Welcome to the 8th meeting of the Health and Sport Committee in 2019. I ask everyone in the room to please ensure that mobile phones are off or on silent and not use mobile devices for photography or recording proceedings. We have received apologies today from David Stewart MSP and Sandra White MSP, Bob Doris attending as a substitute member, and also welcome Christine Graham to the committee. The first item on the agenda is subordinate legislation and consideration of four negative instruments. The first negative instrument is the national health service optical charges and payments Scotland amendment regulations 2019. The delegated powers and law reform committee have considered this instrument at its meeting on 26 February and determined that it did not need to draw the attention of the Parliament to this instrument on any grounds within its remit. Do any members of the committee have any comments on this instrument? If not, is the committee agreed to make no recommendations? That is agreed, thank you very much. The next three instruments relate to the European Union withdrawal act 2018. The instruments are as follows, the food and feed safety and hygiene EU exit Scotland amendment regulations, the food composition, labelling and standards, EU exit Scotland amendment regulations and the nutrition EU exit Scotland amendment regulations all 2019. Under the protocol agreed between the Scottish Government and the Scottish Parliament, we have already considered these matters at our last meeting in order to come to a view on the categorisation and the procedure for dealing with these instruments. We agreed last week that each of those instruments had been laid under the appropriate procedure and given the appropriate categorisation. They are therefore of low category and negative procedure. Can I ask comments on each of those in turn? First of all, the food and feed safety and hygiene EU exit Scotland amendment regulations, the delegated powers and law reform committee considered this instrument on 5 March and determined that it did not need to draw the attention of the Parliament to this instrument on any grounds within its remit. Are there any comments on this instrument? If there are none, does the committee agree to make no recommendations? It's agreed. Thank you very much. The next instrument is the food composition, labelling and standards EU exit Scotland amendment regulations. Again, the delegated powers and law reform committee considered this on 26 February and determined that it did not need to draw the attention of the Parliament to this instrument. Are there any comments on this instrument? Yes, please. I'm a heartburner. My understanding is that these amendments are minor and technical, but it made me think about the future or future considerations with labelling and the standards that are required, especially when one of the paragraphs that we read was about the origin of meat from certain countries. My concern is that as we move forward with future trade deals and trade negotiations, I want to make sure that our food products and standards wouldn't be compromised with any future trade deals or labelling requirements. Absolutely. That reflects the point that you made when we first considered it last week. I think that it's fair to say that the nature of these amendments doesn't directly bear on those issues, but it would be entirely appropriate at this point to write to the minister while approving the instruments, if that's the view of the committee, and ask for some general update on the position regarding the protection of Scottish beef and other designations. Is that in line with what you're—would that meet your needs? Yes. My concern is that if we're going to change labelling or how would it change, do we make sure that we protect our own produce in the future with any future trade negotiations? Thank you very much. Clark's have a note of that, and we will ask for assurances from the Government on that basis. Are there any other comments from members on this instrument? If not, does the committee agree to make more recommendations? That's fine. We'll do it along with that accompanying letter. The final instrument for consideration is the Nutrition and EU Exit Scotland amendment regulations. Again, the Delegated Powers and Law Reform Committee considered this at its meeting on 5 March and determined that it did not need to draw the attention of the Parliament to this instrument. Are there any comments from members? If not, does the committee agree to make no recommendations? That's agreed. Thank you very much, and that disposes of all of those items. The second item on the agenda is an evidence session with NHS Borders, whom I welcome to the committee today. This is part of our series of evidence sessions with territorial boards. I welcome to the committee John Rehn, Chairman, Jane Davidson, Chief Executive, Carol Gillie, Director of Finance, Nicky Berry, Director of Nursing, Rob McCulloch-Reyham, the Chief Officer for Health and Social Care, and Dr Tim Patterson, John Director of Public Health. Welcome. I understand that Mr Rehn that you will be coming to the end of your eight-year appointment at the end of this month and also that Jane Davidson is retiring in April, so I hope you will agree that this is an ideal opportunity to give us the benefit of your experience before you move on. Clearly, an important area of consideration for this committee is financial sustainability. Again, with the benefit of your team and also of your experience, can I ask, first of all, for your summary of the position regarding financial pressures and your view on the prospect of achieving financial sustainability going forward? Thank you very much, convener. As representatives of a comparatively small rural board, now in special measures, I do hope that our experience can be helpful to the committee and perhaps offer to you a different perspective. We are in special measures because we don't have a balanced financial plan. We need additional funding and we applied for brokerage in the middle of last year. That meant that we were escalated to level three on the government's escalation framework ladder. In a way, there's a bit of a shock to us because borders has always been seen as a good-performing health board. We've always delivered on the budget up until this current financial year. Then we were taken even more by surprise to find that we were escalated to level four in November. We didn't really understand why that should be until we received the letter, which informed us that the seriousness of the financial situation we faced was such that it justified escalation to level four. Also, that coupled with the fact of planned leadership changes, which we can only assume is the fact that Jane Doverson had, meanwhile, announced her intention to retire. It was well known that I was coming to the end of my eight-year appointment term at the end of this month. That happened all quite quickly. We've gone from being seen as a board, indeed a board that has delivered well in terms of waiting times and services to patients, but a board that has keeled over in terms of managing the budget. One of the advantages of being escalated and being on the ladder is that we do get help with turnaround, and yesterday we had a turnaround team, which is funded by government, arrived to assist us. That's consultancy report to enable us to get back on to a firmer financial basis. There's going to be no quick fix to this. We're planning on a three- to five-year turnaround, the extent of the overspend. We have had brokerage now of just over £10 million, and that on a budget of just a little more than £200 million. It's a significant proportion. To pull that back is not going to be easy. Brokerage, of course, and that sum in this currently has been written off, which is very helpful, but it does mean that we have an overheating of the economy of NHS borders, that we still have to reign back. We need to find ways of transforming services, because we're not going to deal with this just by getting firmer grip and control over relatively small parts of expenditure. This is pretty big stuff. The financial settlement that we've been looking at that we have for this coming financial year from next month gives us an even bigger gap to be bridged. I think there are two main reasons why we need brokerage. One was the inability to deliver sufficient efficiency savings of the magnitude that was required and on a recurring basis. I mean, we've delivered, we've put a lot of effort into the efficiency programme, much of which has resulted in efficiencies that are of a one-off nature. Indeed Audit Scotland in their report as our external auditors last year talked about savings required of an unprecedented magnitude. The other thing is the low level of uplift that we've had as a board. Our base allocation under the NRAC formula has provided for us increases in each of the last four years of 1.7%, 1.6%, 0.4% and 1.5%. That's led to some pretty tough challenges. We're a rural board with the smallest mainland board in Scotland in terms of population, but we have, of course, a large geographical area to provide services across. We have the highest percentage population of elderly people and all these, of course, contribute to additional costs. I would not want to be here pleading poverty. I think there is more we can do to be more efficient. We can deliver more, I'm sure, but it will take time and the turnaround support we're now getting will help us. At just a final point, I would say that the board has not been blind to the difficulties coming down the track. My own view is that whilst we've owned the problem of not being able to manage within the budget, we've also owned the solution and I think we've been trying to own that solution for too long rather than to have a perhaps elevate the conversation at government level. I'm not saying there hasn't been a dialogue between officials and the NHS Scotland and the health department, but I think I will accept some responsibility for not elevating the concerns that have been building up now for two or three years. Thank you very much. You used the phrase keeled over, which is quite a strong piece of language. I think it's clear from that initial answer that there was a degree of surprise on your part at the speed and scale and severity of the difficulty into which you the board has come in the last two or three years. To try and unpick some of what you said, was part of your suggestion that as a smaller board it's more difficult to find efficiency savings than a larger board? Is that part of one of the points you're making? No, I don't think I would want to say that. The question is very often put to me, is are we getting a fair crack of the whip under the NRAC formula? The answer to that is we don't know. We know that rurality has taken into account, but whether it fully reflects the additional costs of the rural board with scattered small communities does face something we don't know. We are funded at the level of NRAC parity. NRAC has existed now for 10 years. I do know because I've been a member of TAGRA, the technical advice group on resources allocation. I do know that there have been reviews of elements of NRAC, primarily the additional cost-facing island boards. There's been a review of the mobility and life circumstances element to see whether that is properly and fully reflected in the formula. I'm leaving the service now, unfortunately, because I'd like to stay, but I'm leaving. I do think the time has perhaps come for a more fundamental look at the NRAC formula. I say that knowing that that will be a major task. It's not going to deliver a quantum of larger resources, of course. It's about the allocation and the sharing of resources. You receive relatively low annual uplift because you start from a position of being above NRAC. You have more as your base funding than NRAC. You picked me up convener on the expression I use of keel over, which is perhaps rather an exaggerated position because in terms of services we haven't. At the end of this month we're on course and barring a devastating turn in the weather or other calamities, we're going to be announcing and I think we'll probably be the best in Scotland in terms of delivering services. We will have no patients waiting over in patients or outpatients waiting over 12 weeks. We'll have no patients waiting for diagnostic tests beyond six weeks other than MRI, people waiting for MRI scans. I think that's going to be the best in Scotland. We await that. I mean, it's not in the bag as it were, but I'm hopeful that that will be achieved. We've always been consistent achievers in terms of A&E targets. Yesterday it was 100%. Day before that it was 97% on the four-hour target. We've been consistently good on cancer waiting times. So, in a way, that is a bit of an irony that we've not been able to manage the money effectively, but there are reasons for that. Thanks for that. Clearly those measures are very important measures from the patients I view, but, as you say, financial sustainability is essential in order to be able to continue to meet those kind of targets. Given what you've described and given the scale of shortfall, if you like, brokerage, certainly, that's involved, I think you said it won't be easy to achieve financial sustainability. Do you believe it'll be possible to achieve financial sustainability? Yes, I do. I'm reasonably confident that, over that time span of three to five years, we will be able to pull this back, but much depends upon future settlements, funding settlements, as we move forward. I know some of the things that have been described as mechanisms to achieve future financial sustainability. Are things that are already in process, for example, the shift from hospital care to community-based care? Yes, there's a lot of attention, obviously, and I'll call on colleagues to describe those, attention given to shifting the balance of care, shifting the resource that goes with shifting the balance is perhaps a rather trickier matter. I think perhaps the reason I use keel over is that being on level four does have a demoralising effect across the organisation. It concerns the board greatly, although, interestingly, colleagues and I travelled on the boarder's railway this morning and we sat with somebody who we did not know and who listened to our conversation as we were discussing coming here today and who said, I'm a consultant at boarder's general hospital, he'd been there eight years, none of us here knew him and he was saying and he works also elsewhere in Lothian and other board areas, but he was singing the praises of his working environment, the team spirit that exists and the conditions that he works in. When I asked him what the medical view was of the board being at level four, it wasn't exactly dismissive, but he was saying, well, we just get on with the day job and we accept this kind of thing happens in cycles across the NHS and it just made me think that it would be a really good experience and information for this committee, for your committee, to hear from people on the front line as to how they experience the real-life world of delivering services. Good to do that as well. Can I ask you finally before I pass on to colleagues, the Scottish Government's recovery team that you mentioned, what is the actual nature of the engagement there? I think you suggested that there's completely a new engagement, that there was no prior engagement until very recently. What is the engagement now and what effect do you think that will have? Okay, Llywodra, can I bring in colleagues on this and they can perhaps identify the individuals even in the recovery team? The letter that we received from the director general in November said that there would be a tailored package to help borders to turn around its financial position. We've had in place, sincerely, December support from the Scottish Government's board recovery unit, who have provided us with expertise, external scrutiny and support to try to turn around our finances. We have learned from them tried and tested methodologies, processes from other places, particularly down south, where there's been success in financial turnaround. They've brought that to us and have helped us to set up—well, they've reviewed our governance roundabout turnaround. They've helped us to set up a project management office, which all of the things that we want to take forward are going through that process. We've got new documentation that we're following, so they've helped us to make sure that finance is a key agenda item in the organisation. As John referred to yesterday, the Scottish Government has supported us to get some external turnaround individuals that have worked in other organisations just doing turnaround. That's their area of expertise. They started with us yesterday to provide that focus for us going forward. The package has been very much tailored to our needs. Although it's the early days, we have changed a lot of the way that we are working with the advice and support of the Scottish Government. Did I understand that to mean that staff have been seconded to NHS borders from the Scottish Government? I don't know if the word's seconded. They work with us. They're in borders a couple of days a week from the Scottish Government. We've also got some external support that our non-HS staff are working with us at this point. Thank you very much. Jane Davidson To add to what Carol said, we've had people from the recovery unit at the Scottish Government pre-Christmas. We're very much working as much as we can in partnership with them just to get a level of confidence around the plan going forward, so that by the end of March the intent is to have a one-year plan put before the board and then by August the next three to five years. However, just to be clear, it is a company that is providing turnaround support to us in that company started on Monday. The name of that company? Bold Revolutions. They're supporting you on behalf or on the appointment of the Scottish Government. Yes, broadly that's right. Okay, thanks very much. That's useful to know. Brace supplementary, Brian Whittle. Good morning. It's just a point of clarity here. He said it's a three to five-year plan on turnaround. Can I just be sure here that does that mean you'll require brokerage for each of those years before you hit a financial sustainability, or will you across the piece hit? A brokerage in this coming financial year, beyond that, Carole. So we haven't bottomed out our three to five-year plan, but I can say with confidence next year that in 1920 we will require brokerage and likely for a number of years after that. I couldn't pinpoint how long exactly, but yes, we will require brokerage for a number of years. Okay, thank you. The Scottish Government has indicated that brokerage will be provided and will be effectively forgiven over the next year or two, but certainly not for five years. So they've agreed to give us brokerage for the current financial year, and that was helpful to enable us to deliver our financial targets. They've indicated that the brokerage we receive for this financial year that we don't need to repay that. We've flagged up to them. We'll need brokerage for future years. We haven't finalised exactly amounts with them, and they haven't confirmed that they're comfortable with that, but we've flagged up that will be an issue. Thanks, Yvira. Just to confirm part of the submission by the end of March of the first year's financial plan will allow that conversation to happen with the Scottish Government, and then by August, when it will look to three to five years, and what this turnaround team through bold revolutions is going to help us identify, that's when we'll be able to more or less nail what potential brokerage might be required going forward. Is it not the other way around, arguably, that you have the discussion with Government first to find out what's possible and then talk about the turnaround? So I suppose we're doing it in parallel. We've been having those discussions with flagged up that, certainly next year and probably the following year, we'll be looking to access brokerage. So they're aware of that in their financial planning, but it's actually just about coming to something that's a bit more concrete in terms of amounts. Thanks very much. I think that Christine Grahame wanted to have a quick supplementary question. Yeah, just a couple of quick ones. I mean, and to pick John Rain up on something that you said that, you know, it seemed that everyone was going along swimmingly, and then you were surprised to find that you're in financial difficulty. Why was it a surprise? I mean, it came out with a blue, and the second point that I want to ask is to Carol Gilly, when she said the turnaround came and said, made changes in the way you work. What were these changes? The surprise was more being escalated up the ladder, and I did say we were not blind to what was coming at us down the track. We have recognised that over the last two or three years it's been extremely difficult to make savings on a sustainable basis. So the fact that we were in some difficulty financially was not, that was not a surprise. Audit Scotland, our external audits of last year flagged this up as being a real issue, but I think we were surprised that really the change in the fortunes of NHS borders as a board that has not been on the government's radar as a difficult board, we've managed ourselves and done well. So it was that surprising change really from being seen to be a good board to, in effect, seem to be a failing board, and we're not a failing board. And I think that's a message we need to get across strongly to our staff, and I did this in an address to our workforce conference on Friday. We are not failing staff who are working hard, we are actually delivering, and the figures I gave you on access by the end of this month are good. I think what they've helped us do is refocus on the financial agenda. So in the health service there's always lots of new initiatives going on, and what we're trying to do is prioritise the ones that will have a financial impact, not to say that we won't do other things, but it's about actually focusing on the ones that will give us a financial benefit in the short term and maybe in the longer term look at other initiatives. So really refocusing the organisation. What example? Give me an example of where we've focused. I don't know what that means. So I guess maybe in Nicky's world there are lots of initiatives that we can do to improve some of the care we give, but it might not have a financial benefit. What we're trying to find is opportunities that improve the care and also have a financial benefit. So maybe we'll refocus on things like looking at our prescribing costs and looking at saying that we've got the most cost-effective prescribing, which is good for the patient, but also saves money rather than doing something that just focuses on the patient benefit as well. That's the kind of things that we're trying to focus the organisation on, taking into account both the care agenda and the financial agenda. Does that help? I'll just pick up what Carl was saying. I think one of the key priorities will be prescribing. I mean prescribing costs have gone up significantly in recent years. I mean we currently spend about 20 million in primary care prescribing, 25 million sorry in primary care prescribing, 10 million secondary care prescribing, but the secondary care prescribing has gone up by 42 per cent in the past four years. Now there are many causes for that actually, out with our control. One of the big causes, particularly for secondary care prescribing, has been the changes in policy for the Scottish Medicines Consortium. Scottish Government policy now is not just to consider evidence-based whenever we're introducing new drugs but to consider patient and the public's view as well as clinical view. That has really broadened out access for the new drugs. The funding, because of the increase, as I say, 42 per cent in secondary care prescribing in the past four years, there hasn't been a commensurate increase in prescribing, funding coming to fund that broadening of access. We're looking at prescribing as one of our key priorities in order to get what we call financial grip and we're working very closely with our primary care and secondary colleagues. We're supporting the primary care and secondary colleagues with additional pharmacy staff and we've also agreed local enhanced services with GPs. Local enhanced services is actually focusing on areas where we are outliers in prescribing. Borders are outliers, for example, in gabapenoids, as well as antibiotics, so primary care will be looking at those areas in particular. We're also looking at areas where there might be medicines of limited value and we're working closely with the GPs. In the secondary care, we're particularly looking at biosimilars, which are extremely expensive, increasingly effective, but again not funded through the prescribing budget allocations. Even though the access to these drugs is now more, our consultants are now really looking and drilling down on those areas, particularly moving from proprietary drugs to generic drugs. This is a joint and collaborative work with our primary care and secondary care to focus on this really important area, which is responsible for quite a significant part of the overspent. Does that suggest that in the past there hasn't been that level of monitoring and management of demand? There hasn't been access, so what's happened is that there's been an increase in access. As I've said, the Scottish Medicines Consortium now used to actually focus purely on evidence-based, particularly on quality adjusted life years, so any drug that would deliver on £30,000 per quality adjusted life year, it had to really achieve that criteria. Now access has been significantly increased, now we're in a democratic society, I can understand there's a discussion with politicians and the public about what they want in terms of new drugs, so the access has been significantly increased to not just deal on quality adjusted life year costs, but also on what patient groups think and also what clinicians think. So that has really significantly kicked the kick started the increase in spending and secondary care, so we're having to deal with that. The other factor which is driving our prescribing is the increase in the elderly. I think John has actually said we have seen significant increases, particularly over 65s. If you look at primary care list sizes, even though they've only gone up by about 2%, the actual number of over 65s in the borders on the GPs lists have gone up by 26%, and the over 75s to the 85s has gone up by 12% and 12% in the over 85s. That's a significant amount of older people. Most older people have not just one disease or one morbidity, they've actually got multiple morbidities, they may have four of them to deal with. That has actually put a lot of work and stress on our GPs and one of the concerns which has been shown in the borders and elsewhere, it's that that's actually causing a huge amount of stress. A third of all GPs are saying the stress and the capacity and workload and also the prescribing costs have been driven by, in primary care, particularly by older people with multiple comorbidities. Now that's been a really good, we've increased our life expectancies and we're trying to actually increase our healthy life expectancies, but that has been another factor that I understood. Emma Harper I'm interested in exploring further issues about potential ways of cost savings or difficult decisions that might have to be made in order to pursue supporting better practices or processes. It was interesting to hear that you had shared the train journey with somebody that's worked for eight years and nobody knew him. It's a consultant working at a level where I would imagine there should be some leadership engagement, so I'm wondering, you probably reflect on that, but what processes do you have to directly engage with the workforce, whether it's nursing or allied health professionals or the front line doctors?  Many of the front line people we know have good suggestions for supporting and saving and providing measures that will help, so what plans do you have or what do you do to engage with the front line staff? I'd like to start off by replying, but then ask colleagues to add to what I'm going to say. The fact that we didn't know this particular individual, he worked part-time at the hospital and in a function where perhaps you wouldn't ordinarily see him, but we do take very seriously the appointment of consultants. We actually have probably the best, the lowest vacancy rate of consultants in Scotland, only a few percent, there happened to be those few percent in very shortage areas and shortage specialities, but we do as a board, I chair the appointment panels for consultants and Jane Davidson, chief executive and medical director will always be there and that's really a symbolic to say that we take our consultant appointments very seriously. In terms of what we do to relate to staff, encourage staff, support staff well-being, I'll just touch on a couple of initiatives but ask colleagues to add to it. When I came on the scene, I was very keen because I'd seen this done in other areas where I've worked in the NHS in England, that we really need to recognise staff achievement right from the point of saying thank you directly, but also in a public setting and we have now run for five years an annual staff awards celebrating excellence function. Christine Graham knows this because she's attended as a guest and no doubt will vouch to the fact this is a big event, nearly 400 people, it's run very professionally and it gives us an opportunity to recognise staff and also partners and the wider community. We do also, I write personally to everybody who's retiring from the organisation, might say you can do that in a smaller board but it's still, I think it's important to acknowledge people who've given perhaps a lifetime of service to the NHS, at least get a letter from the board to say well done and we put on an annual little low-cost tea party for people who've retired and we can do that as a smaller board and I think that's important but Nicky Berry may want to add to what we do particularly around supporting nurses. Hi Emma, I actually apologise to the chap this morning because like you when he said he worked in NHS Borders and he'd worked there for eight years I was shocked because I'm very visible. I have been in his department but it is one of the departments that I'm not in on a regular basis and he's not he's not out but I know his wife who is another member of our staff and I know his wife well. I think like you yes we should be out and about and we should know our staff. What we do is we, the chief exec welcomes every induction so opens every induction with a welcome which I have since taken over since November so that's about me welcoming every member's staff coming into NHS Borders wherever they work and I think that's really important. It's really important that we are out and about and I meet every student nurse in NHS Borders wherever they work. I meet them throughout their three years and keep up with them as well. From a value in our staff we have a number of initiatives that we have ongoing so we have a well-being Wednesday in which this member of staff spoke about this morning that's about every Wednesday there's new initiatives so mindfulness sessions actually writing out to staff thanking them leaving bottles of water somewhere fruit so just small tokens but I think what it's about what the staff are actually saying is it's not actually about them getting something it's actually about being visible and somebody asking them how's your day been is what you know is there anything I can do to help thank you for what you do so there is things on going but again this morning that was an example that somebody works in NHS Borders and I don't know them so I'm going to email them today and I'm going to make a point they meet on the back of their i matter they have a coffee morning they stop at 11 o'clock in their team so I'm going to make a point going along twice a week and I will make a point and go to that department I mean I think it's fabulous that we celebrate our staff you know as a former member of NHS in Fries and Galloway I think it's great that we celebrate that I think my question was trying to focus on what are you doing with the staff on the front line to look at cost savings or financial potential savings or difficult decisions that have to be made are you directly engaging with front line staff that look at how can we how can we show a way to reduce costs that way Jane Davidson thanks Emma yeah so so we're particularly going out speaking with staff talking to them different groups of staff to just replay and communicate as a bit of a repeated communication around what the financial position is trying to help them understand the magnitude of it because it is pretty serious and also to engage with them to see what their ideas might be we're using our partnership colleagues in particular to to do that so they're engaging with staff directly to see what kind of ideas people might have for efficiency savings or just their identifying waste and just to get their ideas about what might be able to to change going forward I think that's been really important but I suppose the biggest potential changes are not going to be just the small pieces of control or small improvements which they're very important because everything adds up so all those ideas that might be coming through need to be heard and responded to but I suppose most of the changes really are going to be in our clinical models etc and how how care is actually delivered going forward and that's going to need to be really quite bold and we don't necessarily know what that's going to be but some of the ideas or insights that the staff have would be able to inform that I think and I'm just probably going to bring in Carol and potentially Rob if he wants to speak about what's actually happening in the community around garnering engaging with staff and garnering ideas around the financial position. Okay so I was just going to go back to what I said earlier about some of the changes we've made we set up a project management office it has five streams of work you know actually delivering schemes and reporting on them and data but one of the streams is ideas where we're actually taking ideas from the engagement that Jane referred to from our staff and clinicians and we're actually reviewing these in a kind of methodical way and feeding back to staff on whether there's something we can take forward so that's first of all we have got a process to try and get those ideas from the front line on your question round about difficult decisions again I referred earlier to our new governance arrangement round about turnaround so we set up governance framework which goes every scheme that will come forward will go through our area partnership forum and something called the clinical advisory committee which is really looking at our clinicians to come together to review any ideas we're taking forward so we can actually highlight any risks or any issues to the board before we make any decisions on going forward so in a very open and transparent way we're trying to make sure we engage right across the organisation with ideas that are potentially going to go forward I wouldn't want the committee to get the impression that none of this work has been happening in the past so the board has been successful in producing a balanced budget in the past but it's been non-recurring savings that it's had to do so there's been a build-up of a gap and that's what we're having faced now we haven't got the cavalry coming across the hill in terms of bold revolutions coming into supporters it's actually joining with us and how we actually develop the work that we're actually currently doing I'll give you a very quick example so I've been with the board for almost the year and a half now in my position as chief officer we do listen very closely to all of our workers and also our patients and our people who use our services so one of the things that we introduced just over a year ago was a new service called hospital to home and this was to try and alleviate some of the delays that we have both in our community hospitals but also our general hospital as well and that was working with our care organisations patients themselves and also our district nurses to actually design a new initiative so that we can actually enable that our support patient flow within there and there's a direct consequence on expenditure within that as well so that was introduced just over a year ago it's now running across the whole of the borders it's in all five localities that we operate they have capacity for up to about 70 patients and we've seen a significant difference this winter that we've just had in comparison with last now that's on the back of comments that we've received from staff and it's been well welcomed by staff as well and one of the things one of the things I noticed when I joined the borders was the engagement with both partnership and also the staff unions within the council there's a joint staff forum which has been in existence for several years now we're both unions from the council and also from the NHS borders meet I think it's on a monthly basis and I attend those as often as I possibly can and we take through those initiatives with them we listen to them and we develop them jointly together and that helps the introduction of it in the implementation of those Can I just pick up on a specific example that I am aware of because Christine Grahame was asking about specific examples and I'm aware that pulmonary rehab is part of a process that works in other health boards to keep people out of hospital and so increasing uptake and flu vaccine smoke incisation and pulmonary rehab for people with chronic obstructive pulmonary disease so that's something that really really works pulmonary rehab is cheap so what progress has been made in NHS borders with processes around pulmonary rehab? Yes I would entirely agree with you because obviously a chronic long life condition and we want to support people with chronic obstructive areas disease so that they can live in community where they actually want to do so we actually this year have initiated a project and put some well put significant funds into it to support pulmonary rehab programme and this will mean recruiting additional staff particularly physiotherapy staff and as you say focusing on supporting them in the community compliance medication and to try and really so that they can live where they want to live and avoid hospital admissions so I agree that evidence is pretty strong and we have prioritised that as one of our projects going forward which has flowed out from our clinical strategy as a key long-term illness in addition to diabetes they're the two areas that we're actually focusing at but I fully support that. Can I say as well that part of if we're looking at deficiencies one of the areas which Catherine Caldacut or CMO has been leading on is realistic medicine and I think that we must remember it is the clinicians who actually commit most of the resources so anything we can do for realistic medicine you're probably aware of this initiative and this is this is about reducing risk and harm to patient, reducing variations in care, prioritising best practice and supporting self-management so our GPs and our hospital clinicians are actually leading on this and I think that's probably one of the big priority areas that we will be able to generate significant savings. We have a good structure in place in East of Scotland, we're working across the three health boards, the medical directors meet regularly, they've identified prescribing, they've identified frail elder, identified end-of-life care where a lot of cost is, we have local projects, we have a local lead for realistic medicine so we're working with Anita Tys and our pall of care services to decide what should happen, how to engage with not just clinicians but families about having anticipatory care plans for people towards end-of-life care. We have a big project called respect which is a national project again supporting anticipatory care planning so we ask patients and their families do you want a curative type treatment or do you want a comfort type treatment and I think this is where some of the real cost savings because it's something which until Catherine Calder who had really pushed for I think really wasn't on the agenda so now we have posters up in outpatients, we have leaflets that we give to patients, our GPs are fully on board with this so I think that is a really fruitful area for if we focus on variation, if we focus on what patients actually want, I think that will help generate savings but as well as that provide really excellent care for patients and their families going forward. Can I go back to a couple of the financial points? I noticed that there was a proposal to transfer a million pounds or more from capital to revenue. I wonder whether that creates risk given that you have one major hospital which is of some age and where there are clearly capital programmes that need to be invested in. What are the implications of that for the healthcare environment at Borders General Hospital? Edwin Colleagues referred to the non-recurring measures that we have taken to deliver financial balance. That is one of the measures that we have used for the last couple of years, you are quite correct. NHS Borders gets its pro-nata share of the capital formula allocation that exists across NHS Scotland. That is about £2.4 million for us so that is not very much money but it does help us to keep a state at a decent standard. Our backlog maintenance level is £8.4 million which is a big amount of money but if you look at pro-rata compared with other boards it is actually at the lower end so we have managed to keep our state at quite a high level of standard. I could also mention there that the highest category of backlog maintenance is categorised into four categories and the highest one I am not sure what is called higher significant but the highest one we have none of our backlog maintenance is in that highest category it is all in the three lower categories. Just to re-emphasise we have managed to keep our state in a fairly good condition. What NHS Borders has been quite successful is bidding for additional resources and that is a tax that we have taken so we have managed to get a significant investment in recent years in our IM&T infrastructure and also an investment programme across our primary care premises. We have actually bid for additional money and managed to be successful there. In this current financial year we have managed to get additional funding for IM&T but also to secure another MRI scanner. Yes, there is a risk but we have actually been very successful in getting additional resources from the capital perspective into borders and that has offset that, mitigated that risk. Finally on finance, there is a £7.5 million overspend I believe with the health and social care partnership. Where will that money come from? Okay so I might ask Rob to come in a minute but our scheme of integration that's the kind of the way we do business with the IGB integrating joint board sets out what happens with that overspend so basically the IGB is supposed to come up with an action plan to address that that overspend if that's unsuccessful then they can come back to either of the parent bodies either the councillor or ourselves and ask for additional cash to offset the pressure they have and the case of this financial year that's the situation we're in and we have agreed to give additional support to the IGB so it can deliver on its financial targets. So the scheme of integration says that our rules are that depending on where the pressure is it goes back to the relevant parent bodies so the financial pressure in the main this year for the IGB is with the NHS so it's the NHS that's coming up with the majority of the pressure but Rob may want to comment a wee bit more. There has been additional money coming into the health and social care partnership from the council there's an additional three million that came in through this year so they've rebased the budget. We are facing particular challenges around the population that Tim touched on as well. If we project that to 2036 we're expecting a hundred percent increase and are over 75s and we're beginning to feel that increase now so we are having greater demand year on year for our services. We had we carried a shortfall last year from unmet savings of 4.8 so the 7 million that you refer to now 4.8 of that has been carried over from last year so we are facing significant challenges within that how we're going to address that is fairly long term we know that people who are cared for within our health facilities that's more expensive than we have if we do that within our care facilities and we do know that we've gotten in balance at the current time so the work that we are undertaking at the present times to see if we can shift the balance of care so we've undertaken several pieces of work over the last year to try and identify what that number is and we'll be redressing the number of care hours that we provide at home and also the number of care beds that we provide. One of the particular challenges we have is the number of nursing beds particularly for advanced dementia cases that we have and we've invested a further half a million this year in opening up more beds within one of our excellent nursing homes and that's reduced the pressure and one of our mental health wards within the general hospital so we expect to be doing more of that over the next two to three years to try and shift that balance of care across there and that doesn't mean that we make savings on any beds that we close or are able to close within that because we do need to carry an investment into the council services as well so there will be a proportion that will go to providing a balanced budget however we do need to make sure that we shift that across so there is a capacity within our social care provider. Thank you very much. Good morning to the panel thank you for coming to see us today. I'd like to ask about leadership. John, in your opening remarks you referenced the fact that yourself and Jane are both about to leave and that's a planned departure I absolutely accept that, that's entirely your right. Obviously though we have a rather worrying trend of leadership churn throughout our health boards in Scotland and I just want to ask what reassurance you can give to your successors that goes against the sort of starting to feel like a feeling that some of our health boards those jobs are almost ungovernable which is a prevailing sort of view that is starting to be felt in perhaps unfairly but can you what reassurance can you give to your successors coming into this difficult task? Good question. Jane Davidson was good enough to give a six month's notice of her tension to retire which meant that we're able to recruit a chief executive and Ray Roberts will be joining us shortly from Shetland and I must say we had a very good short list we had a lot of interest we had probably in excess of 20 to 30 applications so I think there's still an appetite out there amongst professionals in England and in Scotland to bid for jobs as a chief executive that there is no replacement permanent replacement for myself as chair the vice chair will be acting up from the end of this month the recruitment of chairs of course is not a matter for the board it's a matter for government and the public appointments unit they conducted a recruitment exercise at the back end of the last calendar year for a number of chair vacancies I was informed on the 21st of december that they had not been successful in attracting anybody to replace me in borders and and I do understand now that the arrangements for re-advertising are likely to start any day now and it will be for borders and perhaps three other areas I in a way it's disappointing I do think the position of a chair in an NHS board in Scotland is extremely good it's very challenging it's tough and there have been some lows and we're currently going through a low but there have been a lot of highs as well and I would commend it to anybody who felt that they had the competencies to have a go at it because I've been a non-executive in England and Scotland now for 21 years three chairmanships and I must say I think the system in Scotland is extremely good and I've enjoyed my time it can be high risk and I think people will see that there is a reputational risk for senior people in the NHS both executives and non-executives when things go wrong that may be a deterrent but from my point of view I would encourage anybody to have a shot at it and I think whoever succeeds me will be in for a pretty stimulating time I'd like to just ask a follow-on from that so Jane but please do address the substantive point but can I also ask you Jane are you content I mean it sounds great that you gave so much notice because there's a lot of succession planning that can go into that but it is also uncommon to lose both the chair and the chief executive at the same time so are you content that you built into the systems and the people around you can offer a continuity of organisational memory and in terms of that sort of shared vision of where you need to take the board have you built that in so I suppose actually you might be better asking the colleagues around the table for that particular one just just but I will address that so the levels of interest in this the chief executive's posts were high and it was levels of interest from people who are already in the health and social care system so I don't think that that there's any less desire to aim for the chief executive role or senior manager's role in NHS Scotland certainly not through the boarders job boarders is a great place to work and without everybody who contacted me to ask about the boarders it is a tremendous place to work the people that work in it are absolutely fantastic so I could only commend the role in the boarders that's not to say it isn't incredibly challenging but it's also very rewarding and I think this period that we're going through is probably in the next year or two with the you know the Audit Scotland for example we're talking about you know bold changes because the demand in health services is outstripping the resources that are going to be available just in this public sector environment and I mean that that's just just understood but I think that will bring a level of excitement and probably innovation to to the environment that will be really welcome as far as I'm making sure that there's organizational memory I would say yes to that and the people who are in the executive team do have organizational memory there's pretty long serving executives and the most recent ones are and we're working very very closely together and certainly have been even more so in the last six months to make sure that people are absolutely understanding where we're at so that it's not all within one person's knowledge base so I have for the last six months been making sure that my colleagues are involved absolutely involved even in some of the decisions or management pushes or actions that I would generally just crack on with but that I've been involving them and helping to take you know take them along with my thinking around all of that so the very fortunate position is that Rafe Roberts actually used to work in the Borders and while it's a different organisation from the one that he left he has he has the knowledge of the people just just just hear around me actually as well so I think that's going to be incredibly helpful too. Thank you convener, good morning. Let's go on from Mark Cole-Hamilton but come down from a different tact. You mentioned Mr Ruins at special measures and the fact you can't balance the budget at the moment but when you do look at the fact that the chief executives retiring in April the chair of the board yourself is leaving as well the director of nursing with Bifre left in November 2018 my gut instinct my gut tells me that this is an organisation and a management team that's struggling or there's a lack of leadership there you know is that the case do you believe that's the case or is there something you can explain I certainly don't believe that is the case perhaps ultimately clear that I have no option I've come to the end of my second appointment term so I haven't completed eight years there's no way that I would continue or be able to continue I think one of the one of the challenges we have as a small board is that we are seen as a bit of a ground for staff to develop and move on to bigger boards in my time we've had four four directors medical directors Nicky's the fourth nurse director director of nursing midwifery and acute services two chief executives in my time so that's all in eight years which you could sense a healthy thing people will move on to bigger and better job or retire so I don't see that as a worry there are still people who have that corporate memory who've been with the organisation for a long time senior people Carol Gilley for one and I think Nicky's been a boarders employee for many many years so and further down the chain of course in terms of management staff people do have that long experience but I do think there's an issue about the fact we're small and people look to progress and become directors of nursing or medical directors in larger boards compared almost to like a provincial football club that you start there and look for a bigger team without the rewards I'm afraid but could basically you've said earlier on Mr Renn that you owned the problem you said you owned the problem and you owned the solution but you seem to continue down the same tack so you also said you'd like to stay if it was possible if you stayed what would you do differently now I think and I perhaps hinted at this that I think we we did own we we own the problem we own the the whole issue we tried to own the solution for too long and I think if I turn the clock back a bit I think it was up to me to elevate the the seriousness of the financial situation rather earlier than we than we did and I think and I'm struck by your governance report where you do talk about the need for health boards executives non executives to speak up and and I do think there is a reluctance sometimes there's an inbuilt sort of protective instinct really that is this is a problem we can solve it within ourselves we don't want to to be discussing bad news but there comes a time when you have to. Mr Renn, if you owned the solution your own professionalism would kick in at that point say right and he'd sort this. Yes I agree we own the solution for a period of time and then it got to a point of being unmanageable we have put a lot of governance into our efficiency programme and we've had a I established this some years ago almost a select committee type arrangement where we've had a finance group of non-executive directors who call managers and executives to account on the delivery of the efficiency programme and that has been meeting regularly and staff come in to explain how they're getting on and where there are problems and what can the board do to unlock those problems we've now converted that subgroup into a fully fledged committee of the board as a finance and resources committee to perhaps re-energise put more effort into finance governance and also take some of the weight off the board because agendas do tend to be and they have of course in the last 12 months been dominated by finance issues although we do try to keep the primacy of quality and safety very high up in the agenda of the boards. Thank you very much. Obviously there's financial challenges with the board that that comes out clearly so one of the things we'd like to look at would be in relation to where you are accruing costs and for example the use of agency staff is a clear way of accruing costs. Now reasons given for that range from sickness cover, patient acuity, vacancies, there's a variety of reasons given for that and I'm not going again to sickness absence cover because one of my colleagues wants to particularly look at that but what I would ask more generally to begin with that's a cost very £3 million a year in agency cover. Do you think you're starting to get the spend under control committee spectac to reduce if so by how much and what are you doing to make that happen? One of our biggest areas of overspend is on nursing costs and use of agency and Nicky perhaps will explain what has been happening to reduce that overspend. So yeah Bob regarding the nursing the agency spend we have had issues with recruitment like every board across Scotland and we've been very we've been extremely proactive but it isn't just about recruiting from you know HEIs from student nurses it's about actually growing your own so we've been going through there's a we've had a number of initiatives which have been about looking at our skill mix and making sure that we you know if we can't get registered nurses then actually what what does the skill mix look like how do we deliver care what is that how do we deliver it differently so we've this year we've trained healthcare support workers we worked one in the local colleges and we have a band two healthcare support workers that are training to become band four healthcare support workers we've been working with our agency the agency students open universities return to practice so that we could actually manage the vacancies so we have 23 registered nurse vacancies at this moment in time across the NHS borders and the majority are within the acute within the borders general hospital we had an extremely successful recruitment just in the middle of February where we interviewed over 30 student nurses and we have appointed to 30 we have appointed to 30 posts now they won't register they won't get the registration until September but what we've done over this last year we did this last year was we brought the student nurses in as band fours we paid them band fours because they finished their management students one day and then they work on the nurse bank as a healthcare support worker in the next day but we recognise their skillset and we developed a framework of competencies and they're supported by the practice education facilitators so they will go into the wards that they've got the registered nurse post and they'll be in that in there as a band four until the registration comes through. Regarding the agency spend we've we have been running the workload nursing and midwifery workload tools and looking at what actually what is the establishments on the wards so we've been running them using the professional judgment because you need to obviously make sure that you know what is the what is the staffing levels on the wards we have been working really closely with our senior charge nurse regarding rostering and looking at actually the the basic management principles of rostering and managing the rosters on the wards so managing the annual leave. The sickness absence again is is one of the areas and I know Brian's wanting to come in on that but the sickness absence has been so the the standard is 4% and with NHS NHS borders and the nursing sickness absence is at 6% nursing and midwifery and so we we've been I have taken so personally I have taken every phone call I take every phone call for agency NHS borders and I have done that over this last year and actually we are beginning to see a reduction in our agency spend so at the end of the financial year last year it was £1.2 million was our nursing spend this year it will be at the end of the financial the end of financial year it is less than the £1.2 million it's just under the million and so there's still a lot of work to do but we are we are focusing on that and that's about making sure that we have staffing post and we're not relying on agency and looking at our supplementary staffing as well so looking at our nurse bank I just checked then so 23 vacancies which are currently been filled by either bank nurses or agency nurses and I had a longer term basis unfortunately 30 posts for band 4s going to be embedded in acute wards by around September Mr nurses in September yes okay now are you suggesting then there will be no nursing vacancies by that point no so so again we've got return to practice so we have returned to practice we have open university staff that are doing open university we're looking at the skill mix so that was the the band 2 to the band 4 so actually how do we skill mix differently so there's that there's multiple things that we're doing because there's 23 vacancies and those are band 5 vacancies for example so my wife's a band 5 nurse in Greater Glasgow and Clyde and you've got a newly qualified band 4 nurse coming in when you're really an experienced band 5 nurse then you still effectively have the same levels of vacancies in relation to the skills mix so the very clear question I'm asking is not is welcome these 30 posts are coming in but what I'm asking is what will the vacancy level remain say September this year what will it be because you're saying there's 23 just now you've mentioned 30 that would suggest everyone outside looking in that will just disappear what will the vacancy level be in September this year so I don't have that and I can get that to you I don't know what the vacancy level will be it will be okay I think we can say is that there will be a vacancy level because we have a turnover that we would expect to see I think what we're trying to do is trying to minimise the the vacancy level as we're going forward with these recruitment examples that Nick has offered you so I would say without I don't think we'll be that forecast but I would say that 20 is something that we see quite regularly with turnover and retirements etc as well but we just need to try to minimise that so 20 vacancies for a gap of a couple of months whilst recruitment's on going's fine but an enduring 20 vacancies is a whole in service so I'm unclear how any of this benefits us so you don't know what the projected vacancy level is later the year but turnover of 2.6 registered nurses per month so we did have a mass recruitment but we still recruit we still have on-going recruitment so it's not that we're sitting waiting for this mass recruitment to come in in September we still have on-going recruitment this was an opportunity to recruit from the universities in the newly qualified but we're still doing recruitment out with that as well so to push it up to a little bit longer convener it's all right as I get the fact that there's attrition in the NSF whether it's retirements or or nurses moving to maybe a more senior band position even another health board or whatever so the attrition level is very very helpful are you managing the attrition levels when you suggest 23 nurses is the vacancy level anyway that's separate from the attrition level is that correct so we can discount the attrition level in relation to the level of underlying level of vacancies that's 23 and we're Jane Davidson suggesting after these 30 posts come online later the year that will drop to around 20 that's still a significant issue isn't it yeah and I think you know we recognise we still have a you know we still have a significant issue and that's about how do we so if the registered nurses if we aren't able to source the registered nurses how do we you know what is our skill mix look like and how do we it isn't just about the skill mix it's about how do we actually retain our staff as well so how do we recruit the staff how do we retain the staff and how do we reduce the sickness absence which obviously has an impact on the ward so there is there's multiple things bob and I think we we we need to focus there isn't just one solution and that solution isn't just looking at your universities and your your students coming out of the universities it's about actually what is the workforce need to look like for the borders from myself and I'm happy if you want to follow up and write with this given time constraints or whatever but I've always been apologetic when I asked this question but one of the biggest risks that we have in the public sector at the moment is in relation to uncertainties in relation to brexit there's no speech going to happen in relation to brexit but I know that a lot of public or local authorities in COSLA for example are scanning forward in relation to what those risks look like whether that's going to be EU nationals leaving or or recruitment dependent EU nationals a lot of agency nurses for example will be EU nationals as well have you written to all your EU national nurses for example and says you are well complete stay what can we do to retain you what is the exposure that the health board has in relation to the uncertainty in relation to brexit and what are you doing to deal with those challenges I won't ask you any more about that convener but I think you've been a mess of me not to ask that question in the drawing room I think we'd like to reply to that as well Tim is a resilience champion here and knows about the brexit preparations yes I mean with brexit we hope for the best and plan for the worst and there's been a lot of planning going on each board has a brexit planning group and our group is chair by our director of workforce so we have actually undertaken a survey of any of our workers who might be affected any EU national who might be affected we're making sure that they have full information and we're supporting them particularly in application for the resettlement scheme so I can reassure you that we are very active in it's a small number in the borders I think it's 57 we've identified obviously there's a lot of other brexit planning going on there's we have on our multi agency group our multi disciplinary group we have pharmacy inputs so we're talking about medicines I think that the Scottish Government and the UK Government haven't asked boards to do anything specific around medicines I think the manufacturers will be stuck piling for a six week period rather than ourselves we've been looking at all our contingency plans particularly around food supplies again we have business continuity plans for those anyhow and we're obviously working with our partners in the council who are very active in this and very concerned about brexit particularly the impact on small businesses and particularly farming community so our our preparations are I think well advanced we're working with our partners we now have to report to our health resilience Scottish government group on a very regular basis going forward any any issues flagged up so they can consider what the implications might be for things that be reported to them for NHS across Scotland a brief note on the staff survey would be helpful Emma Harper just a quick sub thank you convener to bob doris's questions and thank you nicky for answering him about sickness and absence and everything I'm interested if there's 2.6 nurses per month turning around is it acute care primary care is it across the board is it in a particular area is there any trends as to where these 2.6 turnaround are most of the vacancies are within the acute division but that's where most where the biggest nurse in workforce is and we've had a large number of retirement and so and that's one of the things that we are factoring in there isn't any trend and a lot I think what we're up against is that actually it's a it's not an employer's market it's an employee's market so we have I haven't I have some nurses that are moving within within NHS borders because there is there is vacancies the choice is there and the choice is there across Scotland you know when I qualified and I'm sure when you qualified Emma there there wasn't the the choice that there is now so this is about actually how do we make ourselves really attractive and that's why I'm meeting every student nurse that comes into NHS borders is because I'm saying how do I make you know how can we be as attractive how do I make sure you get the best experience you can you know what is it we need to do differently what type of job would you like you know is it a rotational post so there's not any I'm not seeing any trend I'm seeing retirement um it's been one of the big reasons but nothing else okay thanks okay thanks very much uh David Torrance to go back to brexit um you're talking about stockpile and medicines there has there been any work done around the costs of medicines coming from the EU and how it will impact on your budgets in future years um I think I mentioned that this is really a Scottish Government in UK Government management or the advice to us is really just to be aware of what's happening they will provide us with advice so we haven't I haven't had information that would be done at the UK and Scottish Government level also okay thank you I was um listening very carefully to the the responses you gave to Emma Harper around your interaction with with staff also to to Bob Doris's line of question here and we know you've got you have a long standing high sickness absent rate which to me suggests um a system that's under pressure um I think that's something that's come out along our questioning of many many of the boards I think um if I marry that up with with your sort of off the cuff suggestion that you met your the consultant in a on the training the way up who suggests the in fact the working environment is a very positive working environment currently for your staff notwithstanding the fact and I'm sorry to say this the six members of a board here didn't recognise one of the consultants who'd worked with them for eight years I think my question is around or my concern is around your interaction with staff here because there is a system under pressure here I would suggest in terms of recruitment retention and this high sickness level just for clarity could be there are any three of us on the train this morning not not all all of us thank you so sickness absence so if you look at the the statistics which were very which were last year but our sickness absence rate in NHS borders was was actually just below the Scottish average within nursing though we do nursing midwifery we do have a higher sickness absence rate so in NHS borders your sickness absence rate is 6.49 for nursing midwifery and we are looking at that so again across every other board the sickness absence rate for nursing midwifery is higher than the national average which is five point something percent and we are looking at that we're looking at why are people making sure that we are actually being a decent employee and making sure that employer and making sure that people have the return to works when they come back to work are we following the sickness absence policy do we have flexible working and you know 45% of the nursing and midwifery workforce is aged between 45 to 55 in NHS borders so actually you know how are we supporting those staff occupational health and safety and our well-being Wednesdays is one of the things and one of the one of the things we mentioned today today on the train coming up was actually a hydration station and the the memory staff that we met on the train was saying what what do you mean by that and I was saying this is about having a award clarcase being the first point of contact an award and having a juggy water and when you come into the ward them saying can I give you a drink this is about your well-being but this was about the teams so we do recognise the you know the sickness absence we do recognise that it's higher than we would have liked but we are actively working on that and that's one of the things that I think looking at where we are for our financial turnaround if we actually look after our staff and take care of our staff then obviously we won't have the cost pressure we will have a reduced cost pressure on supplementary staffing under the agency staffing so I'm not I'm hoping that I've answered your your question Brian I think it's challenging I don't think we're alone and it's not something we're going to fix overnight it's something that we need to keep need to keep at and it is about the well-being and I think it's something across the whole of NHS Scotland and the resilience of our staff and well-being I thank you for that and you're right it's you're not alone here you know I've worked with here Srinarnan a very similar issue to this and if I may maybe a little chat with them might be helpful because they've managed to turn their theirs around but I'm very interested in this I've hear this over and over and over again we have an aging you know sorry to say aging 44 to 55 year old we knew that we've kind of always known that so I've never quite on this nobody's quite answering me the question why have we not planned for that so I think we well I think we did plan I'm not sure we planned for nurses retiring at 55 if we actually really planned for that so I think we we have planned for our for the workforce but actually being able to retire this the the special class status and being able to retire at 55 did we appreciate that did we appreciate how many staff how many nurses would retire I don't think we did and I think it is also about we the focus may have been about students coming in I think we need to think differently because actually we can't just depend on student nurses we need to look at what do we need within the borders what is it we actually need from our workforce from a a health and social care how does that need to look so I think it's a it's changing yes it's changing for many reasons it's changing financially it's also changing because people want to be at home people don't want to be in an acute setting and they want to be looked after in their own home but we need to have a workforce that is that is designed to deliver that rather than a workforce that has for many years been designed to deliver acute nursing so it is it's changing and I think I think the retirements we probably didn't appreciate how many nurses would retire but I think we have planned but things have changed over the years I think Camino this goes very much to a wider question of training of workforces in the NHS and recruitment and education and Jane you may want to comment on that so I think it's really a question is national workforce planning and I think there's a workforce planned due for publication quite soon to to to take us looking forward but I think if you look at some of the disciplines and you know radiology as well as nursing etc I think there's just been that as Nicky says actually maybe a different appreciation or an appreciation gap of how people might want to live their lives live their working lives and later lives as well but having enough people coming in through the pipeline is definitely a challenge I think across across Scotland across the UK and internationally as well. Thank you Camino and good morning to the panel from the evidence which you submitted you pointed out that NHS borders is reliant on NHS Lothian for some specialist cancer treatment and so I wanted to ask specifically how is this treatment negotiated by NHS borders with NHS Lothian for patients across the borders? Yes obviously sorry can I yeah shall I take that we have regional planning and obviously Lothian is our provider for specialist cancer care we work through a network called SCAM and it's been a network managed clinical network which has been operation for a number of years and has worked extremely effectively. I think what also has changed I think I mentioned previously about about the pressures on acute sector prescribing and I think you're maybe referencing as well particularly some of the more expensive cancer drugs which are putting pressure on a prescribing budget particularly the secondary care that's all managed through now what's called a PAX tier 2 panel and the PAX tier 2 panel that Lothian use they make the recommendations and we usually in fact we do actually listen to their advice so our system is to actually be advised by SCAM and be advised by the Lothian PAX tier 2 panel in terms of these really expensive drugs and a bit like all our drugs which have come to the SMC if drugs haven't been approved by SMC they would go to this panel and the decision isn't just round effectiveness and cost effectiveness the decision is very much round what the public feel and also what the clinicians particularly who are managing the patients feel so it's a much more open access and again puts pressure on a prescribing budget because the SMC open access agenda as well as the PAX tier 2 which deals with drugs which haven't gone through the SMC that's increased the pressure on prescribing which isn't currently funded so you've had these policy changes without commensurate funding coming to the boards that have to apply them. A question was more around surgical procedures than drugs and specifically in the evidence you gave you stated that the board monitors the situation to ensure NHS board patients are not disadvantaged now I'm at Lothian MSP and I know the pressures the cancer centres under just for Lothian patients and there's currently only two slots I believe provided for out of board areas so in terms of that monitoring what takes place for patients because there's no further detail on on that. Cancer patients patients with cancer they're tracked on an individual basis so we've got a a team our waiting times team actually manage it patient by patient and they've got really good relationships with Lothian the network that Tim speaks of our clinicians of great relationships but the team's managing it have good relationships as well so that's how it's managed and I guess there's also that kind of anticipation and sort of forecast and we're built we're built into Lothian's planning as well. You know there's discussion at the moment around a new hopefully replacement cancer centre for the whole east region and given the budget pressures we've heard of are you already part of that discussion as well because it would be significant for all health boards to fund that in the future as well and is there any commitment being made around that? So we are part of those discussions going forward but we're also part of making sure that what we provide in the borders is sustainable and actually expanding and is robust so we're doing both. I can ask Harold to just give you a little bit more detail around finances if that's helpful. So again going back to what I was saying about earlier about capital funding we bid for capital funding so if you're bidding for a significant amount of capital funding there is a process you have to go through and part of that process is you have to get a regional approval so we're very much bought into that agenda looking at you know the future of the borders general hospital, look at the future of as you say the cancer centre at the western, we're working jointly with our regional partners on trying to prioritise which of these schemes go forward on behalf of the region. I just wanted to go off-piste really on this question because I know in September borders council had recommended or made a statement around the merging of NHS borders and borders council so I just wondered if you had any thoughts or views on where that was going because you know we have a lot of health boards who are coming to see us who don't have the advantage of having the same geographical areas and from what we've heard today about obviously radical reforms may be needed in the future not just around financing but the delivery of services for an aging population what work was being undertaken by the health board around that suggestion? It's at a very tentative stage but we have had preliminary discussions with Scottish borders council around the further development of joint working with the council and the health board bearing in mind that we in terms of the health of the population things that have to be done to improve health so it takes pressure off health services a lot of those functions and services reside within the council. Tim Patterson is the joint director of public health with the council and the health board and there's a good joint working relationship already and we've had tentative discussions about whether we can build on that taking the the IJB model really of improving health and social care services but doing it collectively and and I do think and it's a personal view that we we really need to look at resources collectively rather than just health just local authority. I mean local authority as you all know is responsible for such a wide range of services from housing to planning to education services and leisure which impact upon health so I think the the proposition that we have worked more closely together has a lot of validity we've had those preliminary discussions the council was very keen to submit to the local governance commission report that became public knowledge because it was taken through the council unfortunately it caused some repercussions because we hadn't got to the point of even discussing it as a board it caused concern to staff and we've had to assure staff that we're not talking about a merger we're not talking about a takeover of one of the other we're actually talking about better joined up working for the benefit of patients frankly it might because the council have a notion that ultimately we could see a single public authority in borders that may or may not be achievable I think if it ever is it's way down the line and there are governance issues of course that need to be dealt with but we have looked at matters like relocating to council headquarters where they have a surplus accommodation and we don't having more shared arrangements in terms of central and support services with the council so I think there's it's there's a big conversation to be had around the development of local authority and health boards in terms of improving the health of the population by locality and because we have that single local authority single health board I think there's a potential there for us to have a constructive conversation but I think Tim would want to add to that. There's a long history of co-operation between the council and the borders and the NHS borders even before the IGB before the joint bodies act was put in place we have many services which are jointly run so our learning disabilities is an example of that not some of our mental health services are run jointly with them there was joint budgets so there's a long history of that and if you just look at the borders itself the two biggest employers within the borders are the council and the NHS so logically we need to be working very closely together and I'm sure that's going to get even closer in the future the act itself gives a mechanism for for expanding that expanding that further and those talks are on ongoing and and around specific cases where we do share services and I expect in the future we'll be sharing many many more services. I was just to agree with what Rob has said I think we must recognise what comes to health of populations 40% is related to socioeconomic factors the council has a huge role in this it's a huge role in employment as you said the board and the council actually employ 10,000 staff so we work very collaboratively and in particularly dealing with these upstream issues particularly early years child health alcohol and drugs the chief executive of the local authority Tracy Logan is extremely interested in health she supports the joint collaboration we want to actually bring this differently i have different cultures we must accept that there are different cultures but she's very keen to actually bring the cultures together and particularly to see what opportunities there might be so we're really focusing on some of the public health opportunities particularly around the new national priorities and for example Tracy is now leading for the east of scotland on diabetes prevention I mean in my professional life having a chief exec actually taking that forward galvanising support within local authorities in east of Scotland actually getting involved in some of the more medical and health issues such as weight management I think it's been extremely welcome and very supportive so there are opportunities we're working very closely together I think what's john said let's see what opportunities also present themselves in the future thank you convener I'm interested in some of the work that's been undertaken about health and social care integration there's three principles that have been listed in our papers improving the health of the population improving the flow of patients through and out of hospital and improving the capacity within the community for people who have been in receipt of health and social care to better manage their own conditions and support care for them and there's also seven partnership principles prevention and early intervention accessible services care close to home delivery of services with an integrated care model greater choice and control optimize efficiency and effectiveness and reducing health inequalities so I'm interested in how the three key ijb objectives and then the seven partnership principles impact on how the health board considers performance and improvement that specifically health board rather than ijb I think is the point okay so the we reviewed our strategic plan last year and we refocused it down to those three very clear objectives so that it helps give that vision across all of the services both in NHS but also in the council as well and the idea of that is that we provide better quality services at each of those objectives but also they will drive out efficiency so that we are sustainable to be able to carry those services forward you asked specifically around monitoring I think it was so the monitoring within the ijb we carry out there's a monthly monitoring report we have committees set up we report to both the NHS board and also to the council as well within that so the three entities of the ijb itself the NHS board and the council itself are kept abreast of what the performance is across all of those areas there's a number of activities that have now been brought into play specifically around those objectives and some of the funding that's been allocated through the ijb over the last 12 months are directly to support each of those objectives and there's a whole list of them that we've funded to do that we mentioned some of the pomeray work that we were doing earlier the ijb is funded at directly talked about the hospital to home service brought in earlier as well within there and we've looked very much at patient flow through all of our acute settings the last one is perhaps our most difficult one to make sure that we've got sufficient care within the community to look after people after they've been through a process and we're working very closely with our council colleagues and with the independent sector to make sure that that is the case and we one of the factors we look upon that is the the return to hospital and that's one of the factors we look at and the early findings we've had from hospital to home that's been significantly reduced so we are looking to providing much more services after those interventions with health so that we can maintain people within the community one last thing if i can add within that the council is very well placed to access what we're calling the community asset is to really look at what the communities themselves can actually offer this agenda so the corporate plan from the council is around your part so it's trying to work with our communities and our residents to find out and the citizens to find out what is it that you can provide with this agenda and we will help you to do that so the review of the strategic plan for the health and social care is followed suit with that so we are expecting to work with carers and with other organisations and direct with the public to do that one last thing sorry so we operate within five localities and that gives us great access to the communities that are there within our five major towns that we have and we've supported our local working groups to actually help us to actually develop our policies and to develop our services and they are active now and we support them and they have representation on the strategic planning group too so there's a good link. We've heard a lot about set-aside budgets in this committee and what it's used for and you've mentioned that the iJB is funding the pulmonary rehab and Dr Tim Patterson talked about diabetes as well so and I probably should mention I'm the convener of the lung health cross-party group so I'm very keen to hear about any processes about keeping folk out of hospital and supporting lung health so I'm interested to know about is it set-aside budgets that's being used to support pulmonary rehab processes if that's iJB funding or what specific activity is being directed at improving patient flow and reducing admissions then across the borders. I'll pass the term in a second so the funding that's come from the iJB is from a fund called the integrated care fund so that's flexible funding we've been able to use to pump prime initiatives within the community there are other services that are funded within the community that are in our mainstream budgets within there it's not specifically within the set-aside. Tim, I don't know if you want to? No. David Torrance. Thank you convener. Around delayed discharges how difficult is it for you to eradicate them because of a lack of, around delayed discharges how difficult is it for you to eradicate them because of a lack of care on places? We've done a huge amount of work around delayed discharges it was a particular challenge not this winter but the winter past and we had a very very challenging time within our acute facilities within that and we learned the lessons from that we did a review and on the back of that review we introduced a winter plan for this year particularly focused on patient flow and delayed discharges a very close part of that so we introduced a number of initiatives and we expanded quite a few others around step down care around intermediate care and around getting people to their homes as quickly as we possibly can we set a direction for the nhs and also for the council around discharge to assess because we believe very firmly that the best assessment that we undertake with patients is actually in their home and so that's what we're trying to do to get the services out there we've worked also with our providers of care homes and also within our providers for care at home to ensure that their systems are efficient and that we're getting as much of that provision as we are paying for us is we're trying to increase the capacity that they can actually offer within there one of the difficulties we have in the borders is the rurality so there are great distances involved in that so it's more expensive for us to provide these services and it's saved within the city here or elsewhere so we are looking at increasing the capacity both in care home and carers and we've got more this year than we've had last year there's been a direct investment coming from the council it's out with igb money to fund some of those care places and that's been a significant help with our elderly patients with mental health issues and that's been much better this year than it has been last so it's an ongoing target for us we want to get down to zero we've seen a significant improvement this year and we've seen improvements in length of stay with an acute of around 15 percent and we've seen a reduction and overall delayed discharges than about seven percent if we measure the same time last year and also we're ranking we're sort of middle ranking now if you compare us to other boards or other igb's within the country thank you convener um you say there's your surprise that the increase in the number at under 65s who are needing 24 hour nursing care how are there needs being met there's there's many ways in which they're they're being met so within the home we've put in further services within the community so within the central locality in the olden locality where there isn't a community hospital we've moved out some of our physiotherapists to work alongside our healthcare support workers they're linked into our district nurses and our GPs are operating within their clusters as well so there's a very strong partnership to make sure that we have the right people giving the right support at the right place at the right time and now the co-ordination of that is vital to make sure that we are able to do that within the funds that are available and that's what we constantly monitor the advent of the primary care improvement plan is another bonus for us in seeing that through and our GPs in particular are very engaged within that and they're leading on six of the programmes under the primary care improvement plan to which we'll answer some of the issues that you've just mentioned. Thinking in terms of patients coming to Lothian for treatment what's your cross-border arrangements like and are you seeing an increase or decrease in terms of patients going to NHS boards for treatment or response for within England? I wasn't quite clear if you were asking about Lothian or England could you say that again? NHS England so in terms of I'm acutely aware of patients coming to Lothian for treatment but in terms of patients going to England I know Newcastle increasingly is across Scotland where some patients are receiving treatment I just wondered given your geography if you're what the pattern is like currently and how that's being financed as well. Okay so we used to have quite a lot of people coming from England to borders actually and that's tailed off over a number of years as the north of England's reorganised itself so some of that's tailed off. In terms of our flow across the border I would say it would be mainly in elective patients so for knees or hips etc and that's very much on whether we can source that capacity and also it's part of our standard operating procedure has been for many years to be able to access particularly Newcastle actually to support us with that and that's part and parcel of our planning for our waiting times to deal with that so we factor in whether we've got the resources available to do that sometimes we get additional funding from the Scottish Government to do waiting list extra waiting list initiatives and we've done some of that this year as well. Has you used your golden jubilee capacity for these operations as well? Sometimes we use it golden jubilee it just depends what it is but some of our patients it's easier in many ways to go to Newcastle so we've got relationships with both less so not using as much capacity at the jubilee now we're trying to do as much of it in house as we possibly can. Thank you very much for letting me in convener and as you know I've been a critical friend of NHS borders for a couple of decades and in high regard for staff that said I'm sure you'll be checking up you know all your consultants now can I just have a couple of points clarified from you please joint working with the council I understand can you just confirm for the record this does not mean borders council running NHS borders or the BGH because that's what the paper said and that's what scared people that's the first thing second point is bold revolutions what a name what the act what's that company actually said you can do right away to make savings because we're coming back to this and I take no pleasure in your financial difficulties but what's bold revolutions said in your processes let's exclude prescriptions the dot prescription that you can do to make savings two questions then John Renn the first the answer the first question is absolutely not no take over by the council of health and the the NHS brand is sacrosanct terms of bold revolutions they only started work yesterday so I think we're waiting so just to add to that we have had the Scottish Government's board recovery team instances before Christmas to help us just make sure we've got enough rigor around what we had which was a project management approach but that is bringing expertise to us from from their experiences if I look at if I look into 1920 with our financial settlement after we've paid our pay awards and this has been the case for a number of years now we're left with something like 600 000 pounds to apply and deal with other pressures so if you just think about drugs for example so it's a it's a massive challenge for us so bold and the the recovery team are setting our stall out that they will be able to help us identify four percent five percent of five percent over the next three years which in very broad terms would be looking at something like 10 million each year and we don't know Christine where that's coming from because what I would say is if if you don't mind if I go back to our annual review from 2016-17 you know it was pretty clear in that letter that the demand and the challenges around public sector settlements was across across the whole public sector was going to be quite demanding but when we hit last year with all the benchmarking we looked at and we've got about 8 million pounds of what we need next year in the bag confidently already but we weren't prepared to class that as unidentified because we couldn't actually identify or or see where the big bold changes were going to come from and that's why we need assistance which is really very welcome and if we're able to achieve that four five and five percent that's that's what's going to really make the difference there but they only started on on Monday but these people and the experts from the recovery team as well feel are saying to us and we take confidence from that that that's achievable. A final area of questioning Brian Whittle. Just a simple one really we're obviously working on their new GP contract and there's a sort of suggested disparity among acceptance between urban and rurality and given that you're quite a rural rural area I just wonder where are the gps and the borders are they supportive of the new contract and everything that it currently entails? That is yes but I'm going to ask Rob too to come in on that but I just want to make at one point that and we've I've done this in boards and I've done it in the IJB and the board accept that it's it's impossible to overstate the importance of GP practice in what we're trying to achieve sustainable affordable services it's very much shifting shifting care shifting resource GP practice is pivotal to the success of that we have 23 GP practices in the borders we're working hard to sustain good relations with our GPs it's work in progress but Tim I think can give us Rob rather can give us a bit more detail around the primary care plan. Thank you and I can refer to this earlier really the just as John says the GPs are vital in the work that we are doing with our communities both for providing quality primary care but also supporting our acute and emissions avoidance within the hospitals too. We held a development session on Monday last and the GPs were represented there this was across the all of the delegated services within the IJB and we were looking at what the future holds for us and the challenges that we're actually facing there. It's true to say that the financial return from the new GP contract doesn't benefit those GPs who are in rural situations as much as perhaps it does within the cities. Having said that the GPs are welcoming of it in the borders because we think it'll allow them to get better or get a free up their free up their time so that they can get involved in the overall health agenda within their local communities and that's to be welcomed. These are an expensive resource a very worthwhile resource and they work tremendously hard and we need to make sure that we are able to use that asset more than we're currently doing at present time. One of the comments that was passed at the meeting on Monday by one of the GPs was just precisely that. They're looking forward to a time where some of their work in their workload is passed on elsewhere so it will free them up to do the real health prevention work and health support work within the communities themselves and I really look forward to that as well. One very quick example from one of the GPs that I've met saying that they deal with in their consultations was about 50 per cent of their consultations with around mental health and in the main all they were doing was referring on to other agencies. Now that's a really expensive piece of triage that we're undertaking there and it's not utilising the GP for what they're there is the generalist expert and that's what we need to move on to. So the GPs the 23 practices within the borders are really keen they fully worked with the development of the primary care improvement plan and as I said they lead in all the six work streams within that plan itself. So we're looking forward over the next couple of years with the implementation of that of moving some of the other tasks to other health professionals and elsewhere so that we can actually make best use of the GPs. Before I move on back in a moment, how do you envisage then tackling that particular problem of mental health referrals in rural areas? Will that mean more mental health nurses in practices? What's the plan for a decent adaptation? That would be one of them. There is a working with our mental health colleagues in those services to make sure that they're more accessible within the communities so that we can actually provide services where people are rather than people having to travel there. Some of that's within practices, some of that will be within other services within the communities and some will be the third sector too. Given what you said that Mr Mayne about the importance of the GP practice in delivering the sustainable model that you're looking at, can I ask it how then are you monitoring GP practices and does the new GP contract alter the way in which you gather that kind of information? Yes, the new GP contract has changed how practices actually monitor the quality within their practice. Previously we had the quality outcomes framework, now we have what's called a quality cluster model, so with four clusters within the borders and each has a quality cluster lead with a GP with some time to actually lead on that. I think we probably need a bit more time for them, but that's another discussion and in each practice has a quality practice lead. They have actually looked at the quality outcomes framework previously, what is important for them, so it's actually an improvement because we're looking at what is the local needs in that area, particularly around long-term conditions such as diabetes, COPD, heart failure, blood pressure and what have you. So they've identified key areas that they want to work on, they then work with those practices and the health board can be aware of that work and actually support it as well. I think that one of the things that Rob has said is that one of the key areas is actually the new concept of expert generalist, or expert generalist, and the idea is that they really focus on things that you need a GP to actually work on. So one of the big developments is actually, well, let's look at some of the other areas of work that perhaps an advanced nurse practitioner can actually do. So I think that they recognise that that is a key area of development and working with our director of nursing round having a common framework for training. There are also lots of innovation going on around quality enhancement as well, particularly working with Scottish Ambulance to undertake some of the calls in the community, particularly in the rural areas. The primary care contract has actually pushed a lot of developments and as Rob says, the primary care improvement plan particularly, we're taking vaccination immunisation of practices in the next couple of years. We're dealing with pharmacy, we're dealing with MS cave and physiotherapy and this will allow them to actually focus particularly, I think I mentioned earlier, the increase in elderly. I mean, we are expecting next 15 years an increase by a third of over 65s and an increase in 75% of over 75s. They're very, very complex, very, very complex, very complex. So getting those clusters to work together, particularly, for example, they could run in the future, they could run water and clinics on behalf of clusters, they could run long-term management on behalf of clusters. So it's not only what the benefits are now, I think it's the benefits down the road and particularly once we bring in the real opportunities around new technology, I think the contract will give us a good foundation going forward. Very much, Brian Rittle. Just a very quick one, convener, if I could. I just wondered in terms of the primary care fund, has that money been fully distributed now and maybe give us an indication of how much that was? We haven't used the full funding in the first year, but it's transferred into the following year, so we'll be able to use it fully in 1920. So all in all, I haven't got the figures to hand, then I'll have to pass them to you later, but it's just short of 3 million over three years. So we got this year just around 900,000 this year, and as Rob said, we only do down 70% of that, so we're carrying 30% forward. The figure increases to just over a million next year and the following year up to 2 million, so it kind of ramps up when we get the investment. Okay, thank you very much. That's been a very full session. I thank our witnesses for their comprehensive answers. There are a number of items that have been raised during the evidence session on which we will want to come back to you, and I think a couple of things that you've already offered us some more data. So thanks for your attendance. Morning, you will hear from us on that matter, and we will now suspend briefly and resume in private session in two or three minutes. Thank you very much.