say that there has been increase in demand, there are more GP visits, there are more inpatient episodes, more outpatient demand, plus the cost of drugs are going up. In terms of what is being delivered from that money, which is the real measure of efficiency, it is true to say that we are getting more bang for our buck, if you like, in terms of the output from the health service. There are far more people being treated in the health service than ever before. Outpatient demand, inpatient demand, GP demand, yes, absolutely. The Audit Scotland point is that demand is growing and we have to manage that demand and make sure that we use the collective resources of all the skills of the NHS to perhaps get people to the right place. That is the programme of reform and transformation that is under way. That is the caveat. Although there are additional resources in the NHS, including a redirection of existing resources, demand is growing. Just one final point, then. Clearly, there is a direction in the national clinical strategy, integration, et cetera, and health boards are coming forward with proposals that the state are aligned with that. Clearly, each of those proposals would need to be examined to understand whether they are aligned with that strategy or whether the health board was just putting it in the context of that and it did not actually align with that strategy. Clearly, everything that the health board comes forward with does not necessarily comply with that strategy just because the health board describes it in that way. If you look through the Audit Scotland report at the end of that, it talks about an example in New Zealand where they have made that shift in Canterbury from towards more integration and towards community spend. I wonder if you had looked at that in a bit of detail, and if you had any understanding of how they actually did that and what it delivered in real terms. At the moment, it is very much about an aspiration. We think that it is going to save us money in theory. It should, but as the report says, we will not have hard and fast numbers because that New Zealand experience gives us any confidence of how much can be delivered by going down that road. We have looked at international experience. You can draw some information from that, but every health service has its uniqueness. The solution has to be a Scottish solution, whereas I am sure that there are lessons to be learned from elsewhere, but I think that the plan, the strategies that we have are very much bored and out of the needs of the Scottish population and the type of systems that we have here. One of the aspects of Audit Scotland's report, which has not been touched on within the Parliament, is around the buildings estate that we have. The fact that there are now repairs needed to almost a third of all NHS buildings with a 50 per cent maintenance backlog with boards now classifying these is high risk and significant. What programme are you aware of of this being addressed and are we actually seeing a situation where we are building up an NHS buildings crisis in the future? On the other point, just to touch upon Ivan McKee's question to you, what do you actually think health inflation sits at? On the states, there was a recent report that showed from memory, and I can write the details to the committee that there had been an improvement in the amount of work being done on the most urgent parts of the estate. I think it is also important to note that there has been a massive and continuing massive capital investment in renewing the estate. If you look at the hospital bill programme and the investments in new health and care centres and primary care, there is a lot of capital investment in renewing the estate and making it fit for the future, but I am certainly happy to write to you with more details on that. In terms of health service inflation, the traditional pay and prices in inflation varies from 1 per cent on pay to 10 per cent on drugs, taking as an average across all the areas of expenditure paying prices and inflation between two to three per cent, probably closer to three than two. We also estimate that changes in demographics amount to about 1 per cent per annum in costs. In other words, if the demographic trends continue, that will cost us another 1 per cent a year. To come back on both those points, I think what is concerning for me in terms of the estate is the report outlining the fact that both NHS Lothian and Tayside, who are both in the most difficult financial positions, have fallen back in their estate under that report. The number of buildings at high risk and significant have increased, so we really have to be aware of the decision-making that is being taken by those boards. The health committee has had a number of people giving evidence who have said that they see health inflation at six per cent. I think that is where a lot of discrepancy seems to be between budgeting within the health service if you are working towards between one and three per cent from what you just said. I cannot really account for what others say in terms of inflation. What we are saying is that those are the figures from the work that is being done around the health department. If you look at the GDP deflator, it is 1.8 per cent, which is a proxy for general inflation. In health, it is around 3 per cent taking in account of the other aspects that Paul Gray talked about, and that is the basis of the calculations that we make. I am just to be clear that Audit Scotland has got it in here at 3.1 per cent. That is what Audit Scotland thinks it is. Given that we accept the Audit Scotland report, that is probably a good place to agree on. In that there is some correspondence with health boards, because my own health board tells me that it is sitting at 6 per cent. Clearly, if NHS centrally is working to a different figure that boards are working to, we have a problem. It may be that some correspondence might be helpful. I am going to have to finish us there. Thank you very much, cabinet secretary. We will suspend very briefly, and we will try to catch up on time in the next session. The second item on our agenda is the final evidence session on recruitment and retention in the health service. I welcome to the committee Shona Robison, cabinet secretary for health and sport, Shirley Rogers, director of health, workforce and strategic change, and Fiona McQueen, chief nursing officer of all Scottish Government. I invite the cabinet secretary to make an opening statement. Thanks, convener. Thanks for the invitation to speak again to the committee this morning. We are all aware that demand for health and social care services is changing as is the way those services are delivered. In response, the Scottish Government has a programme of transformational change to take us towards the 2020 vision and beyond, but we cannot deliver that without a sustainable workforce. Our approach to delivering that workforce is described in Everyone Matters 2020 vision. In short, we need to ensure that the right people are available to deliver the right care in the right place at the right time. Key to our ability to recruit and retain our staff is our attractiveness and inclusiveness as an employer. Through our work on staff governance standard, NHS Scotland has made significant progress in recent years. We have worked closely with our staff side partners and health board colleagues to ensure that we have developed high-quality supportive policies in terms and conditions for our staff that also recognise the highest standards of equality and diversity and help us to deliver on our vision for NHS Scotland to be an exemplar employer. I am delighted to see the good work of NHS Scotland being recognised in practice with the Golden Jubilee national hospital being recently voted as employer of the year at the 2016 awards. Under this Government, staff numbers have increased by over 11,000. That includes more than 5 per cent of qualified nurses and midwives and more than 25 per cent of doctors. We now have a record number of consultants up by 43 per cent during the term of this Government, but we are not complacent. We recognise that challenges remain and continue that we need to improve the long-term sustainability of our workforce, particularly in remote and rural settings. We are growing our medical workforce in addition to increasing specialty training places by 124. In the last three years, we have increased undergraduate medical school places by 50 from this year, with those places focusing on widening access criteria. The Scottgem graduate medical school will add a further 40 places from 2018 and will have a focus on general practice and rurality. We have signalled our intention that the Scottgem programme will have an element of bonding. By that, I mean an arrangement whereby in return for reimbursement of the costs of their education and individual commits to a period of employment in the NHS. I am aware of the evidence given to the committee last week and realise that there are a range of views on such arrangements. We are in the process of developing our policy on bonding and I welcome this opportunity to discuss it further with the committee and the wider stakeholder community. We are committed to producing a national and regional workforce plan by the spring of next year. The plan will seek to address capacity issues consistently in the right places and at the right levels within our workforce to help to deliver the transformation agenda envisaged in our national clinical strategy. We recognise the need to strengthen workforce planning to ensure that the workforce is able to deploy and manage its huge range of knowledge and skills to best effect not just in the right numbers but in the places that they need to be at the right times. I recognise that these initiatives will not produce instant results. We are therefore also looking at actions that will help address the challenges that we face now. A number of key actions are under way to reduce the use of costly agency staff, including the use of a staff bank system and a long-standing framework contract. We accept that we need to do more and have launched with National Services Scotland a nationally coordinated programme to ensure the effective management of all-temporary staffing and help boards to reduce their reliance on these. We are also well aware that some parts of the country, including rural areas, have particular challenges in relation to recruitment. We have invested £2 million in GP recruitment and retention, which includes the Scottish rural collaborative and support for deep-end practices. We are also working with universities to increase meaningful exposure to remote and rural placements at undergraduate level. Additionally, we are encouraging those who are trained or worked in NHS Scotland to return and work here in the health service. Finally, in relation to Brexit, I have to highlight that, in the context of a highly competitive international recruitment and retention market, there is a real risk that we will lose many valued individuals if we cannot offer reassurances on free movement and future career opportunities. I am certainly committed to building a sustainable health and social care workforce for the future and welcome the opportunity to discuss these issues. Thank you. We are extremely short of time, so people could be brief with questions and answers. Last week, we heard evidence from the midwifery profession and the nursing profession, both of whom revealed that, five or six years ago, the Scottish Government cut back training places in the midwifery profession that I equated to about more than a half of training places lost. However, now they talk about a crisis of recruitment based around retirement. Given that workforce planning in the NHS at the moment is only five years, will the workforce plan that you talk about next year take account of the Audit Scotland report that points out rightly that we need to be staring much further into the future, recognising that it takes up to seven or ten years to train some primary care professionals? Will that be reflected in the plan that you bring forward? Of course, over the last three years, we have increased nursing with very numbers, not just in terms of the positions that we have looked at, but also in increasing those in advanced training, so increasing the number of advanced nurse practitioners post by 500. We are very aware that that workforce is critically important, not just in our hospital sector but in our primary care sector. We have been working closely with NES to develop opportunities, particularly for that advanced nurse practice career route, because we know that whether that is in emergency medicine, whether it is in primary care, the roles of those advanced nurses are going to be critical in delivering those new models. I think that the RCM, when they spoke last week, recognised at the time of the cuts of the reduction in the undergraduate numbers, that there were hundreds of unemployed midwives and nurses, so we had 800 nurses on return to practice. We had nurses and midwives qualifying and not able to get jobs, so we have a planning process that does look at return rates, and clearly people have now a choice of retiring from 55 onwards. Therefore, that is a challenge, because clearly overproduction is not helpful either, because that stops good people coming into the profession. Over the past three years, we have increased the numbers, and the numbers of midwives in training have been increasing over the past three years. Who signs off the annual intake? Ultimately, the cabinet secretary agrees. That is fine. That is fine. I suppose that the negotiation of the profession and the unions are involved. The care home sector is now involved. I would like to get my head round some of the figures around vacancy rates. The ISD published a figure for June and said that the nursing and midwifery vacancy rate was 4.2 per cent, and for other EHPs, 4.4. What would you see as a usual percentage of vacancies, because we are not going to have every post-filled all of the time? I guess that one of the challenges here is that the more posts you create, the higher the vacancy rate, particularly in some areas where it is harder to recruit, and boards will have varying vacancy rates. That is obviously a national figure, but there will be variations across the board. I think it takes time. At 4 per cent, if you look at individual norms, that is moderate. I think it depends on which post you have. If you are talking about a staff nurse who is delivering care all of the time, then you need to replace that person right away, similarly with your support workers. That is easier to have a recruitment line along with workforce colleagues, nurse and midwifery and workforce directors and boards, looking at how you can efficiently fill posts. Again, someone might give four weeks notice, but the recruitment process takes longer than that. A number of boards are anticipating looking at their turnover and bringing people in so that there is almost no vacancy for that post being left. The more specialist posts take time to recruit. Even if there is no difficulty in recruiting, the time someone gives you one month notice and then you pull people in, it is going to be longer. There will be a period of vacancy. I think that it depends on which area you are in and how long people are leaving their posts for. It does vary, but 4 per cent does not seem unreasonable. I think that the over three months ones are perhaps indicators of where it is beginning to get trickier to recruit into, but surely they might want to. It is very difficult to take a global answer to that. There are specialties that are harder to recruit for. I wonder whether or not the committee might find it helpful to understand a little bit more about the nature of the workforce plan that currently takes place. I recognise the time chairman, but if I could briefly say a few words in that space. Mr Cameron, I think that you were asking earlier on about the prospective nature of workforce planning. Over the past couple of years, we have put in place arrangements now that allow us to see existing trained workforce and the supply through specialty doctors of those things that are coming through the training process so that we can see both the consultant workforce as we have it and all of those people emerging from medical school and track them through training. That is the case across all of the 56 major specialties in the health service. It allows us also to be able to make intelligent decisions based on projections around retirement age, for example. The committee has heard evidence before about the impact on UK pension changes and so on. It allows us to see what happens if that consultant workforce decides to retire a bit earlier or stays on a bit longer or whatever it is. The approach over the past couple of years is using something called the six-step workforce planning methodology. It is an industry standard, it is an international industry standard, it does not pertain just to the health service, it is used by a number of big employers across the globe that looks at short, medium and long-term recruitment needs, how to nuance those depending on the circumstances and individual choices that people make. That methodology has been shared across the health service, so it is now a requirement for how workforce planning is done in every board in Scotland. That is a relatively recent development. Perhaps more importantly, in the space of health and social care integration, we are busy sharing that with colleagues in local authorities to make sure that they are using a similar methodology. Indeed, we have made an invitation to any other employer operating in that space to use a similar methodology. That should allow us to be able to address as best we can those issues that are now, but more importantly to deal with the medium and long-term. I thought that it might be helpful to give that context to the committee in terms of the workforce planning methodology. I want to come back to something that is a bit more specific about nurse retention, if you like. I need to declare an interest here because I am a registered with the NMC and I am currently going through the revalidation process, and it is really round about registration and revalidation. I am wondering if any work is being done on how many nurses and midwifes are leaving the profession due to the revalidation process, which is quite a complex process. It is also round about nurses and midwifes who fall off the register due to late payment of the registration fees and the excessive amount of time that it takes the NMC to get people back on to the register up to three months at a time, which leaves nurses and midwifes without a source of income, often women, often part-time, often sole parents. I would be keen to hear the comments of what the Scottish Government is doing in terms of supporting that part of the workforce. I am happy to do that and equally happy to give you some granular information on a month-by-month basis about the revalidation and people either lapsing or not. What we have found is that there is little difference from the number of people who are remaining on the register, and particularly in September was going to be our crunch month as we had a lot of registrants qualifying in September, and the end of revalidation would be three-yearly from that. We have found, both in the care home sector and across the NHS in Scotland, that there has been little difference since revalidation has come in. We have watched that very closely. We invested money over the past two years to support each board, so we gave them resource to support practitioners with revalidation. We worked closely with the NMC to get the statistics and the data on that. The matter of paying—other committee members may not know that every three years we now have a system of submitting for revalidation, but we have to pay an annual fee. Until, quite recently, the annual fee, if you missed it by a few days, then it didn't matter now. The NMC says that it takes between two and eight weeks. We are continuing to encourage the NMC to be as quick as they can in their processes, fully recognising the financial challenge that registrants have. There is also the issue about care delivery—they are not able to deliver care as a registered nurse. We are continuing to work closely with the NMC on that. We are looking at ways that we can flag within boards to make sure that nurses are reminded, because the NMC does remind people quite regularly on what needs to be done. However, in terms of their fees, the nurses know that they have an annual fee to pay. Anytime we do hear of anyone having that struggle, we will direct them to someone within their board who can help them to make sure that they are paying. The NMC has also introduced a way to spread fees in terms of direct debits, so instalments, rather than the £120 a year as well. The NMC is doing its best to support registrants to maintain their registration. It takes an average of five to seven years to train a doctor. I was surprised when I last met the BMA that a doctor once had trained can just go away, can go anywhere in the world. You said earlier, cabinet secretary, about bonding, which is a new word to me. Why do not we actually tie them down to a contract that they have got if you have been trained in Scotland, you live in Scotland, you work in Scotland, should you not pay back to Scotland before you leave? I hate using that word. I will say a little bit more about this in a moment. Obviously, we want people to remain here and train and work here. A lot of evidence is that, if they have had a good training experience and good experiences in their placements, that is a big encourager for doctors to want to stay here in Scotland. However, it is an international market, and we have looked at how we can encourage whether that is with financial incentives or other ways of keeping people here in the NHS. The graduate programme lends itself well to bonding because, obviously, it is a second degree and, therefore, the fees are not automatically paid. Therefore, there is an opportunity to offer any payment of fees through the graduate programme with a commitment to the NHS here in Scotland. I think that would be more challenging to do in the undergraduate programme. It is not that it is not being explored, and, of course, we will keep an open mind of what more we could do, but that would be more challenging in the undergraduate programme to do that. You will be interested in this particularly around the widening access. The 15 new places from this year, which we agreed with the medical schools, we felt that it was very important that those studying medicine were drawn from a wider socio-economic base, and that is why we linked those 50 additional places to the widening access criteria. Again, we think that the more we do of that and drawing people from a wider variety of backgrounds, the more chance we will have of them staying here, working in the NHS in Scotland. Thank you. Scotland has five of the most highly regarded medical schools in the world. It draws and attracts candidates from all over the world. I think that it is one of the things that Scotland should be very proud of. It has a long history of medical academia and a long history of medical research, which is very attractive in an international marketplace, and we operate in an international marketplace for medics. It is right that we do. We are extremely innovative, but we are not the only innovative place. However, there is evidence that suggests quite strongly that those domicile students who attend Scottish medical schools are more likely to either immediately practice in Scotland or come back to practice in Scotland, so they may go somewhere else to gain some experience and then return to Scotland at a later date. What we are trying to do is to create a space where NHS Scotland is internationally recognised as an attractive place to practice medicine, and there is an enormous amount of work been done to improve working lives across the NHS, but specifically around junior doctors, for example, and that recognition is starting to accrue. We, as the CABSEC has said, have focused a particular endeavour around the introduction of a first for Scotland, the first time we will have a graduate medical school in Scotland. We have done that because we recognise that people who are doing second degrees, generally speaking, are a little bit older, a little bit more settled in the environment space that they want to live in and have perhaps made some decisions already domestically that would cite them more readily in Scotland. They have perhaps made some life choices already. It seems therefore that if we can support those individuals to make those choices, then the options for us to be able to have some payback for that investment are in front of us. As the cabinet secretary indicated, we are in the foothills of that consideration at the moment, so whilst there are a number of schemes and committee members may be aware that this is a model that has been used in the military for a number of years, it is used in some parts of the world. There are a number of models, but we are making sure that what we have got is a balance of trying to make sure that we have got people who really want to work in Scotland to make their medical careers here and make their lives here. I believe that that is something that we will be able to do. How much is the funding or bonding an offer? We have not reached that stage yet, but we would be looking at perhaps a situation of if a year's fees were paid, you would expect a year commitment to the NHS. It would be an obvious way of doing it, but we need to work through the detail of that before the programme starts.  That is an option. Okay, Marie. As a representative for the Highlands and Islands, I am keen to ask about rural recruitment. I am interested to know if that widening access scheme, we heard time and time again that people from the Highlands and Islands are quite keen to get back, and I know that from my personal experience. Is this widening access scheme going to cover people growing up in rural areas who might face challenges and get in the right qualifications to enter medical school because the limited options available at the high schools in rural areas in the Highlands and Islands? Three further members who wish to get in and were really short of time. The ScotGem system is going to partner with Highlands in terms of rural placements and rural opportunities. Plus, there are existing programmes through the rural collaborative to try and encourage and retain staff working within rural areas. I think that the graduate scheme has the ability to give people a very positive experience of working in a rural area. We will also have a bias towards general practice. I meant specifically in terms of getting access to medical school. It is one of a number of things that we are hoping will do that. We are currently working with schools to look at the triangulation of a qualification medical school applicant and the child's desire to study. We are working with education colleagues to try to make sure that the curriculum that is necessary is available. That is probably the biggest win if we can achieve that. There is no doubt that the postgraduate entry requirements lend themselves better to those students who have not been able, for example, to study higher chemistry in rural parts of Scotland. The other thing that the cabinet secretary mentioned briefly in her opening remarks was the rural bursaries, which we have seen as being terribly advantageous in looking to recruit in rural parts of Scotland. It is a totality of things, as opposed to just a thing, but that totality ought to achieve that objective. Again, there is very strong evidence that people from those communities who can practice in those communities stay in those communities. Absolutely. To broaden the question beyond medical staff, we heard from all the professions medwives, nurses and allied health professionals particularly that they are struggling to offer opportunities to get work experience in rural areas and that there might be additional costs for people who want to go and work in rural areas during their training period, either as undergraduates or postgraduate students. Will the Government do anything to tackle that? I have to say that I do welcome the strategies that you have put in place to tackle the issues already. We have already provided 300 pre-registration nursing places through the University of Stirling and the University of the Highlands and Islands and a further 16 nursing students from seven boards covering remote and rural areas through the Open University. I think that does provide a very good option for those who are from the Highlands and Islands. The Western Isles have a particularly good programme. Again, it is about home-growing your workforce through from school right the way through to qualification. We are also reviewing the financial support that we give to other undergraduates, so that each undergraduate nurses already get travel and accommodation when they are on placements and again we are looking at more rural placements for our undergraduates. We are just very quickly to comment on the workforce planning tool and I am glad to hear the comments that Shirley-Rodger made just now. In previous sessions, we had people telling us that workforce planning was difficult to the point of being too difficult. We could not expect them to deliver anything coherent on that, so I am glad to hear that you are on top of that. Having done it in the past, my experience is 90 per cent science. It is about getting the right variables, understanding how those are trending and making adjustments based on that. More importantly, you will get it wrong by knowing what to go back and look at when you do get it wrong to understand whether the decisions that you made were coherent based on the data. The only question is, is it possible to have a wee look at the planning tool? I would be interested, I do not know if other members would be interested as well, just to see what it is capable of doing. I am happy to share the six-step methodology with the committee. I would like to ask what action has been taken to ensure that those working in the professions are having access to a suitable level of on-going professional development. I think that it was Jill Vickerman again who said that that is an issue, and it is one that is perhaps not making medicine as attractive as it might be in Scotland. Also, very quickly, convener, if I may, to ask what specific action is being undertaken to recruit in our deep-end practices. Partly, it is about making sure that people can have the time and backfilling to be able to take on professional development opportunities. We need to ensure that there is an equality of access to those opportunities. I think that there are issues in some areas where it is more difficult, but without a doubt, CPD is hugely important for career development and for opportunities. If I can pick that up and also identify myself as the individual that is leading the work to develop the transformational strategic change plan, which we have mentioned a number of times already at this meeting this morning, in amongst that we recognise that education and re-skilling, upskilling and maintaining skills is a fundamental part of transformation. The opportunities to be able to do that, some of the testing that has been dealt with already in terms of new models of care, are absolutely critical to that piece of work, and we are configuring to do that in a whole range of different ways. If I give an example that goes a little bit beyond the remit of doctors and nurses, because we always tend to talk about doctors and nurses, one of the quiet successes of the last couple of years has been the development of the educational framework for healthcare support workers, which extends way beyond health into all of the social care provision and gives a career framework, educationally based, that allows people to join at a relatively modest level of skill and use that framework to develop their skills and, of course, enhance their careers as they go, and that is the approach and methodology that we are taking throughout. In respect to the deep end practice, we were talking, I think that the cabinet secretary mentioned deep end practice earlier on, if not, I can say that the work that we have been doing to explore the benefits of a rural bursary, we are now starting to give consideration to whether a bursary around deep end practice would also be effective. It is also a full review of all aspects of GP pay and expenses that will take place next year to inform options from 2018, which, of course, is the Scottish allocation formula, is part of those discussions. I think that I have said before that we need to get that right. Our support for deep end practice is important, but we need to look beyond that in terms of how we ensure that those GPs working in more deprived areas get the support that they require. Of course, we have also got the other supports through the things like the 250 link workers to support practices in deprived areas, but there is very much a focus of our discussions as we take forward the new contract. Mails. Thank you, convener. Between 2006 and 2013, the number of student nurse placements was cut by a quarter. Does the panel now believe that that was the wrong decision? With regard to universities, the number of places for domiciled Scottish students at Scottish universities is capped. What impact do you think that this is having, especially given that we are now seeing a historical low of just 52 per cent of Scottish domiciled students going to our medical schools? Fiona can come in on the nurse numbers although I think she answered that in some detail earlier on about the oversupply at one point and needing to adjust the workforce requirements. That does change over time and it is quite difficult to land that 100 per cent accurately, but of course the last three years we have seen an increase in the number of undergraduate places and that will filter through into the workforce. It is also important to have an advanced nurse training as well as undergraduate training. In terms of the places, it might be of interest to the committee to look at the numbers. If you look at the overall numbers of medical students in Scotland, as Shirley-Anne Rogers said, we have five medical schools that are quite high for a population of 5.3 million. If you look at the overall total number of medical students across the UK, it is just over 40,000. Our population share of that, if we were taking a population share, would be just short of three and a half thousand. However, we have over 1,400 more students than that. In essence, we are providing and producing far more medical graduates than our population share would determine. Therefore, you have to see the percentage of Scots domicile students in that context. Actually, our medical schools, if we are to sustain five medical schools that we want to do, they have to be able to draw their medical undergraduates from a wider source, whether that is the rest of the UK on indeed internationally. We produce far more medical graduates than our population share or any other part of the UK per head of population, which is a good thing. Our five medical schools are internationally recognised, but in order to sustain them, as we want them to do, they have to draw from a wider pool than Scotland. Do you think that that is a financing issue regarding the fact that international students can be charged up to £30,000 to study at Scottish universities, whereas Scottish domicile would not be? I think that universities, and we discuss this with them and the funding councillor, are obviously involved in this, but our medical schools have always drawn from a wide variety of backgrounds and places. I suppose that is part of the richness of those medical schools. Clearly, there are a number of international students who study medicine in Scotland. There is also a large number from the rest of the UK. We want them to stay working here in Scotland, and we try to encourage them to do so through the mechanisms that Shirley-Anne Outland earlier on. The reality of it is that universities survive by having a mixture of students from their domicile countries, from international backgrounds and from the rest of the UK. We have a very close relationship with the Board for Academic Medicine, which represents the medical schools in Scotland. I meet them very regularly. Coming back to the question from Ms Todd earlier on, they are very keen to work on a collaborative basis now to provide placement opportunities for example in remote and rural locations or deep-end practices. Those relationships are very good. My endeavour as the workforce director for the NHS in Scotland is to have a sustainable world-class workforce. Within that, of course, we do want more Scots-based students, which is why we are widening the number of undergraduate medical places even further with the additional 50. That will be 250 places over a five-year period, plus a graduate medical school, so it is not that we do not recognise the need to expand the number of Scots-based students. That figure is capped. That is my question, which has not really been answered. That figure is capped of Scottish domicile students getting to go to these universities. What impact is that actually having? I am going to come back to that question, because I do not recognise the point that you are making in respect of the cap. 64 per cent of Scots were going to medical schools when this Parliament was reconvened. It is now down to 52 per cent because of the cap. If you look at the overall numbers, we produced a huge number of medical graduates beyond what our populations share. If we only produced a number of medical graduates as a percentage of the 40,000. Ms Rogers has said that it is important that domicile people are able to study in their country. In Scotland, we are reducing that. In terms of tackling the shortage we are seeing, if we have more Scottish domicile studying, that is going to help surely. That is where the cap is not helping. We have just increased the number of places by 50. We have linked those to widening access. Those will be people from poorer backgrounds getting into medicine that would not have previously gone into medicine. That is 250 more medical places over the course of five years. Plus, the Graduate School will draw mainly from Scots domicile students because of the nature of them being a bit older and more settled, as Shirley Rogers said earlier. We are expanding the number of Scots domicile students, but it is within a context of a large pool of medical places here in Scotland that is sustained partly by drawing people from elsewhere. The third item on our agenda is the evidence session on our mental health inquiry. The session will look at child and adolescent mental health. I welcome to the committee Rachel Stewart, Senior Public Affairs Officer, Scottish Association for Mental Health. Sophie Pilgrim, director, Kindred Advocacy and a representative of the Children's Services Coalition and Michael Gowan, member of the Scottish Youth Parliament. I could ask any of my colleagues if they wish to begin. Before I begin, could one or all of you, probably one would be better, given the time restriction, explain the kind of tiered intervention in relation to child and adolescent mental health? I can do that, if that would be helpful. CAMHS is set up in four tiers. Tier one is the least severe, tier four is the most severe. Tier one is the identification level where the first instance where a child would seek help from universal services, whether that is teachers, whether that is GPs or others who would be working in universal services. It is the first port of call. Tier two is community-based CAMHS specialist services, where you would be working with primary mental health workers. Tier three is a bit more specialist, and that is where the actual access target starts to be applied, where children and young people should be seen within 18 weeks of referral to CAMHS support. However, it is for more severe, complex, persistent support. Tier four is specialist in patient CAMHS, where young people need to be treated in hospital for a period of time. My very limited experience in this when teaching was that there was quite significant pressure being put on support for learning staff and the like not to include children in, for example, individual education plans, make referrals, all of that kind of thing because of basically resource pressure. Is that your experience? Or are you finding anecdotal evidence of a bit of a mixed picture across Scotland, to be honest? There are some places that have quite good links between education and with CAMHS within the health service. There are other places where young people that we have served and spoken to say that their guidance teacher did not know about CAMHS and so on, and that line of communication and awareness link does not seem to be as good as it could be. In terms of whether universal services are being told not to refer because of pressures, I think that we would need a bit more of an evaluation about what is happening across the board, and that is why SAMH has been calling for a wider review of the whole CAMHS service and the wider the four-tier system. The information that we have is about the access point at tier three and onwards, but, before that, we do not know how many young people are seeking help and are either being turned away or being told that they might grow out of it and that they should just rest easy, that it will pass. I think that that is why one of the reasons that we have been calling for a wider review is to have a bit of an exploration as we are on the cusp of a new 10-year mental health strategy, a new 10-year child and adolescent health strategy, that having a wider focus about the access points, how well professionals are equipped to deal with people asking for help, should be explored. In a way, in the system, is there been statistical analysis of how many young people are at each of those tiers? Over a period of time, are the numbers going down or are they fairly consistent? The numbers of young people who are being referred to tier three services has been going up. There has also been a rise in the number of young people who have not been referred to tier three CAMHS services. They have not been deemed unwell enough to require that level of support, but there has been the statistical analysis of the young people seeking support at universal level at tier one or at tier two. That is not measured in the same way because there is not a target attached to access points within those earlier stages of CAMHS support. Okay, that is very helpful. Thank you, Alex. Thank you, convener. Good morning to the panel. I think that it is well known, right around this table, both from the parliamentarians and stakeholders at the committee today, that the real difficulty that we have in terms of delay in the CAMHS setup is not in any way belittle the work of CAMHS workers. That is measured out in a number of cases. For example, the fact that we do not have any tier four beds north of Dundee. Those that are available are not always actually available because there are not staff to man them. In some cases, in some parts of the country, children will have to wait up to two years, a considerable part of their young lives, for an initial appointment. In my own constituency, I had a situation where family, a child was struggling at school, education psych referred her to CAMHS on the belief that she might have undiagnosed autistic spectrum disorder. She was seen comparatively quickly within a couple of months for an initial triage, and they said that the family received the devastating news. Yes, your daughter is on the autistic spectrum. She had to wait another year before formal diagnosis. In that time, she missed out on any kind of state support that would have been afforded to her with a diagnosis. Can the panel reflect on that situation, what they think needs to change? Is it money, is it investment, is it a change in policy direction, is it all of those things? I am the director of an organisation. We support about 1,000 families every year and a very high proportion have neurodevelopmental disorders and mainly autistic spectrum disorders. In the situation that you are talking about, we experience that schools often do not recognise quite clear signs of autistic spectrum disorder early on. It is actually when things start to go wrong that children get picked up. As you say, the problem then is that it can be a very, very long lead time until there is an actual formal diagnosis. Looking after a child with autism is just completely different from looking after a child without autism. Obviously, there is a huge range in terms of autistic spectrum disorder, but there are certain things that people with autism have in common. One of them is a need for structure and probably a need for a less stimulating environment. Until you get that diagnosis, you cannot put in place that support. Working with children with a very high level of additional support need, I think one of the issues that we see is that, as you mentioned at the beginning of your statement, there is a lack of the very high level tier 4 services. In Scotland, we have no inpatient services for children with learning disability. We have no specialist inpatient services for children with autism, and we have no forensic inpatient services. There is a report produced by the Scottish Government on the Mental Welfare Commission, which is about to come out recommending the provision of a central belt inpatient care for those children. At the minute, what is happening is, in fact, the impact of those children who have extreme needs means that the other services are actually distorted because they are so much in need in the community. They are in a really high level of distress. What happens is that the community services are drawn into those emergencies. Their time is taken up. Anyone who knows those CAMHS psychiatrists, if you are in regular contact with them, you see the times that they are not able to get on with their regular duties because it is taken up with this emergency care of children who need acute short periods in hospital. That is a very big fact, because we need that top level of support for children so that we can free up CAMHS time to be diagnosing quicker. Thank you, convener. Good morning. Can I start by congratulating the Scottish Youth Parliament for the work that they have done on the survey and report? I think that it has been really helpful in looking at what is a huge problem for our country. One of the things that interests me is early intervention and prevention. We are getting a lot of mixed messages about what is needed and how we have improved that and how the Scottish Government's new strategy should be shaped around that. I was wondering from the panel what you think would make the most difference as an intervention or as additional information for young people and how that should be rolled out. Thanks for the plug. One of the key things that have been identified, and that links into the convener's point earlier, is about how in schools resources are stretched too thin. We end up with teachers' quotes from our research, teachers are stretched too thin and there are not enough resources. Another 25 students in one class is way too many for a class to be able to give one-to-one support. It should be 10 or 15. There is a point about how many young people were expecting front-line practitioners to be able to manage and to be able to detect those issues. The other point is perhaps on training. How many teachers can afford to go through CPD, for example in more rural areas where they have staff retention issues, they cannot necessarily afford to have staff leaving as often for that continued professional development. Another point that has been raised is how comfortable are young people talking with front-line practitioners? In our research, only 24 per cent of young people said that they would be comfortable talking to a teacher. If you have only one in four in a classroom saying, I am willing to talk to the person that I am seeing every day, it creates a barrier for trying to get potentially quite young, quite vulnerable and perhaps underconfident young people to open up about any problems that they are having and catching that earlier. Perhaps looking at how do we build those bridges between young people and practitioners? Can I follow up? I would absolutely endorse everything that Michael has been saying. We know that there have been pilot projects in schools where mental health and wellbeing has been promoted. CMEs in schools are running pilots, which is having an impact on the whole school in terms of young people feeling much more able to ask for help. Teachers having been through some Scottish mental health first aid having been able to respond much more appropriately. I think that teachers often feel very stressed under their work as well. It has got a very high rate of sickness absence as well, so it might actually be helping them as a protective factor. I know of other pilots in the likes of People's High School and so on, which have done work in linking up with community third sector organisations such as Samaritans and Penumbra, where they have raised awareness within the schools and that has made it much easier to signpost young people to support. Health and wellbeing is one of the three crucial elements within the curriculum for excellence. Children and young people have been telling us that the only thing that they ever hear about from a mental health perspective is about exam stress and how to deal with that rather than being less stressed in general. If health and wellbeing was included in the inspection of schools and there was more curriculum guidance about mental health, it would set a good tone. Michael's point about CPD is very well made because of the rural challenges. However, teacher training, one of my colleagues in SAMH does an R term for some of the teacher training colleges on mental health, and that is not enough for the fourth year students, so that is something that could be considered. In terms of support for children on the autistic spectrum, there is a lot of positive developments in how we support children. They can make a huge difference at virtually no cost, and that is in terms of spreading ideas about intensive behavioural support for families. We have got two services in Scotland, both in NHS Lothian, which provide positive behavioural support to families. It is something that is being promoted within adult care of people with learning disability and autism, and it can really mean that you prevent the very much higher level cost of inpatient care. Thank you to the panel for coming along this morning, and I am sure that we are going to find out some really valuable information from you. I was interested in a point that you were making there, Sophie, about inpatient beds and development inpatient services. Obviously, the focus of health at the moment is about developing community services as opposed to reprovisioning and inpatient services, and I am aware that there is already a children's inpatient unit in the sick children's hospital in Glasgow. I wonder if you could comment on the use of the beds there, and if it has been considered that perhaps some of the bedtime there might be used for more specialist areas of children adolescent mentally? The provision at the Glasgow hospital has a very good reputation, but it is for support of children under 12 years. Obviously, it is predominantly in the teenagers that children and young people experience mental health, and we have at present three inpatient units across Scotland for adolescents. The issue is that those provisions are not suited to children with learning disability or autism. When we are talking about children, what age are we talking about? I am confusing children with adolescence. We do not have any provision that is specific to learning disability and autism, basically, for any child under the age of 18 or young person. The Glasgow hospital does have some expertise in that area. Over the last five years, there have been, according to records, an underestimate around 85 children who have either had to be accommodated in adult wards or sent down south. It is not the case that they are being treated in the community. They are actually inpatients, but they are very inappropriately treated. As a result, they end up being very long time in hospital at great cost. We have seen examples where children or young people are in generic young people's units, one of the three young people's units. Their mental health deteriorates dramatically. If they are transferred to a unit that is appropriate to an autism understanding and environment, literally within days, they are beginning a process of recovery. Those children can be, after a very long time, returned back to the community support services, but it is really detrimental to their own health. It is at great cost if children are sent down south to provision. Just for clarification, you are talking about adolescence as opposed to the children that you are talking about with specific disorders or specific illnesses. Over 12. There is very little incident of that extreme level of need for inpatient care in the under 12s. At present in Scotland, we have a national provision in Glasgow, which has a very high level of expertise and is well regarded. Is the issue then with the level of training with the current inpatient staff and the adolescent mental health units, if you are saying that these adolescents are admitted there and the environment is not suitable? There is just a sort of difference between provision that is suited to children with autism and children who have severe mental health issues and require inpatient. Those would be children who are bipolar or who have eating disorders or who have extreme anxiety or depression and self-harm. Those children require the three services that we have across Scotland, but what we do not have is for children with autism, you need a very highly structured environment and you need psychiatrists and CAMHS teams who are specialists to that. We do have a very high level of specialist knowledge in Scotland. What would be advantageous about having a service would be that, and what is proposed is that we then have dissemination of that expertise to the health board so that the experience and the support from those professionals could be disseminated to the community CAMHS teams. We would then be really trying to prevent as much as possible the need for inpatient care, because obviously inpatient care is very distressing. It is the last thing you want, but you need it for any sector of the community. At present, we have inpatient care for all sectors of the community. The one that we do not have is for children with learning disability and the Scottish Government itself has decided that as a discrimination against those children. To be absolutely clear, between 12 and 18, we currently have no provision, inpatient provision, for those who need it, for children and adolescents with learning disabilities who require that level of inpatient care. It is another way of putting it. We have no secure inpatient psychiatric care. The children who require secure care are those with such extreme challenging behaviour that they are either in extreme danger to themselves or they are in danger to the public. Those children, that very small group of children, so what we need in Scotland is to be able to say that we can care for any child. There is no child that needs to be sent away because their psychiatric needs are such that they cannot be cared for within Scotland. That group would include children with a forensic background with psychiatric need, children with extreme challenging behaviour generally because they have autism and children who have impaired understanding so that they have learning disability. It is that very small example. Thank you. That is very helpful. I just wanted to pick up on Claire's point. Yesterday, I visited the Edinburgh Crisis Centre, which is run by Penumbra. One of the issues that they had was that they can only take referrals from people over the age of 18, yet they have capacity. It could be quite an appropriate service for those between 16 and 18 years old. Does the panel agree that breaking down people above 16 would be a more appropriate way of looking at this? In younger young people or children, do you feel that a more appropriate situation would be an intensive home nurse service to provide support so that those young people are not being taken out of their homes and communities? In short, I think that issues around self-harm are not being well catered for for young people. We know from the Scottish Health Survey that there are higher rates of detection of self-harm, especially among young women recently. What we think and are calling for is for professionals who interact with young people, whether they are GPs, teachers or youth workers, to receive the training to respond appropriately if they discover or if a young person approaches them to say that they are trying to cope with their mental health problems by self-harming. Given the sensitivities of that and how unwell that young person may be, it has to be done in a way, which is why we call for the training. We know that the onset of mental health problems in adolescents tends to start around 14, and you can see through the research that young people's self-esteem and confidence often takes a dip from 14 to 15 onwards. Having a much earlier access to treatment to support would be very appropriate and desirable. From the point of view of an at-home nurse service, where that is possible absolutely, the mental welfare commission published a young people's monitoring report a few weeks ago, which showed that there has been a decrease in the number of young people who have been supported on adult wards in the last year, from 207 down to 135. That is still too high a number for those very unwell young people, but they attributed some of the decrease to an increase of beds in Dundee, but also to the much more wraparound multidisciplinary support at home in the community, so I think that is to be welcomed and it would be good to see more of that. To explain why children need inpatient care for acute treatment, partly because in some circumstances their behaviour is so extreme. For example, the other siblings might be at risk, sometimes they don't sleep, they are violent, their behaviour is extremely antisocial. The family breaks down under those circumstances, it is intolerable. It is partly the extremness of that, but it is also that you need sometimes to be able to take that young person out of that environment into clinical environments so that you can assess and generally that assessment is for three months to be able to assess what disorders are going on there so that you can appropriately treat. Just on the first point about lowering it to 16, one of the things that came out of our research is that a lot of young people and adolescents felt that a transition service between the ages 16 to 18 up to 24 would probably be beneficial. Rather than simply lowering the bar to 16, it might be worth trying to create a above-spoke service within the NHS that focuses on tailoring them through that sort of transition period and then trying to get the third sector working with TSIs and IGBs to try and get a linked-up approach where that is mirrored throughout. Just for clarification, Sophie, if I may, do you believe that young people with neurodevelopmental disorders are best treated within the CAMHS framework? Are best diagnosed and treated within the framework that exists in CAMHS or are you looking for something else? Personally I think they have to be really because it just has to be within a very consistent framework and it is a medical diagnosis. So it's no good just to be, but I think what's a problem is that people are not identifying when the signs are very evident and then, as other people have said earlier, that when they are referred it takes a very long time for diagnosis. My next question, I'll perhaps address this to Michael. We know that certainly several studies have indicated that adolescent girls in Scotland particularly suffer from poor mental health. I just wondered if perhaps Michael and Rachel could suggest why they think that this might be the case and what we're doing to tackle that.  So if a young girl says I feel depressed, perhaps the response is going to be on your period, which you need to tamp on. That's a social structure that I think needs to be addressed somehow, but I think as well practitioners need to be able to take young girls and adolescents more seriously. So is that early intervention can come in rather than it sort of being suppressed. Nobody will take me seriously until self-harm and more severe issues come out. I don't know if you want to add anything. Absolutely. Some of the research has been done through the children adolescents health research unit at St Andrews on the health behaviour of schools is children, looking at the mental wellbeing and emotional resilience of young people, looking at rates of depression. As I say, if you look across the board at the age of 13, boys and girls tend to be fairly even. Going to 15 boys seem to still be quite, I'm using my hands, which is not going to be very helpful for the official report, but 15 year old girls see a drop in their mental wellbeing. There's a general drop, but there's a sharper drop for young women. The researchers have posited that this is due to exam pressure or that young women seem to feel more distressed about the pressure of exams. Impacts around social media and body image are certain things too that have an impact on their mental health and wellbeing. It's really hard to tell, because we know that there are protective factors around peer issues and positive feelings about school. Whenever there's negative feelings about school and I must pass those exams or my life will be finished, that is not very helpful. In terms of making things better, I think that it's teaching young people to cope and to become more resilient and to be able to face what life throws at you as well as rather than just saying, here's how to cope with exam pressure, it's more about here's how to deal with everything and then the exam pressure may not be as much. A lot of the written submissions focus on rejected referrals and there seems to be different views about why they might be rejected. Some organisations suggest that they might be rejected because it will make waiting times increase. Others suggest that they might be rejected because they were inappropriate in the first place and could perhaps have been picked up by tier 1 or 2. Do you have any views on whether we need to review the way we refer? Any views on that evidence at all? I think certainly a wide review about how we refer or how tier 1 anyone who is approached by a young person about their mental health, we would hope that GPs or teachers are equipped enough to recognise that this young person in front of them needs some support and they need some fast support for it in terms of whether the referrals are inappropriate or whether there is a waiting time gaming going on and not wanting to increase the waiting lists. It's really hard to tell without a review because we simply don't know how many young people are coming forward at a tier 1 stage asking for support and as Michael said, getting an inappropriate response about you're a teenager, you'll grow out of it, it's puberty, it's your period, something like that for young women or if they are simply seeing calms as something that begins at tier 3 and I think universal services need to be able to cope with the mental health children and young people as it's presented to them. One of the other points that came up in our research was about how maybe resources are very stretched, so for example school counsellors, quotes we've got, my school counsellor has a waiting list of 170 people, counsellor sessions are infrequent, you have to be put on a list in a week months to see the school psychologist, it's not good. So when you have issues like that inside a school where the school feels it can't cope with the young person, they're naturally going to want to refer onwards whether or not they would have the capacity to deal with that issue, they might not have the resources. As for meeting waiting time targets, this isn't in the research, this has been since I've had some practitioners coming to me talking about it, saying how they've had reports of young people basically being handed information pamphlets for their first meeting and then sent on their way as a way of kind of dodging that first waiting time target. I'm not convinced necessarily that it would all be focused on waiting times, it might be a part of it, but there are other ways that you could just get around that if you didn't want to flag it up in a system. It's maybe more about the two, tier three doesn't have the number of cpns to support the young people, tier one doesn't have the training or the resources to provide the staff that do have the training to support them and they're kind of bouncing off each other. I think the other challenge is that the waiting time target is only a snapshot of the access point into CAMHS, but we don't actually know what happens after a young person goes into CAMHS, we don't know how long they wait in between appointments, we don't know what community support they're receiving, we don't know if at the end, once they turn 18, if they feel that they have made a recovery or if they are moving into adult services and what impact moving into adult services is having on their mental health. So I think the picture that we have is quite patchy and not quite good enough from our point of view. The young people we've spoken to have not been terribly happy about their experiences, whether they are within the CAMHS system having been assessed as requiring that more severe support or if they're amongst the 6000 a year who are not, who are being rejected in the rejected referrals and then are left with nowhere to go, their GP or someone has said you need additional support, the more specialist support to come back said no you don't and they're in no man's land and everyone has mental health and those young people are not being serviced. Can I ask you specifically about the age of eligibility for CAMHS services? So we had a little bit of discussion there around whether people should be able to access more adult services at the age of 16. My experience of working in psychiatry was that I had concerns about people coming into adult services at the age of 16 when they're still frankly I mean I think some young people are still vulnerable right up to late teens early 20s and probably an adult psychiatric hospital isn't the most appropriate place for them to be cared for. I also saw when I worked in psychiatry people who in Highland certainly there was a decision made over whether you were still in full-time education and that was how the judgment was made on whether you qualified for CAMHS services or adult services and I think the difficulty I had with that was that I saw many people who had very very severe illness which meant that they had come out of education but they needed to go back in and then because they were then in adult services they didn't have access to the specialist support to get them back into education and I think you know mental illnesses at any age is hard enough but mental illness at a time when it really disrupts your potential to fulfil your educational ability is it can have a really devastating impact on the rest of your life. Just wondered what you all thought. Sorry it was just a point when he said that adults at 16 services what I think young people have said very clearly is they need their own service not to go up to adult services and I think that would be inappropriate and I think that some CAMHS units are actually trying to do a sort of bridging service because there are issues with you suddenly turn 18 and you know the waiting time till you're seen by a cpn triples and you're moving away from school your friends have all left to university you're expected to either get a job go into university or you end up in a benefit system which can be quite stressful so it's not about putting them into an adult service it's about creating one more bespoke for the issues that they're likely to face at that transitional period. Sammy it's just called for a review of the age at which people can access CAMHS and we think that if young people are vulnerable and they need that additional support then stopping CAMHS support at 16 in some health boards or 18 in others is not appropriate and they should continue to receive the specialist support up until they're 25. We know that brain development continues until they're 25 so it follows that and it follows the children and young people's act which looked at how vulnerable people should receive support beyond their 18th birthday. You were right about the NHS boards there's a cut-off point about 16 in places like Dumfries and Galloway in Lanarkshire in Shetland if those young people are not in full-time education and Tayside I think and also Ayrshire and Arran as well so it's something that the NHS has said we want CAMHS to be provided to 18 those health boards are working hard I think to achieve that that also has an implication on the pool of young people who would be going forward and eligible for CAMHS support. I was speaking to a young woman on Friday who had who's been receiving support from SAMH since she was 16 when she was referred to CAMHS and she's now 20 so she's been in children services for two years and now in adult services for two years and she said when she hit 18 that was the end and it was like dropping off a cliff basically because she built up a relationship with her CAMHS nurse over two years she felt that she was making some progress she'd had a very difficult time when she was 17 when she was actually detained in an adult a mixed adult ward which was a terrifying experience for her but she had made some progress and when she hit 18 that was it and she was into adult services there was no transition between adults or between children's and adult services there was no discussion really with her she knew it was coming but she didn't really it wasn't made clear to her what that what it would mean for her support the approach taken by adult services was totally different from the children's services so she felt that everything she'd been doing with her clinicians for two years beforehand was a bit of a waste of time from her presumably she was very angry about the way she felt she'd been treated because she felt that there was there was no continuity there was no logic in the situation she was just suddenly abandoned to adult services and she didn't have that kind of support that she felt that she needed and she's still a very vulnerable young woman she's only 20 from that point of view we do think you know there needs to be an extension and a much more specialized service for for young adults because I think if if mental health problems are developing at this stage and they can receive consistent levels of support as young people are developing into adulthood then they're much more likely to make a recovery because what Jessica told me was that she actually took a setback when she went into adult services and she felt very challenged by the new system and etc back when you know she could have if she had had a wee bit more of a transition and joined up approach she might have been able to accept things a bit further on and she might have been a bit further on where she is now also just adding to that it also has a fairly harsh effect on young people waiting to go into the system so if your mental illness isn't diagnosed until you're say 16 17 and then you're told that you're on a waiting list and then at the end of the waiting list you go into adult service and then you're on a completely new waiting list completely different times you have to wait for that to to take you through into an adult service that can have quite a powerful feeling of not being wanted or feeling like nobody's taking you seriously. One quote I have for my young persons is I'm on a waiting list for CAMHS I've been told that I'm waiting for them to hire a new psychiatrist they've told me I'll be waiting around eight to ten months I'm nearly 18 so I bet I'll get just get passed on again so if young people are feeling like that that the system is just viewing them as a number to get passed on you can imagine what sort of effect that's going to have on the mental health of someone who's already at tier three in terms of mental health and how much more difficult it is going on the road to recovery and it's something to be aware of it say it's not just the people in the system it affects it's the people waiting to get into the system too. Thank you. I just wanted to make a comment actually about I'm aware that certainly in Greater Glasgow and Clyde NHS they changed their transition from adult mental health services into older adult mental health services and now that's much more needs led so there's no longer a cut off that at 65 your care is then automatically transferred over so it's interesting that some health boards and I'm not sure if it's across the country have already acknowledged that at that end of our lives it's not particularly helpful for your care to be transferred over to another service. I wonder if I could raise the issue of health inequality it's one of the issues that this committee has said is one of our priorities and I want to pick up on the issue it's the only analogy I can have with dyslexia in my own area in one of the poorest compared in one of the poorest areas in one of the most affluent areas the level of identification of an issue like dyslexia is much higher in the affluent area than it is in the poorer area now I can't make that analogy a mental health problem but what I want to ask is are you finding similar things with mental health issues for example a diagnosis of autism or ADHD or or something like that where in affluent areas the diagnosis is happening quicker and there are higher rates of diagnosis than there are in areas of multiple deprivation I'd actually say no but we we run our post codes through the Scottish index of multiple deprivation we're more likely to support families in areas quintals one and two which are the higher areas of social deprivation it's interesting that almost all our projects those are the highest and then it drops off with the middle and then quintal five again rises a bit but we disproportionately provide our support to families in very high areas of deprivation I know that goes against what most people believe to be the case but my experience is that we families are really desperate to support their children and they go to huge lengths and I think one of the things we're sort of missing is that parents are such a huge resource and actually they come away from the treatment and the support feeling very belittled and demoralised I think it's one of the reasons families come to our service a lot is they they've felt criticised they've felt that they're being told their child's condition is to do with their parenting whereas actually if you you look at the sort of evidence you can see that you know you could almost see it as sort of statistical of course there'll be children with extreme needs in all you know across all sectors of the community and the rest of the panel want to comment on that I mean I think there are very definite trends amongst looked after children who have you know higher rates of per mental health I think that there I think it's a variety of trends really you know you've got some young women from less deprived areas seem to be feeling under more pressure about their mental health during their adolescence than than other demographics so it's quite a mixed picture in terms of following that through to the issue of inappropriate referrals and you know under reporting over reporting what can we do about that what can be done about the nature of people you know inappropriate referrals and whether we are under reporting or over reporting I think it comes back to education I think children and young people need to be supported from an early age about how to look after the mental health and to look for signs about per mental health and asking for help at an early stage there are duties on public services in Scotland through the Children and Young People's Act to have regard to the UNCRC which is all about listening to children and young people basically listening to their opinions and informing their decisions and making sure that there's an ask once get help fast approach really I think children a young person doesn't wake up go to bed on a Monday night and then wake up the next day and need two or three cams we need to move backwards and start thinking about how we can help young people at an earlier stage give them the confidence to ask for help and appropriately respond to them when they do the points that came up in our research is as PSHE being failing young people effectively it's patchwork at best I don't think it's been updated since 2008 though please don't quote me it has been several years either way and it does predate curriculum for excellence if ever an organisation approaches education Scotland the response is invariable well that's down to local authorities and down to individual schools so you get quite a remarkable patchwork of of how much support is offered and how much mental health training is available so there was one young person who said that they had one session on mental health in the six years that they were in school through that and that's then you get other young people that say that actually didn't shop in PSHE that was about how do you write applications to get into university how do you write application forms there isn't enough about how do we build young people's resilience and make sure that they're able to survive outside of a school environment and how do they survive in that school environment how do they deal with exam pressure anecdotally my speaking to a local cams worker says that she gets about two times as many referrals when it's coming up for exam period self-harm anxiety and stress just because so many young people are crumbling under the pressure we're putting them under and though the schools in in that sort of catchment area don't have as good a PSHE as perhaps you would hope for so it's maybe worth linking up with education lifelong learning committee looking at how do we develop that into PSHE guidance how do we try and get inspected in schools how do we make sure that there is a universal standard that is being met that will try and build young people's resilience so that it doesn't happen as much and then at the very least they're able to recognise them themselves this is a point where where I should ask for help and they're confident enough to do so I said I would try and keep the time for people is anyone else want to come in at this point Alison very briefly yeah just a very very quick question many submissions indicate that demand outstrips the capacity of the service and I think that is coming across in your evidence but British psychological society state that just not 0.46 if the NHS budget is spent on CAMHS just wondering if you were aware of that and if you feel that this is an area that requires greater investment not 0.46 and then of mental health services I think it's 5.81 is spent on CAMHS so children are really losing out in terms of the proportion of spend and actually that's just you know just I mean where's the early intervention there you know it's it's you know surely we should be investing in children and young people a psychiatrist described it to me like a plane taking off you know that that young person is developing so fast and during the adolescent years they're learning the resilience and the skills that they need for later life so if they're they're really sort of taken out of the picture by mental health during that time they're not going to recapture those skills so I think you know it's a it would be a really positive investment if we put more resources into child and adolescent and thank you you go for the mic one of the things that kind of occurred to me as you said that is more in what said that the government was investing 150 million into mental health over the next five years and that sounds impressive but when you break that down that's 30 million a year there are 32 local authorities that's about 900 thousand per eight priorities in the strategy so that's about 115 thousand per so for children and young people that would be 150 15 000 assuming that it was an equal distribution per local authority a rural areas the western islands won't probably get as much as glasgo for example so I think that statistic I didn't know it it doesn't surprise me because when we say mental health has this much when you actually start chipping away and breaking down how much is ring fenced for youth services it's not actually that much I think it's a big headline figure is what we hear and there isn't as much looking at how much can that actually afford for young people 115 000 is what maybe three cpns tier three power region if that I think it's very hard to put a price on how much you should be spending on cams until you actually fully evaluate what the demand for cams is because you know it's it's one of these limit this amounts at the moment you know because we we don't actually know how many young people are seeking help from tier one and tier three services because the measurement is starting at the tier three end of things I think we know that the Scottish Government has increased investment over the past few years and have earmarked 54 million for cams over the next few years some of that is already some of that is already attributed or it's been set aside for certain certain spending in terms of workforce development and service re delivery and evaluation but I think we need a wider review basically because then we can actually put a price on what we need to spend we would very much want some of the funding to be targeted at the early stages because I think that you can increase the workforce you can increase the supply side of things and there have been improvements in the volume of staff working in Scotland we're now at almost 18.2 per hundred thousand and I think the goal is 20 per hundred thousand of cams staff but until you actually start you know helping young people to manage the mental health and recognise it the demand for services is not going to dry up and all the supply in the world is not going to actually be able to meet the demand so I think we just need a wider review so that we can fully evaluate the need and start supporting young people the first time they ask for help thank you okay can I thank the panel very much for the evidence this morning we will have another session on cams next week and then we'll have a session on adult mental health and a further session with the minister for mental health later in the month as agreed previously we'll now move into private session thank you very much