Welcome to the 16th meeting of the Health and Sport Committee of 2018. Can I ask everyone please to ensure that their mobile phones are off or on silent, and please ask not to use mobile devices for photography or recording? The first item on our agenda today is subordinate legislation. We have two negative instruments to consider. The national health service superannuation scheme Scotland miscellaneous amendments 2 regulations 2017 amendment regulations 2018 is the first of those. That is to correct an error identified by the Delegated Power and Law Reform Committee at its meeting on 16 January. There has been no motion to annul this instrument. The Delegated Powers and Law Reform Committee has considered this instrument, the amendment and determined that it did not need to draw the attention of the Parliament to the instrument on any grounds within its remits. Are there any comments from members? If not, does the committee agree to make no recommendations in relation to this instrument? The second instrument is the national health service pension scheme Scotland additional voluntary contributions regulations 2018. Again, there has been no motion to annul, however. The Delegated Powers and Law Reform Committee considered the instrument at its meeting on 8 May and agreed to draw the attention of the Parliament on general reporting grounds in respect of four drafting errors. The Scottish Government has indicated in correspondence on those matters that it intends to correct those errors at the next legislative opportunity in the late summer of this year. Are there any comments from members? There are being none. Clearly, it is disappointing that, again, this consolidation instrument has made a number of minor errors, which requires another instrument to come to the committee at a later date. However, if there are no comments from members, does the committee agree to make no recommendations? That is agreed. Thank you very much. We turn now to the second item on our agenda this morning, which is an evidence session with representatives from NHS Orkney, NHS Shetland and NHS Western Isles. This is part of our programme of scrutiny of NHS boards. I am pleased to welcome to the committee Ian Kinbarra, who is the chair of both NHS Orkney and NHS Shetland. Gerry O'Brien, the interim chief executive of NHS Orkney. Ralph Roberts, the chief executive of NHS Shetland, and Simon Booker Ingram, the director of community health and social care and IGB chief officer at NHS Shetland. Neil Galbraith, chair of NHS Western Isles, and Chris Ann Campbell, who is the nurse director and chief operating officer of NHS Western Isles. Welcome very much to you all. I start just for clarification uncertainty to ask Ian Kinbarra about the position relating to the permanent position of chief executive at NHS Orkney. I know that you share a chair between the two boards of Orkney and Shetland and it would be helpful to the committee if you could simply comment on the current position and future plans. Thank you very much, convener. The current position is that we are presently making arrangements to advertise for the permanent and substantive post of chief executive, and I would hope that those arrangements will be put in place fairly soon, and we would conclude that to allow us to move forward with a degree of certainty for the board and potentially for the individuals concerned. I want to kick off talking about geographic challenges, which should all be experts on, and I am sure that that exercises you all day and daily. Clearly, from the political side, there have been some political devices historically that have helped the air discount scheme, ARI-T, for example, structural funds, which have obviously been focused on GDP and population. If you want wider examples of what other countries have done, the Japanese Islands Act of the 1950s was an early example of help for islands. Could each of the boards describe how difficult the daily challenge is between providing services in-house and having to go to other board areas? From a regional point of view, I have had constituents that I have raised with Western Isles about patient travel, which I am happy to talk about at a later stage. However, if I could kick off on geographic challenges, how do you manage that in a day-to-day basis? I think that that is the most important question for us. One of the things for me around it is that when we talk about performance, very often in the island context, we are talking about sustainability of services as opposed to relative performance, because very often you are either delivering a service in which case you will be meeting the targets or you are significantly challenged in delivering a service and therefore you may then be significantly away from a performance target. It then plays out in a number of issues, such as recruitment and retention of staff and, obviously, also in patient pathways. The way that I would categorise it is that, as an island health board, we have to collaborate both internally within the islands and then particularly within the region and with ourselves, Grampian, who most of our patients off island go to. We have, particularly in the last year, or the number of years, I suppose, but in this year, last year, we made some success around it, is understanding how we can actually support more patients to come back to Shetland and manage the pathways so that as much of their care is being provided locally as possible. The question and answer perspective is maybe useful just to point out that there is a vast difference in reality amongst the islands, because we have Otney in Shetland and the North, but the North East and the Western Isles by definition not only in the North but in the West. So our communications are with both the Northern region but also, in fact, with Glasgow. Many of our Barra patients, for example, go straight to Glasgow rather than be brought up to Stornoway. We face the same internal challenges in all the islands. We are dealing with a string of islands in which we are trying to make sure that a national health service is, in fact, giving a quality output no matter where the people live in the islands. However, as you have already mentioned, we face sending people, as we do and have to, to the mainland, whether it is to the North or to the West. We have to consider the costs that are involved. It is not so much the cost of patient travel, but the cost of escort, which, if you mentioned the Western Isles, for example, is a matter of debate at the moment, because we are now applying the existing policy and the existing rules as they should be applied, and that is producing, of course, a number of complaints. However, irrespective of that particular fact, anybody who is under 16 will always have an escort. Other than that, we are moving as far as we can in the direction, I think, because, as Ralph has made the point, we are trying to provide more of the services in-house rather than sending it to the mainland. Equally, telemedicine and telehealth are coming to our aid because we see no real reason why a recall to a consultant in Glasgow for a 10-minute occasion cannot be handled, in fact, over either the phone. In fact, it is a simple approach by telemedicine itself. We are seeking to make savings, particularly on patient transport, and I am happy to talk about it in detail. However, it is not about the patient, it is about the escort. I think that, without reiterating what Ralph has said, there is also the factor that it is a relationship with the Scottish mainland, but it is also the inter-island relationship as well. Orkney has 18 inhabited islands, so we continually face that challenge of not only how do we provide services in our main, what we call the mainland, the mainland of Orkney, principally through the Balfour hospital and five independent GP practices, but across our range of aisles, and it is how do we support the GPs on those aisles, how do we support the population to live on those islands as well, and how do we actively support those? We have not only got the challenge, then, in our case, our principal link is with NHS Grampian, down to Aberdeen, where we have very good relationships with NHS Grampian, but we are often asking people to travel from North Ronaldsy or Westry, who first have to travel to Kirkwall before they then travel on to Aberdeen. I think that there are particular challenges across all islands groups for the out-of-hours of the dark hours of the day, and that is why we face the particular challenges in trying to provide those services 24-7. As Ralph has mentioned, it is a recruitment and retention issue, but when we have those skilled practitioners on island, it is then keeping them skilled. I am not allowing the skills atrophy because of the volumes, so I have got that continual challenge to face as well. I think that it is worth adding that the three islands are very different in the way that they geographically laid out. Certainly from my experience when I first moved from Shetland to Orkney, I wondered why some of the solutions that we might have put in place previously in Shetland did not appear to work so well in Orkney. It is because the communication links, the physical transport links between the islands vary, and the western isles are different to Shetland and different again to Orkney. We are all island boards, but we have our own individual internal challenges around communication and transport. That is very helpful. I could just raise another issue as far as looking at the hardware that is available across Scotland. By definition, for costs, some hardware, such as pet scanners, propositron emission, tomography scanners, would only be used in much larger boards. That is understandable. You will not have the figures in your head, but could you perhaps write to the committee with the number of patients that go each year to the other mainland in terms of Glasgow, Aberdeen and Edinburgh, which have the ability to provide the scanning? My understanding is that it has much more positive and protective images, which is very helpful in diagnosis, which you would clearly want. Unless I am badly informed, it is very difficult for your boards to provide that. There might be other types of scanners that I know from Western Isles that have had some discussions that you would like to provide. I suppose that that is the known knowns. For a very expensive equipment, there will always be a case that you have to send patients on. There will be some cheaper equipment that you can provide, and presumably there will be the ability to speak kindly to other boards in the regional sense to make sure that consultants are visiting Western Isles, Orkney and Shetland, rather than being based in Inverness and Aberdeen. However, I have had some discussions with the other boards, so I will be interested in your view on that. There is a level of expertise that the staff need in order to use that equipment. There is a level of maintenance that requires an amount of expertise. Although it would be nice to have the equipment at the high-quality end, there is obviously a human angle to that in terms of being able to staff that and sustain it. In terms of low volume, again, a point that has already been made, we would have to sustain that level of expertise in a staff group who may be performing very few scans of particular areas of the body, for instance, that need some expertise in how to position, etc., to get the best images. That would probably be the key factor in terms of skills retention and skills decay in order to operate that equipment in the first place. We have been looking at purchasing an MRI, because we established that we would save around £250,000 a year on patient travel alone. However, when we looked into purchasing one, which is close to £1 million, what we would save would be less than if we just carried on sending patients to the mainland. That is early figures at the moment. The point at issue is that most of our hospitals would classify as rural general hospitals, although the one in Stornoway is a rural general plus. It does a few more things than a normal hospital would do as a small one. We have the particular position that, with the population size that we have in the islands, it simply would not make economic sense, apart from the fact that, in one sense, leaving aside just how expensive some equipment can be, it is recruiting the workers who can understand the equipment, understand the data that is produced, make the correct diagnosis and then have a decision that is an accurate one. We have service-level agreements with various authorities, and we depend on them. We depend on Glasgow, for example, on the Golden Jubilee frequently. We have got this particular position that, for many years, we have worked as a group of islands together with the North for about 15 years now. We are now moving into a regional situation that is much more formal, but for which is no stranger to this way of working. We have been dependent always on small boards to work with the larger boards, and they have, in all cases, been very supportive. I absolutely agree. It is about making a judgment around the balance of quality access staffing on some of these issues. As it is with all our services, the issue that I was going to pick up as an example is that we now have, and I think that Orkneydo has, a visiting dexa scanner that comes up in a mobile van a couple of times a year. There are potentially different solutions in some types of hardware. We have looked at that for MRI, and we do not think that it is practical just because of the practicalities of shipping an MRI scanner in the way that you have mobile MRIs going to some other places, but there are different solutions in different technologies, depending on the exact detail of them. Can I move on to the more suddenly subject of funding? As you know, the National Resource Allocation Committee, the NRAC formula, takes reality into account. I was looking at the Audit Scotland report for 2017, and I could see the variations as far as the various island boards are concerned. Does that formula work for you? I would say yes and no. It generally seeks to address the situation in the islands, but there is something about the small scale of our boards and the fixed costs associated with the establishment and operation of the boards that creates a little bit of an additional pressure. The extreme rurality is perhaps something where there is still potentially a case to be made. In Orkneydo's example, we successfully made a case for additional costs associated with a particular model in primary care that was being operated. There is the potential for a similar, but not identical case to be made around the model that is applied in Shetland. The subtle differences that are not fully taken into account by NRAC, but having said that, it is entirely up to us to make that case and to see if we can get support for that. There is not very much of a problem with NRAC. It is a very fair way of distributing money. Unfortunately, it starts from a quantum, and therefore, if the quantum has to be divided up to suit all the various boards, you end up always with the fact that there is insufficient money for the particular year. Therefore, we have to carry out, in our case, for example, £3 million worth of savings to make sure that we come in on budget. We have successfully managed to do that for 10 years in a row, and I would expect that we will yet again attempt to come in on budget. However, it is a challenge at all times. There is a constant, almost weekly check on how budgets are actually functioning. In fact, I know for certain that my own acting director of finance has a quarter of an hour system running in which constant reports are pointing and explaining exactly where we are in terms of finance. In terms of NRAC, one cannot fault the actual formula, but the quantum that it is working with, we would not object to seeing it increased. Three years ago, when I was the director of finance of NHS Ortonay, I worked very closely with the NRAC technical group in looking at the constituent elements of the NRAC formula, and we successfully made an argument to subdivide the remote and rurality aspect of the NRAC formula into what we might call the even more remote data zones. We used the proxy for that, those entitled to the distant aisles allowance, because we would strongly make the argument that the aisles, again, are different even from the more remote and rural areas of Scotland, Scotland and mainland. All three of the island boards at that point picked up well on the NRAC formula. Iain makes a very valid point. To be fair, this has been discussed extensively at the technical committee. There is a certain level of de minimis costs, which, if you are to be an effectively functioning health board, you must have, whether that to be supported by any pillars of the governance work, but I think that picking up Iain's point, we have got to NRAC where it reflects the remote and rural nature of the boards that reflect that were island boards, so I do not think that we could sit here and disagree with the formula as it stands today. Clearly, our islands and our futures are very, very important. All parties have been discussing what more work we need to support islands in. A couple of years ago, when COSLA met the three previous conveners of the respective local authorities—who, I think, have all moved on since then—they were keen on a single public service operator in each of the islands, which, at one level, will give them more scale, will perhaps give them more health muscle, but it will give them more synergies in finance and other issues. Do you each of your health boards have a position on that concept? I think that we are all at various stages. For example, I think that you will be well aware that most of the discussions on single island authorities have taken place in local government contexts. There has been no involvement, no discussion with any of the health boards prior to any decisions being made. What we have at the moment in the Western Isles is a production of a report by the Western Isles Council in which it puts forward a number of possible options for the future, one of which, in fact, is to dispense not only with the IJBs but also with the health boards and to run the system as just a subset of the council, which, as you can see from one angle, makes a degree of sense. The key point will always have to be certainly useful if we can achieve savings of any kind of move, but it has to guarantee patient safety. It has to make sure that the quality will not be diminished in any particular way. Our board has not yet met to discuss the council's proposition, because part and parcel of what the programme for government included was that the Scottish Government would consider any proposal coming forward. However, that proposal coming forward rests entirely with the council to promote, and it has to do that within a set of caveats, one of which involves the people who have an interest. From the point of view of the Western Isles, we would hope that, at some point, the council will, in fact, consult us. I come in with a slightly different perspective. The programme for government clearly gave local authorities the opportunity to explore a single public authority. It set out a set of caveats that would need to be adhered to if we were to successfully take that proposition forward. It is fair to say that the approach by the three island councils has been different. In Orkney, the island's council is proactively pursuing that agenda, and we are in discussions with them, but we are very much mindful that we need to demonstrate benefits to the community, that we need to protect the staff and the NHS, and that we need to be able to demonstrate improved outcomes. In Shetland, the council has yet to form a position on that. Therefore, the discussion with the board is in an entirely different place. Clearly, in the Western Isles, there is another approach being taken by the local authority. It is quite a mixed bag at the moment. I echo what people have said. For me, it is about doing this together and working through what the potential implications were, and really focusing on whether it would make a difference to the outcomes that we are delivering for the population in the community. It is not a theoretical thing to do around whether it is a good thing to have a single organisation. It is about what does that actually mean in terms of outcomes. For me, we would need to do that, understand what the benefits were and understand what the risks were, and be very clear that, within an island context, accepting that we are intimately integrated within the community and, from the point of view of integration and our primary community services, they are very closely linked with council services and others. Our acute services are as much linked into mainland services, so anything that we do on the islands has got to recognise that we work both ways. I think that our clinicians would take different views, depending on where they sit, as to how they would see that. The other thing that we would need to be very mindful of is that one of our biggest challenges is recruitment and understanding what potentially us being seen to be outside the NHS or a different type of structure, what that might mean for recruitment of staff coming out from mainland into Shetland and what that might mean in terms of long-term careers. I have no doubt that there are ways of managing that, but we have to be very careful that we get that right, because otherwise we could have unforeseen consequences. It is an issue that we absolutely need to explore and understand where the benefits come, but also be very aware of what the potential implications are. Kate Forbes. I would like to ask about the skills mix. How do you ensure that you have the right skills mix in terms of generalists and specialists so that, as many people as possible, are treated locally and in communities, including out-of-hours care? In the out-of-hours, we have community and scheduled care nurses and they are trained to almost advanced nurse practitioner level. We will be taking them forward through the NP funding that is coming for training later this year. Within the hospital itself, we have now moved to a model where there are no actual doctors within the main hospital itself, and that is run by clinical support nurses who are advanced nurse practitioners. What we have found since we have reduced the junior doctors on night shift is that the calls going out to consultants have reduced. In terms of maintaining skills within the hospital at night, I would say that we are quite well advanced with that. During the day, we have also made quite a lot of progress in terms of our acute assessment unit and the nursing staff in there not having to rely completely on consultant staff or junior medical staff either. Within A and E, we have extended-school practitioners and they are all advanced nurse practitioners as well, but we bring them through from band 5 at general level, through band 6 into band 7. We develop them over a period of five years, so we have some succession planning in place. Describe it in a slightly different way. This is a constantly evolving picture. We are having to often peel back the layers in terms of what we actually need to meet need, what are the core components that we need to deliver, the particular functions that we need to make sure that people are safe and look to after, and it is of high quality. I think that what Chris Henn is describing is absolutely right. There is that constant look at what we actually need to deliver this service and who else can deliver it as well. What are the particular skillsets because the traditional way of delivering services is not sustainable? Talking from a Shetland perspective for a moment, we have particular pressures around recruiting general practitioners, and we have had that for some time. Whilst that seems to be easing a bit, we have been looking at what else we can put in place to meet need, a very successful model around advanced nurse practitioners, for instance. The opportunities that come around health and social care integration are a key component of that. It is not just about statutory service providers, so what else can the third sector provide that might have traditionally been provided by statutory services? It is about a root and branch look at what we actually need, what are the core components to meet need across a community at that level. I would agree 100 per cent what Chris Henn and Simon have said. Fundamentally, we all start from the same place. It is an assessment of the staffing levels and the staffing mix that we need to meet in particular circumstances, whether that be in our acute services or mental health services or out-of-hours services. Then we have to add the dimension back to the geographical challenge of, particularly when it comes to the more specialist posts in terms of patients that we may well have to transport off island using the ScotStyl service. There is often this fallacy that the sickest people are taking off the island. That is true, but eventually we can often be looking after the very ill people on the island and need to stabilise them and to intubate them for maybe 12 or 14 hours while we are waiting in the helicopter or the fixed swing to get on island and in the retrieval service to take those patients away. We certainly have a need for that. When we are certainly looking at our consultant medical staff, we are looking for that broad range of experience. We really need that specialist generalist, who is being developed now, so we are certainly looking for that odd animal that can deal with all ages. It can deal with children, it can deal with adults and it can provide for that. We are really looking for people who probably can remain calm in the emergency. It is very interesting. I have a good friend who is actually up with us at the moment. He is the guy who I used to work with in the borders 20 years ago. He is a very, very experienced anesthesis. Even he said the first time he stood there waiting in the ambulance to come through the door, he said that he did not know what was turning up none. I could not dial whatever number informed the orthopedic surgeon, informed the pediatrician, informed the… There are these dimensions that we have to think about. The basics are that we start in the same position as all our territorial board colleagues in terms of an assessment of our needs and then we try to put the island dimension on that. It is slightly different when you then get into the aisles where we might have GPs or advanced nurse practitioners on there. We are probably looking to upskill them in terms of basics or advanced life support and there are probably minimum requirements. Very often what we are staffing up there for is not the in-avers primary care activity, which you might see. It is actually that emergency that might happen out of hours where they need to be very competent to deal with that. With all that, it brings the challenges of recruitment retention and skills atrophy, which we are talking about. In terms of trying to treat people as locally as possible, albeit with the need to sometimes transport off the island, that is your concern or focus at the moment. Secondly, looking to the future, both in terms of demographic challenges and ageing population, and also in light of Brexit and our reliance on European nationals as healthcare professionals, how are you preparing for both the demographic challenges and the potential impact on the workforce? Three small questions. I think that those are two significant challenges. The demographic from both perspectives is the ageing population of which we serve and the challenges that that will bring in terms of the multiple comorbidities that we already see lots of and everything that comes along with that. In line with that, we have also got an ageing workforce. We have got about 32-33 per cent of our workforce, which are aged over 50. About 20 per cent of them within the next two years could, if they chose to do so, exercise their option to retire. We are always mindful of that in terms of our workforce plan and what are the skills that we need. We know on island at the moment that we have particular challenges around old age psychiatry, but we would like to move into the market of engaging our own old age psychiatrists, because we might not have 100 per cent need today, but we will have in three, four or five years' time. We are always mindful of the recruitment timeline that that might take. Brexit, again, we are always mindful of. We are not seeing directly on Orkney at the moment a direct correlation with the Brexit decision and whatever that might bring in that, but it is undoubtedly when I speak to colleagues in the Territory balls, particularly through the medical education field, we have seen that that might well be impacting on the number of trainees coming through the system. What we are doing at the moment—we have a big push-on at the moment—we have had for the last couple of years. What we are really pushing quite hard through our director of medical education that we share with NHS Highland is to encourage the undergraduate levels to come on to Orkney and they are coming on to Orkney and they are having a great time. Both professionally and personally, and they are really enjoying it. We are going to really pause the feedback on that in the hope that we will get some of them to come back, therefore, when they are qualified, because we do recognise in some of our areas that we attract people probably at either end of their career, those just kicking off, or those who have had a very active career and are now coming to look to pass on some of that professional skills. We take all those factors into account, but in terms of demographics, they are definitely prime in our thinking at the moment, both for our population but also our workforce. Brexits that we are not probably seeing the impact at some of my territorial board colleagues are definitely seeing at the moment. To emphasise a bit about the demographics, the west analysis is actually in the worst position of the lot, on the basis that we have proportionately a much more aged and aging population, allied to the fact that we have the lowest proportion of youngsters entering employment, so we have been hit by a double whammy in the future insofar as we look towards it. However, we have tried in collaboration with the University of Highlands and Islands to promote a number of courses, and the University needs no encouragement to find other courses that have actually taken over nurse education. We have a provision in the west analysis. Equally, we are now represented at careers conventions in schools, just to make it clear that there are more jobs in the health service than simply the ones that appear. For example, I work with volunteers quite a bit, and we have a fair number of youngsters from schools that will actually quite happily volunteer to come to the hospitals to do a bit of support work. I have to be honest and say that the girls themselves almost always graduate towards the maternity ward as they have made interests in that kind of volunteering. However, it is that kind of involvement that we would hope sparks an interest and for people to realise that there is a huge range of jobs available in the health service. As far as Brexit is concerned, we are pretty much the same bit. We have in fact, I think, seven of our consultants are Polish, so therefore we have to be concerned that, depending on the Brexit decision whether or not they stay and what the arrangements will be, but, like everybody else, we will have to be a fleet of food in so far as we can when it gets to that stage. It is certainly a risk that we need to assess quite closely because four of our anaesthetists are all Polish, so if they all left at the one time, we would be in significant trouble. If I start with the Brexit issue first, I think that point is really well made about the mix of our consultant staff, and I think that it reflects over time the fact that the UK hasn't trained doctors to work in rural areas. If we looked at where we would recruit from, there are people from elsewhere in the world who are probably a better fit because of the breadth of their training. We have just been out for some anaesthetic posts and we have had locum anaesthetic consultants who work in India, and they have a very broad skill set, so they fit quite well. I think that one of our responsibilities as a board is to try and encourage and ensure that, as a system, we look at that better within the UK. Certainly, we have just been part of the recent GMC visit to Scotland, and that was one of the points that we were making to the GMC around the way that they develop their training in the future, is that we need to get that breadth right because there are very small places like the islands where we have a particular niche, so that's really important. The other bit is this thing about the pipeline, and I think it is about encouraging our own population to look at careers in health. We know all the evidence from across the world that if you come from a rural area, you're much more likely to go back and work in a rural area. We have been pushing quite hard within the access to medical schools. There has been quite a lot of work around kids from deprived areas having support to get into medical school quite rightly, but I would certainly look for that to be rolled out into rural areas because I think that would be very beneficial. The only other point I would make about demographics is, for me, that is actually where community planning comes in. It's about how do we work with our community planning partners to improve or ensure that the population mix in the islands is as vibrant as it can be, as economically active as it can be, and that's certainly one of the main priorities within the Shetland community plan, is how do we make sure that mix of the population is right? Just one small quick point to add to that. We shouldn't forget as well the supplies to social care, so that underpins an awful lot of the care in the community, and without that, that would swamp the NHS. In terms of ageing population but ageing workforce, depopulation of some of our more remote areas within Shetland is clearly impacting as well, and that's making it really difficult around recruitment and retention for those staff that are so integral to keeping people in the community. Just one last point in terms of collaboration between Shetland and NHS, when it comes to trying to recruit professionals who've had experience of rural and have the right skillset, I note last week that the Scottish Government pilot programme around midwifery. That's a great example. What other examples are there or what would you like to see in terms of concrete examples working with the UHI for ensuring or working with the colleges for ensuring that there are trainees who have the right mix for what you need? For one of our other services, that's severely challenged, that's maintaining laboratory services, and I would like to see UHI in particular taking up some push work around supporting that service. At the moment, we're starting to take on MLA's lab assistance who will actually progress on to becoming biomedical scientists, and one is actually attending Ulster University, so we would like to see UHI offering some of the questions that Ulster do at the moment, because of course the travel is significant four times a year, but we're supporting her to progress through that, so anything at all through lab-shared services that could be provided as a means of supporting the local workforce in that way would be excellent. I'm sorry if I just add maybe one little bit. In the past in education, the colleges used to make a specific provision to take students from the islands, a guarantee in fact of entry, obviously as long as they met the necessary qualifications to be admitted. So a system like that that would guarantee entry for those that met the qualification levels, living the islands would help us greatly. For example, we have two of our doctors at the moment who are actually born, bred, raised in the Western Isles who have come back to actually work there, so it's the proof that if you can, if you're accustomed people, it doesn't come as a culture shock when you move from the city in the mainland if you've come from a rural background. Frequently, we can recruit quite successfully, but we can't retain, because after two years of the winds that blow in all the islands, people realise the day they came and the sun was shining is not the norm. I'd like to focus on general practice and particularly the response of your practices locally to the GP contract. Largely, that's been received pretty well across the country, although members of this committee have been effectively lobbied, very effectively lobbied, by rural GPs and groups representing rural GPs who have concerns about the contract and particularly what might happen in phase 2 in three years' time. Given the remoteness of your boards and the particular rural needs of your boards, the risk for that might be particularly acute for each of the areas that you represent, can you tell us how that contract has been received to your knowledge locally and what kind of work you're doing with the GPs to influence the next phase of that? It's very helpful the way that the question has been posed, because the concern is not so much about phase 1 as implemented. It's the prospects for phase 2 when what appears to be the case is that if you're in the rural areas, you're liable to be paid less than would be the case if you're in the central area, for example, payment may move towards numbers. There's a rationale for that, and I would accept that. Second, but just not to miss the point, is that one of the parts of phase 2 is that the health boards take over responsibility for all premises, and that has a financial cost that we would want to certainly make sure was included. However, to go back to the basic point of the question, I think that there's a general acceptance at the moment because of the guarantee that nobody is losing any money that there is a widespread acceptance that unbalance. It's a better deal than has been the case, but, prospectively, there's no guarantee that that will come out in phase 2, and because of that, there is concern. So, there is acceptance, but concern. As Neil said, the way that the question has been phrased around what the impact is in phase 2 for me is the most important bit because, in reality, in Shetland, other than perception, it'll make very little difference. Most of our practices will be protected in terms of income, and assuming that doesn't lead to people moving because they think that there's somewhere else that is getting additional money and that plays out, which we don't yet know, then there shouldn't be a big impact in phase 1, but I think the way phase 2 plays out is the really, really important bit, and we need to make sure that we influence that appropriately. The other bit, to say from a Shetland perspective, is that two of our practices are independently provided, the rest are provided as a set of salary practices, so, from that point of view, the contract doesn't have the same direct implication. Broadly, you would say that there's a difference of opinions within, and some of the practices have been quite exercised about the potential impact of the contract, and others think that a lot of the underlying messages in the contract about the development of multidisciplinary teams focusing the role of the GP, having other members of the team doing other aspects is absolutely the way primary care should go, and the challenge for us is how do you play that out, and that's the work that we should be doing linked into the memorandum of understanding around a primary care improvement plan sitting down with our GPs and saying, right, what does this really mean, how are we going to do this, and recognising that, even in somewhere like Shetland, our practices are different, so we've got a practice in Lowick, which is 7,000 people, and it's very like a real practice in any Scottish town of the same size of Lowick. The fact that it's on an island doesn't make much difference at that level, down to practices of 500 population, so they're completely different as well. Part of our job is to make sure that we apply that appropriately within the Shetland context. If I could just add, I think it's really important that we engage with primary care with all our GPs and encourage them to actively be involved in the discussions and negotiations leading up to the implementation of phase 2, because a lot of the issues at the moment are probably due to either lack of information or misinformation, so making that work more effectively might help us to iron some of the potential pitfalls out of the contract as it evolves. However, there is another point that I would like to bring to your attention around this, and I guess it applies to everything around remuneration, but it's a point that we've made with the team working on GP contract, and that's the impact of the minimum income standard study, which clearly demonstrates that the cost of living in remote and rural Scotland is significantly different to the cost, particularly the central belt. In fact, in very remote parts of the islands, it can be 140 per cent. When we start talking about national contracts and national remuneration, the pound doesn't go as far, so the individuals are possibly indirectly penalised because the cost of living in these remote locations is significantly higher. In the light of everything that you've all said, is there a concern about recruitment given the fact that there is an element of uncertainty about what phase 2 will look like? To that end, would you welcome clarity and uncertainty sooner rather than later, and will you be actively lobbying the process around phase 2? If I may be start, I mean absolutely lobbying, and I have been asked to sit on the short-life working group around rural implementation of the primary care tron contract, and I'm really pleased to be part of that, so that's certainly somewhere where we'll be looking at how will this play out within the rural area. I think the recruitment issue, we absolutely are continually focused on, we've made some progress this year, at the beginning of the year we had about 20 per cent of our GP posts vacant, it has got slightly better, but the area that we are still finding very difficult are the very small practices where we're asking people to work 24-7 for long periods of time, and that will continue to be an issue, and I think that for me is one of the aspects within phase 2 that we need to understand, which is that the feedback we would get from GPs is that the formula and the way that's played out in phase 1 around workload hasn't properly recognised the complexity of the job as a GP in a remote and rural area, and often that isn't about individual patients coming through the door, it's the complexity of that, it's your ability to have colleagues immediately on site, it's the fact that you've got to provide emergency services, so for me one of the aspects within phase 2 as that develops is how do we actually properly recognise what the workload of a rural GP is. I think that that's 100 per cent the key point, just for a bit of context, Orkney has got six GP practices, five of which are independent on the Orkney mainland, and we've got a sixth board administered, which covers our outer aisles. I think that I would describe it as that there is definitely an acceptance of the contract, and I think that acceptance is the correct word rather than embracing of the contract, but certainly what our ambition and our aim through our implementation plan is actually to work through that, is how do we define that role, responsibility of a remote and rural GP, because the expectations of them, requirements of them are different, and they're even different across different parts of the island, so our two practices, which are based in Kirkwall, actually from this time next year will be physically based within the new hospital facility, so it gives them ready access to facilities, which perhaps 11, 12 miles away in the west, or the east of the mainland you won't have, and then again our board administered practice, which covers the outer aisles, they might even have a ferry, and then a busch journey to get to a busky scenario of a ferry, and then an ambulance journey to get into the hospital, so to me it's very much about that, how do we develop that role of the GP, and that's something we are definitely looking to do together, I don't think there's any other way we can do it, I'm very keen, and I've said to my GP colleagues to have a very active conversation with my GP colleagues, and it's how we develop those services, because obviously we've got a new facility coming online in Kirkwall as well, we're looking to get the maximum use out of that, the premises is not really so much of an issue for us, because we already, the health board, already own all the premises, which the practices operate out of, but we're looking to extract every advantage we can out of the new contract, we're probably in a similar situation, and we don't foresee at the moment GPs leaving, because there might be this perception of there's more money to be earned south, our GP certainly makes that lifestyle choice as well, as most people who do, who move to the islands as well as we have some, just picking up a point made, we have some Orcadians who have now come back on to the island's GPs. The recruitment issue, what I'm certainly seeing, is struggling more to recruit at partner level, they're not looking to take on the responsibilities of being the partner, and maybe more happy to be a salary GP within independent practice. We're seeing that little shift there, but she's putting more of that management senior partner, burdening on to maybe one or two key individuals. Of course, are we concerned, and the answer is yes, we are concerned. It's difficult, as you would well understand, to recruit, but it's just as difficult to retain where there may be the decision after two or three years that this is not the lifestyle, in fact, that they have helped for working four days a week, and surfing for two days a week is not, in fact, what they had planned. We are concerned, and it's part of a much more general concern. For example, you know the plans about setting up centres of excellence. The very nature of those would appear to be, that's a very attractive proposition for doctors and consultants, and if we run the risk of losing people, then that will certainly happen. However, we have to make the efforts, as we do, to make sure that there is a sort of welcome to a new recruit. For example, you normally, especially with, let's say, the sort of more elderly but not completely old consultants, you may recruit. You're not recruiting just the one doctor, for example, you're recruiting a family, and therefore the provision has to be there in terms of the socioeconomic background that provides for the possibility that a spouse will want to work, and the possibility that children's education can be promoted. It's a long way around the circle to say that the close work that we have with the councils actually matter here, quite importantly, because they have the same concern, the same problems of recruitment and the same problems of retention, so collaboration on that is extremely important. However, our concern won't go away. It will ease to some degree once we're certain about Brexit, and we can then actually focus on what is possible within the political framework that we operate. I guess that I'm an eternal optimist, and I see this as a real opportunity potentially to engage with GPs in a different way and to construct something that looks different for them as well. In that sense, if we're successful in doing that, then hopefully that will make jobs more attractive and will give us an opportunity to compete, putting the GPs at the heart of what we do, working in localities, doing things in a different way. It could be an exciting opportunity, and we need to engage with the GPs and with people coming through training just to highlight where the opportunities arise and then how much better potentially the job could be for them than it is at the present time. I think that I probably should mention. I also have the pleasure of chairing the Scottish Royal Medicine Collaborative that supports some of this work, and very briefly, I think that the three areas that we're particularly focused on is one, how do you market or change the mood music around working as a Royal GP, because I think that they can be brilliant jobs, so we need to change the mood music about that. Secondly, how do we make the recruitment process as good as possible? Within that, I think that we're very much focusing—obviously, we've got huge opportunities around our locality, but in most cases it's about the job, so how do we make sure that people are focused on what the job is? Thirdly, how do we make sure that we provide people who work in relatively remote areas supported and have networks of support so that they don't get isolated and improve retention? Thank you very much. Now, Telly Medicine was mentioned and answered to one of the early questions, and I'd like to bring in Emma Harper. Thank you very much, convener. Good morning, everybody. You talked about the geographical challenges, and you mentioned Telly Medicine already. Last week, we heard from Greater Glasgow how they're doing orthopedic clinics using remote access. I'm aware that there's an Empower programme, which is part of Dumfries and Galloway, Ayrsharn Arran and Western Isles, to look at keeping people in their homes longer. That's really important when we've got health and social care challenges, so it's not just about acute care, it's about keeping people in their homes longer. I'd be interested to hear about Empower because it's interreg EU money funded, so is that money safe post Brexit? That's a challenge, but how do you measure whether Telly Medicine is effective and to patients like it? Yes, please. I'll ask Chrysan to rescue me from the answer, which is basically to say that in terms of the programme itself, we're working to try to make sure that we first of all repatriate as many of the services that we can reasonably do and operate. For example, orthopedics until about five or six years ago, most of our orthopedic cases had to go to the mainland. We now operate in the Western Isles, and to the stage now that the orthopedics, which was largely, of course, hips and knees, has now extended to wrists as well. We're able locally to make that provision, but because of the advance of technology, we're able to link up to specialists in other areas who can follow quite specifically and give advice if they're asked for it. If I can divert just to the answer about the money, as far as we understand it, because of the transition period, however it's described, the money continues to float to that point. What happens after that is, of course, up to the Government as to how it wishes to see those going. To emphasise the point, the islands and the remote areas in the sense of the mainland are actually obliged by necessity to come up with solutions that are driven by technology, which eventually will be what the other boards will do as well. The collaboration that's going on at the moment through healthcare is quite extensive. For example, we've got a new instrument that basically will replace the stethoscope in which the person can not only sound a chess, for example, but can actually see inside the heart. That itself can be streamed on the internet to specialists elsewhere who can advise on that kind of approach. There's a huge opening in terms of the positive nature of the internet that we can work on and take some of the good bits out of it. We have patients with long-term conditions, cardiac failures, COPD, diabetes and so on who are being monitored from home using Florence. They can input all their own information, their blood sugar levels and so on, on a daily basis. If they're at risk of deteriorating, for example, a cardiac failure nurse will communicate with them immediately and can attend them in the home rather than bringing them into hospital. It's almost like early warning systems are in place for those patients, and they seem to work very well. More recently, we've introduced a mobile eco-scanner within the hospital itself. Now, our ecosynographer can actually view the images remotely and when she's not there, provide advice so that that patient can actually be transferred early to Glasgow or treated locally. I suppose that there are several things that are in progress at the moment. Just to continue the theme very briefly about acute services, but I don't want to major on that. We've been doing ENT clinics, for instance, from Shetland, linking in with the mainland through technology for a number of years. We're starting to use the attend anywhere system of outpatient appointments being carried out remotely, and that's working well. However, those are early days and early steps for some of these. They also rely on clearly the other end, if it's on the mainland, playing into this as well to support Shetland with these initiatives. If I can just touch on the community aspects, at the moment in Shetland, we've got over 600 pieces of technology-enabled care equipment out in the community that is helping to support people to stay safe and be cared for in their own homes. One of the huge limiting factors for us in terms of doing more that links people's own homes, either to a hub in Shetland or to the Scottish mainland, is the availability of broadband width that's adequate to support these pieces of technology.  There is a lot more that we can do, that we want to do. We can see the opportunities, but we're being hampered at the moment by the poor broadband width that exists in many places in Shetland. Some of the most difficult places to use any kind of technology-enabled care are our most remote and rural places, which are the very communities that we could use as technology to support people better and provide a better quality of life for those individuals, and particularly to take out the travel. Having heard from the Wesson Isles, we're a slightly different place in terms of things that we're trialling and using. Suffice to say, we're trying to be really innovative. I think that there's a lot of test of change going on at the moment in various places in Scotland. I think that that's fine. I'm obviously welcome the new digital strategy that will give us a common platform, because again, that's really important. We've got a myriad of systems out there. In terms of the technology, we need systems to be able to talk to each other and share information, because that's a key component of being able to provide integrated care across health and social care. At the moment, we don't have some of the platforms available to allow that as well. I think that there are solutions on the horizon, but we're going to need them really quickly. I think that it's worth saying that clearly telemedicine, telehealth is a real positive for patients and for patient experience, but it's also a good way of unlocking realistic savings, which we can then start to think about reinvesting in expanding that work. I think that in Shetland, in 2016, by memory, we had something like 600 avoided patient journeys, because we utilised telemedicine in the following year. I think that increased to 1,400. Each of those journeys potentially would cost at least £300 purely in airfares, so it makes a significant financial incentive to encourage island boards to work more effectively in that way. The points that have been made around the limiting factors of good communication, good broadband, good phone links, mobile connectivity are things that do limit us in a way from doing more of that. The culture of getting people working on the mainland willing to change the way they work to support us in doing more of that is a barrier that we're working hard to overcome. We're making progress, but there's still more to do around that. I think that Sandra White had a brief supplementary on the travel costs. Basically, yes. Thank you very much for your evidence. It's been very educational to me coming from the mainland. The one that I wanted to ask was about transport costs. I know Engelbraith had mentioned that in escorts. It's one that I know about because obviously Glasgow number of people come from islands to access, and as people have relatives in my constituency who come to me to say about that. I'm really interested in what you said about the budget. 600 less transport because of telemedicine and being able to get broadband, etc. How much of an impact does transportation have on your budgets? Is it very negative or is it getting better for all of you? It's got a massive effect on our system. The Highlands and Islands transport system was originally funded centrally by the Government, so to an extent that there was never any disincentive to send patients and, indeed, to approve of every single escort. That money three years ago, if not four years ago, was handed over to the local authorities to administer. At the moment, in the last financial year, we have spent over £3 million on transport costs, of which at least 46 to 48 per cent of that is escorts. In certain cases, without a doubt, escorts are necessary. In other cases, as I mentioned earlier, if it's a 10-minute follow-up meeting, it can be done by telephone. That's a simple thing with a consultant, and it would bring about savings. We are keen to bring about savings, but I really have to emphasise that it's because we're now applying the policy that we haven't invented anything new or introduced any new policy, but it hasn't stopped complaints beginning to mount. We don't spend quite as much as the Western Isles. We are probably at about 2.4 million, 2.5 million through the Highlands and Islands travel scheme. We are probably organising about six and a half thousand journeys a year of about 1,700 of those for escorts, so it's quite significant. Just going back to Mr Stewart's point, we put a CT scanner on island three and a half years ago. We probably saved £300,000 a year from travelling backwards and forwards to Grampian from that. We used the national pack system and the national reporting system, because it's Grampian who reads the CT scans. There is definitely an incentive in there for us to try and limit the journeys and that will result in a saving to us, as well as it being probably the best thing for the patient. For us, our budget is about £47 million, and last year we spent about £2.7 million on patient travel this year. I think it was going to be near a 2.1, 2.2 once we've seen the final figures. That is partly because of the success that we've had around treating more people locally and partly because we were able to negotiate a different deal with Loganair. One of the risks for us going forward is those of you who are aware of the air service issues in Scotland. We have had this year for the first time a competition on the islands between Loganair and FlyB has stopped again. We are very dependent on a single provider who is obviously a commercial provider. We will shortly be getting back into renegotiating with them around next year's prices. There is certainly a risk there for us that we will have to try and manage. The focus, I think, has to be—obviously, the financial aspect of this is important. Ultimately, we need to recognise that behind every single one of those pounds spent is a patient who is having to make a journey. In many cases, an elderly patient with an elderly escort for a 10-minute appointment might take them 12 hours. I think that we have to remember the patient behind the statistics. If I could just go back to the very early point around the geographical differences between the three islands. I suppose that the successful negotiations with Loganair around patient travel were partly predicated on the fact that, in Shetland, we did have a realistic opportunity to send all our patients by boat, albeit that would not have been particularly attractive. In fact, the public let us know how unattractive that was as a proposition. Nevertheless, it was a real alternative, and it helped to bring Loganair to the negotiating table, so we were able to get a preferential deal from them. That does not apply in an Orkney context, because we would need to have a daily boat going to Aberdeen. In fact, we do not. We have a week going to Aberdeen. In Orkney, we would not be able to effectively put that threat on the table to Loganair and potentially leave us. We are really trying to, I suppose, negotiate with Loganair with a hand tied behind our back if we are trying to get the same kind of beneficial deal that we have managed to achieve in Shetland. It is not that we do not want to share the good practice and to roll it out. It is just that the commercial reality makes it very challenging for us to do that. I will cross on the earlier question about cost. I think that it is a useful example. We moved from having one consultant orthopedic surgeon to having two. The effect of that was immediate in the sense of the number of people that we were able to deal with in the Western Isles. It was a huge saving at that point. What we had not reckoned, of course, was that with two of them working, they are extremely successful and extremely experienced, that it began to cost us a small fortune in ceramics and steel as they began to use that. In fact, we had not budgeted anything like sufficient money for that. What we saved on patient transport was instantly swallowed up in more making sure that people were cared for and were able to walk. Ivan McKee Thank you, convener. Good morning, panel. Very interesting evidence so far. I would like to follow up a bit on the technology side and broaden that out a wee bit. I know that there are issues around financial challenges that are going to come up later in some of your performance measures, although many of them are better than the Scottish average, which is good to see. The area that I want to delve into a wee bit is to get a better understanding of the process whereby you go about process improvement. How do you identify opportunities for savings? How do you identify opportunities for performance improvement? How do you share best practice? How structured is that process? Or is it just ad hoc and you hope that good ideas can make themselves a part? Or have you got a structured way of going about that and digging out the actions that you need to take to continually improve performance? I think that the process improvement, whether that be cash or non-cash, has become a lot more structured for the entire service, but certainly in Orkney over the past couple of years. I am supposed to go back to first principles. Everything starts with the data to try and identify the opportunities. With all of those things, you usually start with those things like, where am I an outlier? Where am I spending more than the average? Where am I spending more than I would perhaps like to? Where am I performing badly? We have taken a lot of time over the last couple of years to train lots of people in the specific skills rather than just randomly saying, well, because it is not always the case as you will know that, just because you are an outlier, you are effectively bad. It is about understanding the data, understanding it over time. We target areas where clinical services are driven by areas in which we are an outlier and it generates improvement plans, whether they be in dermatology, cardiology or ophthalmology. We go through much the same process in relation to financially driven efficiencies. The days that we would all accept of the low-hanging fruit are well, well, well gone. It is one of the challenges that we will discuss later in the committee in terms of how we identify those savings. There has to be a systematic review of the underlying data to tell us where we are going. We have adopted a methodology with an ortony of strategy deployment matrices. Each is envisioned by the end of this year and we are already a good low way along there, as every department will have its own improvement plan in place. Some of those already have those plans in place. Some of those by the end of this financial year will merely have identified the areas where they want to improve upon. As you might expect, the people who are keenest to be involved are the ones that are furthest ahead at the moment. We take a very structured view to that in terms of identifying the baseline, identifying the measure, the changes that we would like to make, what are the expected changes that we would see coming out of those. We have applied that methodology into our infection control and a series of clinical services. I would not like to sit here and say to anybody that we are perfect, but we are trying to apply a structured approach to it. We have limited resources to look at that, so we try to target our experts on that. However, what we are trying to do is a training approach. We get the best results when it is the staff themselves who come up with the ideas and generate the ideas. They all then feed in through the organisational structures into our senior management team, our senior leadership team, which I chair and covers all the direct reports to me and various other heads of department. We pull that together on a monthly basis. It is a fairly structured approach, rather than just saying, let's go through it. I would echo everything Jerry has said. It is about using the data and focusing across the organisation and understanding where you think there are issues. I would pick up on a number of areas where it is unique in the islands. One is our ability to focus individual members of staff in the same way as some of the bigger boards do around improvements. That is a challenge. We have a lot of staff who are dealing with a lot of different areas because they have to cover a whole range of areas. We very much try and use national programmes as much as possible. Sometimes we feel that our ability to do that is maybe disadvantaged because it is harder to get down to improvement events. That face-to-face contact can be an issue for us. Sometimes it can be difficult just to release staff to go because you have one or two members of staff in a team. That is an area that we continue to work on. I think that if you focus it around resources in particular, I would suggest that a number of years ago we set targets across the organisation and expected individual areas to deliver those. We tried to do that in a way that we focus where. We had differential targets, depending on how we wanted to shift resources in the organisation. Increasingly, as we have done that, areas have developed what they have done. We are now moving more to a whole board approach. We have just been running a scenario planning process, which has been trying to look at the whole organisation, what is the future model of service, and that would then allow us to drive efficiencies out of individual areas rather than saying everywhere needs to now deliver, because I think that the easy to, the low hanging fruit, if you like, people use that phrase, has gone. It is now about understanding what are the key areas of major redesign that we need to focus our efforts and resources on. When I'm conscious, there were a few sub-questions there, and I may not pick them all up, but just to pick up a bit of its structure, all of the executive directors, every year, have targets set for themselves. They involve themselves in those targets, all of them are aimed at improvement. They're all starting at the base of the situation as is, and that is what we hope to achieve by the end of the year. At the end of that year, the chief executive reviews all of that progress—hopefully it is progress—and the chief executive is, of course, reviewed by myself. There's a structure there all the time, and because we are small boards, the executive director at a meeting every week, we've now got an integrated management team with the council. There's a beginning to be a coalescence of aims and objectives all aimed towards some form of improvement. I'm not suggesting that it's all perfect and that, indeed, everybody succeeds to the extent that you might hope, but it is highly structured. Now, as I say, I'm conscious that there were another couple of bits in your question, but I wonder if you'd mind. How do you use that to tackle financial challenges and performance challenges? How do you learn best practice from other boards as well? The North of Scotland planning group, which consists of everybody in the north who is now part of the new regional organisation, has been in existence for 15 years, so we've been collaborating to a degree without the formality of the new system for a long time. In terms of the financial challenges, we're all facing exactly the same prospect there. You've got rising demand. You have systems in which, for example, if I look towards the future, we're assuming a 3 per cent pay increase for everybody. We're also assuming that that will be included in the budgets that we'll be able to pay for them. Equally, every year, we're required to carry out 2 to 3 per cent savings, so there's a constant weekly focus on bringing about those savings. Some of them, as identified in advance, are not necessarily easy to achieve, and as the year progresses, you can begin to see that there were good suggestions at the time, but alternatives have now got to be sought. For example, you wouldn't be too surprised that, since December, we were working very carefully to make sure that we put a break on as much as we could, because we were in danger of not meeting our statutory obligation that we happened to have done so at the end of the year, but it wasn't without some pain and some difficulty. I'm sure that it's true for every board, by the way, that there's a constant focus on making sure that you're going to meet your statutory obligations. Comment, I would make. It was heartening to see, it's not new submission, one of your charts, or at least one of your charts is get upper control limits and lower control limits on it, so at least somebody understands Six Sigma methodology, which is great to see. You've made Ivan's day with that chart, I can tell. Moving on to some of the wider questions around regionalisation and integration, Brian Whittle. Good morning, panel, thank you for coming in to give us some evidence. We're well into the integration of health and social care with that sort of focus of care becoming more of community focus, and it's always interesting to hear a lot of your answers how much you talk about community by necessity because of the area in which you represent. I wondered how the integration is progressing in your area and the potential challenges that you feel that you have as a rural community? If I could set the scene before I let colleagues speak a little bit more in depth, integration has been something that we've done intuitively in the islands for a good number of years, so a lot of the joined working took place perhaps 10 years ago, and we began the process that has since become enshrined in legislation and the creation of integration joint boards, but I think that a lot of the potential gains, the way that we've collaborated, have just been a natural way of working in the islands and perhaps it's because we are smaller organisations and more inherently we do tend to work together, so I think that that contributes quite significantly to what appears to be good performance across the board by the island boards and the island integration authorities against the national outcomes and the targets. I think that we've started the journey earlier than some and have managed to get quite a way along that piece. I would, however, say that the legislation and the creation of integration joint boards has possibly had a slightly destabilising effect in the islands because we suddenly then became embroiled in more of a bureaucratic wrangling exercise about who does what and who is accountable for what, whereas previously we'd kind of just got on with delivering things jointly anyway, but it has, I think, helped us to learn to understand each other better, so I think that the health boards and the councils probably have a much better shared understanding of fundamental issues, and that is allowing us to unlock some further benefits from integration than we had done previously. I think that there's a good example that comes out of the fact that we, of course, have, in each area, the one council and the one health board. Therefore, it's been easier for the boards in the islands to work collaboratively. Again, there's a long history. For example, occupational therapy in the western islands has been there for 25 years as a combined arrangement, but the boards from the western islands point of view are working well. The first two years were taken up with rather more constitutional questions than were raised, and I think that we'd have been happier to begin to address some of the problems. But, for example, just to echo Ian's main point there, until we had the integrated boards, the problem of bed blocking was seen as a problem for the health service, not for the council. Whereas we now recognise that this is a joint problem, it's because of the inability to provide care that we end up with the bed blocking frequently. Therefore, the fact that you can move together in an integrated group, we've managed to reduce what used to be in our cases quite a bit of blockage down a bit. I think that, just to echo Ian's point as well, it has created a bureaucracy that I'm not sure was absolutely essential, but at least it's taken us out of the silos that existed before. We understand a lot more from the health point of view of how care is provided and what their concerns are, just as the council understands that health is much more complex than many of them had thought. I can only say that it's been an entirely positive experience in the last two and a half years for ourselves. It doesn't mean that we agree all the sound, by the way. We aren't on to disagree, but it's done politically and it's done politely. Echoing my chairman's optimism of 10 or so minutes ago, my opening remark would be that Orkney is in a good place in relation to integration at the moment. I first joined NHS Orkney's director of finance in September of 2008, and we had appointed the first joint director back then, so there's lots of the work at an operational level that's been going on for many, many years. I agree with Ian. Neil, it's not been without its bumps in the road, but I think that we're in a very good place. I think that the relations between the council and the health world are in an extremely positive place and I think that we will move on well. The other aspect of it that I would like to touch on, especially as we relate to the aisles, as opposed to the mainland of Orkney, is that integration with a fire and rescue colleagues, with a third sector colleague, is actually taking integration on to its full extent. It doesn't need to stop or not should it stop between council and health board, and it's actually looking at that whole economic sustainability of the aisles as a group. We've got the opportunities within the aisles where it's not just that co-terminosity and that single authority aspect, it's the way that we necessarily have to work and how the local population see the sustainability of their local communities, which is the minister, the doctor, the nurse, the fire station, and it's actually keeping all those things going. Of course, I couldn't leave out my substantive employers at the moment, the Scottish Ambulance Service. I think that just about everything that I was going to say has been said, but as an integrated being or person, maybe I'll give a particular view. I think that Shetland had that foresight to get a joint appointment in post well before the IJB came into being. Again, like Orkney, that was a really good move. In terms of the negatives, for a small health and care economy, it has brought around some duplication and triplication. I personally didn't foresee the amount of bureaucracy at a certain level that would come in terms of having a third body that needs to report in a number of ways come into being. Therefore, that has created some work, but at the same time, some of it is highly useful. In terms of the real positive speed of change, I don't think that we would possibly be where we are in Shetland in terms of the health and care economy being supportive of each other, the level of understanding, a common culture appearing, joint training, etc. The decrease in delayed discharges is probably the biggest key performance indicator that would headline some of the successes, but there are many others behind that. As Gerry had said, in terms of transformation, it is not just about the third sector, it is not just about other statutory bodies. There is very much around a level of leadership that is in the legislation and is needing to be shared by more than just an integrated IJB chief officer. I think that the real positive is that that is being shown and that we can certainly see that in the way that I have conversations with my counterparts in Westerdale and Orkney. That level of leadership is across the council, across the health board, integrated services and other statutory partners who are coming to the table around that thing called integration. It is more of a social movement in some ways than just about service delivery. Thank you very much. It was a fairly lean question because it was obvious from earlier answers that collaboration is a necessity because of the reality that you have. For me, the question would be given that you are further down the track than most in terms of integration. When do you get the opportunity to share that learning with other potential IJBs? Very much through—there is a national chief officer's group, so there is an opportunity there. The IHUB is supporting the work that is going on. Importantly, there are a number of other areas in Scotland that are doing great work that we are learning from as well. It is a two-way street and I would not want to suggest that Shetland was further down the road than anywhere else in particular. Although I think that we have seen maybe some earlier successes because of size, I think that, although there are all of those diseconomies of scale, there is an economy of scale around test of change. I think that I would like to see more focus and support from some of those national support agencies coming to Shetland to test change in the islands as well as Shetland. It is an ideal opportunity to see results come relatively quickly. You can see the system from end to end. Some days, there are just two steps between myself and the very front line, whether that is in health or social care. That can be a really good and powerful model for testing change and being able to see positive and negative effects of what we do. Final question from Miles Briggs. Thank you, convener, and good morning to the panel. As a panel will know, it is mental health awareness week this week. I wanted to raise issues around mental health services across the islands. The national standard is 90 per cent of patients to commence therapy-based treatment within 18 weeks. Scottish average currently is 76 per cent and the islands are standing at 63 per cent. From your submissions, you highlighted specific workforce challenges around that. What are you doing as health boards to try to provide that service and bridge what is clearly quite a gap in terms of what should be expected by patients? If I start and then maybe Simon can give some of the detail, I think that it is a very important issue and I am glad that you have raised it. As a health board, strategically, we made a decision a couple of years ago to invest additional resources in mental health. However difficult that was in terms of our financial resource, so that has been a major focus. We have continued to support the team as that new team has come into place. It has been difficult with some of the recruitment and retention issues, but as a board, we have been very clear that we have to focus on mental health, but in terms of the actual psychological therapies target, Simon might want to add. Yeah, absolutely. We are not meeting that target at the moment and that is causing us great concern. We actually have the team working this week as a development week because it is a mental health away in this week on how we are going to meet that target. I think that there are a number of things that we can do. I think that there is better signposting to other agencies where people can get lower-level intervention quickly. I think that we have a very small service. We have two and a half whole-time equivalent councillors. We have one clinical psychologist. The level of demand has been particularly high over the last year, and we recognise that. It does not take a lot to tip us over the edge in terms of not meeting the target. We need to broaden the skillset out to the whole team, including CPNs and mental health workers. Obviously, we welcome the extra money that will hopefully be coming shortly in terms of the 800 extra mental health workers for Scotland. The work that we are doing at the moment is identifying where the gaps are and doing the estimation of what we will need in the future in order to be able to hit a target of not just 90 per cent but 100 per cent, which is our aspiration. I am conscious of the time, so I will be very brief. In the western isles, we have been reviewing the mental health system for the last three years. It had gone to a particular stage two years ago, just before the IJB was brought into being, so we widened the whole concept of the review to include the IJB. Basically, we have five working groups that have been working for the last year and a half. We are hoping to see a report in June and to have an actual policy statement out and a practice implementing in August of this particular year, in which we will see quite a radical shift to the western isles. To all intents and purposes, we are still running a very old mental health system. That is our chance to get into alignment with the Government's own policy in mental health and, indeed, to do something substantial for the western isles. The difficulties that you will appreciate is that we want to transfer money by definition out of hospitals into the community. If we could get less pressure on our hospitals while that happened, it would be very helpful. We have twin pressures on us, but without a doubt mental health, as far as the western isles isles has been left just rather too long. We have had the whole community involved in that. We are going to come up with what I hope will be seen as a leading system of mental health provision. We are probably, as a board, a couple of years behind where we would like to be. I listened to Raytheon about the investment that she chose to make a couple of years ago. You will see in her submission in her operational plan for this year, that we have put mental health at the top of our list. Again, I think that it is similar to Ian. We have had this dependency on a visiting service for the last 10 or so years, and we have had a variety of locums. I think that the clinical leadership of our service has suffered through that. That is not to detract from the locums themselves, but it is that clinical leadership. It is a classic service, where our performance up to about October 2017 was almost at the 80-100 per cent. We lose one member of staff, which actually happens to represent 50 per cent of the service. We suddenly drop down to 50-60 per cent. The challenge for us is to develop that whole system for mental health. We remove that person dependency, but it takes us very much back to those specialist skills and availability. There is definitely a commitment from the world board. We heard the very successful event just pre-Christmas, which was facilitated by the Blyde Trust. We have another event scheduled for July, where we will distill recommendations from that report to establish your mental health framework. Thank you very much, and I thank the witnesses for what has been a very informative session. We will adjourn briefly to allow for a change of witnesses. I welcome to the committee Dr Martin Cheen, Chairman, John Burns, Chief Executive and Derek Lindsay, director of finance, all from NHS Ayrshire and Arran. This agenda item is part of our scrutiny of NHS boards and follows on from an earlier appearance and also some correspondence between the committee and the NHS Ayrshire and Arran board. We are keen to hear from you in person and to understand more fully what the position is regarding brokerage and your financial position going forward. The upshot of the correspondence between us over the last few months has been essentially that the Scottish Government has advised you that you need to return to financial balance and then consider how to repay the brokerage that you obtained of £23 million for the financial year. While the Scottish Government is entitled to give such advice, this is public money and parliamentary funds, so we are anxious to know how far your thoughts have come on the question of how and when you hope to repay the loan. Dr Cheen. I haven't prepared any long opening statement, convener, given the shortage of time that we have this morning. If you are content, convener, we will go straight into the question and answer session. That was my first question. What is your timeframe? When do you expect to begin to consider repaying the loan from the Scottish Government in relation to the financial year? What we have done is started a process of a number of activities. I will ask the chief executive to go into some detail in a second. Clearly, achieving financial balance within a year is going to be very difficult and there will be a plan that will be short, medium and long term. We can go into that in some detail to enable the committee to understand what it is that we are going to achieve. As a board, we have had two very long workshops in recent weeks to discuss the revenue plan currently for this financial year and the future years. There is a great deal of work being done to try and break down into work streams what it is that we will need to do and how we need to get to the point of financial balance. If I may, convener, I will hand over to the chief executive. The discussions that we have had with our colleagues in St Andrew's house is that we are looking to bring forward a three-year plan to address the challenges that we face, recognising that, although there are short-term initiatives and actions that we continue to take, there are some of the more transformational changes that will take more than one year. However, the discussions that we have had thus far are looking to bring forward a three-year plan. I understand that brokerage has not been required by NHS Airshire and Arden in the past, and I will therefore be interested in your view as to why a brokerage of this scale was required in the year just gone. As you say, Arden has not had brokerage. We have worked hard to deliver within the resource limits that are provided. In 2016-17, we started to see some pressures in our system in relation to increasing demand for unscheduled care, and we also started to see increasing difficulty in recruiting to some of our key medical posts. Those two elements demonstrated pressure in the system. We recognised that we needed to be doing work with our health and social care partnerships. We worked very well together in Airshire and Arden to redesign how we meet the growing need for unscheduled care in Airshire. Airshire has had high levels of use of unscheduled care services, so we recognised that we needed to do further work to redesign that. In addition to work that has already taken place, we just opened a new assessment unit. However, some of the secondary was around medical vacancies, where we took the view that we had to bring in local medical staff to ensure that we maintained safe services to the population, while trying to review how we would recruit to those often hard to fill posts, as well as redesign some of the workforce roles in Airshire, where we did not think that perhaps in doctors and training grades, we might not be able to fill all of the gaps. You described a discussion with St Andrews House, with Scottish Government officials, which is around a three-year financial plan. Is that a plan for achieving financial balance in three years or is it a plan for repaying the brokerage for this year within three years? The discussions are about delivering a balance in three years and then to discuss repaying the brokerage beyond that point. Essentially, your expectation is that you will require further brokerage over the two following years. Regrettably, we believe that that would be the case. If I may, I was going to use a couple of examples. You have outlined plans at the moment to close the cancer centre at air and shift that to amalgamate that with the one at crosshouse in Kilmarnock. Looking at that from a patient care perspective, I have had an awful lot of mail around this, as you might imagine. For example, if you live in Ballantrae, that is over a three-hour journey on public transport to get your cancer treatment and then a three-hour back. Even from a practical perspective, if you drive, you know as well as I do that there are no parking facilities or the park facilities there that are already inadequate. In that decision, was that a consideration? I know that the plan is to have four outlying hubs within the community. Is that decision based around patient care? On your current financial situation, can you deliver for community hubs? Or was that decision financial? The decision has not been taken yet. It is still a proposal. Since we were last here in December, we have been discussing with our colleagues in the West of Scotland regional cancer network how we would look to shape the delivery of chemotherapy services going forward. The West of Scotland work, which is progressing, would see the hub model that you describe. It is very much about delivering the right care to patients, recognising the complexity of some of those treatments, but equally trying to do that as locally as possible. We will now work with colleagues in the regional cancer network to determine the best way to deliver chemotherapy services in Ayrshire that recognises the points that you have made. I can say absolutely that the drive for this is not an efficiency, it is not about saving money. This is about delivering the right care and the best care that we can to patients in Ayrshire. What cognizance is then given to the public transport infrastructure for patients in what is a very wide area, a big area, especially if you take air out of that, the south of Scotland transport infrastructure getting to cross-house is particularly difficult. How are you proposing to deal with that? That will need to be part of the on-going dialogue in terms of any changes in the future. We will engage appropriately with patients and our communities. I think that the most appropriate way to do that now is to work with the evidence and the medical advice on how to best meet the needs of our population in Ayrshire. I think that that is also an opportunity, because I think that over time, if we can deliver a model going forward, then it may subject to clinical priorities and clinical pathways allow us to repatriate some chemotherapy back into Ayrshire where individuals may currently go to Glasgow. I think that there is a wider benefit, but we need to be able to be clear about those in relation to that west of Scotland model, and now it can be properly delivered in Ayrshire, recognising the points that you make and recognising the transport issues that exist. There is still work to do. How are you then going to speak with the general public and when do you expect to come out with a reaction or response to that? I would expect us to have a better understanding of the regional cancer west of Scotland chemotherapy model. I would think by late June, given the discussions that we have had to date. I think that there is a regional dimension to this in terms of how we go forward, but in terms of Ayrshire, I would want to have a clear and proper engagement with patients, staff and our community in terms of why any change would need to take place, what the benefits of that change would be and how we would seek to deliver that in a way that tries to address where we can, some of the concerns that our patients and population have and staff have. As you are aware, there was an HHS review into the neonatal unit across house, and in the back of that, I think that there are 24 staff that were brought into the neonatal unit. To me, that suggests a system under pressure and financial pressure. If you are 24 staff short, you must have known that. That is money that is now being spent that I do not think you are budgeting for. I think that we are trying to get here. What kind of financial pressure are you under? That patient service that we were missing within the crosshouse is a financial issue. Yes, we invested in nursing staff in 2016-17, including the maternity unit. We had made those decisions in advance of the Healthcare Improvement Scotland review. They were based on the nursing workforce tools and the reviews that our nurse director had made, and the board considered that advice. Given the evidence that was presented, we felt that it was right and proper that we invested staff into the maternity unit, which we did. My point is that, if you are 24 staff short, in the first instance, there is financial pressure there, which is now in evidence because you are £23 million in the red. I think that what we are trying to establish here is that, within the financial management of what you are doing just now, have you got enough money? Are you getting enough money through there, and how are you managing to redistribute those finances to the best possible patient care outcomes? Our focus is on trying to ensure that we deliver within the funds that we have. We have clearly not managed that. We would not have had brokerage. We are looking at this. The two immediate threads are the short-term immediate changes that we can make in the areas that you would expect us to be looking at, around procurement, around efficient prescribing and effective prescribing. We are looking at our workforce costs to make sure that we are reducing our reliance and use of agency and locum spend where we can to bring those exceptional costs down. In addition to that, we recognise that that is not enough in itself. We need to look at how we change our service model in Ayrshire. We have a number of areas of activity under way. Unscheduled care is one. We are looking at our outpatient services. We want to make sure that we can eradicate any waste or unwarranted variation in our processes to make them as efficient as they can be. We are looking at how we use and utilise our estate. There are a number of work streams and threads under way, both in a short 18-19 focus, but also in 18-19, 19-20 and 20-21. The next question would be, are there other units within Ayrshire and Arn that you feel are in the same situation as the neonatal unit was in Crosshouse that is going to need to be addressed? There is nothing that is on our immediate radar. No, the nursing workforce is because there are workforce tools. We have just had a review and we are waiting on the findings of that, but given that we have invested in our nursing workforce, given that we are looking very closely at our workforce costs, there is nothing that we are seeing immediately that we have not been including in our planning. We have the same issues in Stranraer when people go to Edinburgh for their cancer care, but as part of the regional review that I am aware of, I am interested to know if evidence of increased mortality and travel times is part of consideration. I have been asked to look at the evidence of travel times or mortality. I know that some chemo can be given orally, so that makes it easier to give more locally. I know that some chemo has to remain for hours post-chemo, some even longer, some are given via central venous access and some IV. There are loads of different ways that chemo is given, so that is part of a decision. I am curious about travel times and mortality and any evidence of whether increased travel causes an increase in mortality. I do not have the information to answer that question. It is not something that I have looked at. We will be taking and reviewing all of the evidence that comes forward through the West of Scotland work in terms of our consideration of how we deliver those services, recognising the different ways in which we can deliver chemotherapy services to the population, but I do not have specifics on that question. Is there a way that we can find out if there is travel time impacts on people's ability to recover better or are outcomes related to travel times? That is certainly a question that I can ask the team looking at this. I am happy to provide some information back. We have talked about a three-year plan that you have described and said that you expect brokerage to be required in each of the next two years. What scale of brokerage are you contemplating in the next two years? I am happy to. Obviously, the amount of brokerage that will be required will be related to how much funding increase we receive in future years. I know that the Government is planning to publish a medium-term financial plan that follows on from the UK financial plan. That is a factor in it. At the moment, we obviously have to think about 2018-19, the plan that we submitted in March of this year was projecting a potential £20 million required for next year, however, for 2018-19. However, that will also have to reflect the pay awards that we do not yet know the negotiations that are going on at the moment as to what pay will be and the additional funding that we will receive as a result of Treasury funding, the agenda for change pay awards in England and the consequentials that come to Scotland. There are many contributory factors to that, but we are certainly in close discussion with the Scottish Government about the different scenarios. We have said that, around the end of May, we would expect a lot of those things to be clearer. When you gave evidence in December at that point, you expected a shortfall of £20 million for this financial year. That increased by a further £3 million subsequently for reasons that you have described. Should we therefore assume that the number that you have given us today for this year is really only a provisional starting point rather than a final expectation? It is a provisional figure. The discussions that we have had with the Scottish Government recognise the variables that are there. Things such as our prescribing costs are also provisional figures based on best estimates, but we do hope to be able to firm those up in the near future. In particular, pay is our biggest single cost, so we need to be clear on the funding and the planned expenditure for pay. It is interesting that, in the December board report, we forecast a £24.2 million deficit, so it is a variable figure and one that is a moving feast at all times. Therefore, £24.2 million down to £22.9 million is not ideal by any means, but it demonstrates the movability of those numbers. I think that it is true to say that when you gave evidence here in the same month, you were predicting £20 rather than £24 million. That is correct, convener. I think that this is a provisional position. There is more work that we have under way within the board. As Derek has indicated, we have agreed with our colleagues in St Andrew's house that we will meet them again towards the end of May, very beginning of June, where we will set out the next part of the detail in terms of our revenue plan for 2018-19 and what we see in terms of the transformational work going into 2020 and beyond. Thank you very much. Finally, can I ask the chairman—is it safe to assume that this has been discussed in detail at board level and, if so, where does the board believe responsibility lies for the shortfall of experience? The answer to the chat, convener, is yes. Most recently, we have had two, four-hour board workshops running from about four in the afternoon to late in the evening, going through that in a great deal of depth and detail, and trying to give the chief executive and his corporate management team a degree of support and direction as to what might be acceptable to move forward with the budget plan. We have got to a position where we will be taking that to the board meeting in May, and there will be an understanding. At the moment, we are running on a revenue—last year's revenue rolled forward because we do not have an agreed budget yet, but I can assure you that board members are fully involved in a great deal of detail on the discussions. That is helpful. You have mentioned a board meeting in May and also meetings with the Scottish Government towards the end of the month. It would be very helpful to the committee if you were able to let us know the outcome of those in regard to your financial projections. One last very brief question. It is not a question. I should have declared an interest. I have a close family member who is a health care professional in the Ayrswnan health board. Thank you for putting that in the record and I thank the witnesses for coming today and for giving evidence. We will now move into private session and consider the rest of the agenda thereafter.