Fy angen i gael i gydych chi'n gweld y cwrdd mewn gyfletihau sydd i eich bod cysyllt tu. Yr wych i chefn i chi'n olygu amser oherwydd ta daith yn nu achos'u cyd-dweithio, i bobl ynißtheill yng nghymru i ddiweddol i gyda'r pethau. Yr rhaid i chi'n gweithio, mae'r sefyllfa yn gweld y cyfrifloedd o'r newydd i chi'n gweithio y maeddol a'r cyfrifloedd ar gydwyr, Gwyliann Gwyliann, ond ond mae'n gweithio i gael y cyfrifloedd i'n gweithio i ddod. Iewe reporter? He is already an EU reporter. I move that Emma Harper is becoming an EU reporter. Thank you. Is there not any EU reporter in terthwg? Any other comics. It is agreed that Emma Harper will be the new committee EU reporter. Congratulations, Emma. Thank you very much. Agenda item 2 is scrutiny of NHS boards. We have a guest from Eershire and Arnn board this morning. I welcome to the committee John Burns, Chief Executive, I welcome to the committee John Burns, chief executive, Dr Martin Chain, chairman, Derek Lindsay, director of finance, and Tim Eltringham, director of social care, health and social care partnership. I invite one or all of you to make an opening statement. You have done the introductions for me kindly. We have submitted a briefing paper to you, and I hope that that has been helpful to the committee members today. NHS Ershinddon, like many health systems, faces many challenges as the needs of our population change. It is essential that we continue to adapt and innovate to meet those challenges. As a board, we realise that we have a duty to use the resources available to us to support, prevention and deliver care and treatment to our population. In doing so, we recognise that we wish to do this in a way that reflects the ambition of the triple aim of best value, better health and better care. Our teams working across health and social care are committed to delivering the best services possible to our population, and we have a strong approach to continuous improvement. As chairman of the board, I can assure you that we scrutinise the performance of our services through our governance arrangements, and we have set out the way that we do that in the briefing paper. At the recent annual review, the cabinet secretary did ask the non-executive directors if they felt that they received the information needed and if they could seek additional information did they get it to fulfil their scrutiny and assurance role. In response, the non-executives directors were clear that they felt well supported and would ask and receive additional information if required. I think that this reflects what John and I have tried to do in developing an open culture in NHS Ersin Darn, which values all staff and the important contribution that they make. Thank you, chair. Thank you very much. Can we have Ivan to begin? Yes, thanks, convener, and thanks for coming along to talk to us this morning. What I'm interested in is understanding a bit more about—we've obviously got a number of indicators here and where you are against target, and that's fine—I'm more interested in what sits behind that, what process improvement processes you've got in place, your understanding for any one of those indicators, what causes the number to be where it is, what action plans you've got sat behind, what drives that, where your trends are over time, are you understanding the mechanism, implementing the actions and seeing improvements in numbers? Do you have that mechanism clear in your own heads? Then a bit about what you're doing to learn from other boards that are maybe a better performance, and you understand that there's obviously differentials in terms of your population profile, et cetera, but there will be people out there that are making progress in other areas of your learning from that, and what's the mechanism for doing that. We'll start with that and see how we go on. Thanks, I'll kick off. Fundamental to the work that we do in Ayrshire is around improvement. We have a strong ethos around learning. The indicators that we report on are indicators of that performance and therefore cause us to scrutinise and challenge where that performance isn't achieving the desired goal. Importantly understanding what we can do to improve that, so action plans are behind that. Some of that is quite difficult in terms of some of the workforce challenges that we face that would help with some of that improvement in action, but we're very clear as a board that we need to be able to have a continuous improvement philosophy that's focused on delivering the best that we can. In terms of trends, we use data a lot, and that's really important. We look at the data over time. We understand what our data is telling us. I think that that's fundamentally important. We know across a whole range of indicators that we report on how, as an organisation, we're performing. If you look at some of that, we can see that in terms of HSMR data, where we look at trends over time, our infection control data over time to make sure that we see that continuous improvement and monitor that against all of the data points. In terms of learning from other boards, we do engage regionally. I think that there's a stronger basis now with our focus around regional delivery planning and working in that regional context. We also work across NHS Scotland and through seeking to work in collaboratives. There's been some very good examples of collaborative working in NHS Scotland, which is a strong way to learn and share best practice. We do seek to understand who's doing it in a way that's delivering the improvement that we are maybe not. We can do more of that as Ayrshire and Arnard and keep looking. I suggest looking beyond the traditional boundaries of Scotland and beyond to see who is delivering transformative change in some cases to help us to try and improve targets. Would you like to give me some specific examples now? Pick one or two indicators and drill down and tell me right to fix this, we've done this, this and this. This is what it's done or we've learned such and such from somebody else or we've got a challenge here. We're implementing that ground level, if you like, to try and drive some improvement. I would pick infection control. We have been focused very much around the C difficile target for a number of years in Ayrshire. We introduced a summit about 18 months ago where we brought clinical leads because we weren't making the improvements that we wanted to see. There was improvement there but not at the pace that we wanted. That renewed focus has seen us deliver in the last financial year, deliver on the national target for C difficile. That's a very good example of looking at trends and taking action. The other areas that I would pick out are unscheduled care. This is where we look to learn from other systems and see where we can bring improvements and work with national colleagues. Again, we have delivered change in our unscheduled care programme through increasing our activity at the front door in terms of senior decision making, the introduction of combined assessment units to bring a different support into our front door services and trying to support people to return home earlier. We have seen significant improvement on the back of combined assessment units in terms of unscheduled care. There will be two examples that I would highlight. In C difficile, what did you do, what changed in the operation that made that different? What changed was that having had discussion over many years with clinical colleagues, we created the focus, the summit, for clinical colleagues to come and have. I suppose to be immersed in that discussion with a clear focus around what further improvement we could do, working with Health Protection Scotland and taking learning and suggestion, and then being very clear about the delivery plan and our implementation of that, monitoring the delivery of that and having a very active engagement in that delivery through our infection control team. Getting everybody in a room and having a summit does not fix anything. What did people actually work around the world differently that caused that number to get better? Some of those are difficult to pinpoint, exact actions, but there was no doubt that there was a stronger leadership in terms of the work that we were doing. Our infection control team worked even more closely with our ward teams. We were ensuring—and I think that this is important—that the implementation and delivery plan was rigorously scrutinised and monitored through the infection control committee and making sure that our systems and processes were as tight as they could be and that everyone understood what they were required to do. So there was no one specific thing. I think that there was a range of issues that we brought into that plan that allowed us to deliver that improvement. Flipp-up on its head if I am somebody working in a ward—alright—and I have a good idea about how I can make things better if you are doing this, but if you did that it would improve whatever in the role by the wealth of knowledge amongst people that are working on the front line there. What is the process whereby that gets translated into some action that you make that makes things better? On a number of levels, first of all, we encourage everyone to be able to openly discuss things that they think can improve and, if they think that they can do it in their local team, to work within that team and do it. Secondly, if they think that it is a bigger issue, then to raise it with the appropriate line manager. For that line manager to work with that team to develop that improvement and to help to enable to introduce and progress that. I think that one of the things that we have introduced recently is a staff suggestion scheme. Not everything can be done in a local context and indeed some colleagues will have ideas that go beyond their area of responsibility. We encourage our staff across Ayrshire to share their ideas, to hear their improvement, because it is through our staff that we will find those areas where further improvement can take place. Final question. We have Harry Burns in letter to talk about his review of indicators. Do you have any observations on that, any comments on that? Are we measuring the right things? Are we measuring the wrong things? Should we be doing it differently? I think that the indicators and targets have served us well. I think that they should always be kept under review and I think that Sir Harry's report is a welcome report in terms of some of the challenge that he puts into thinking beyond where we are. I think that as we work increasingly in an integrated health and social care space and arrangements, then thinking about outcome and how we measure outcome in that integrated way is going to be an important aspect for the future. However, I think that there are targets and indicators that continue to set a strong purpose, the A&E target. If I remember Sir Harry's report, he says that it is still a valuable target, not as an A&E indicator but as a whole system indicator, and I would agree with that. I think that it is a helpful challenge. We should be looking to progress and constantly keep indicators and targets under review and move as we can to a focus on outcomes. Okay, thank you. Just in relation to the CDIF stuff, it is still not meeting the target. We met the target in the last financial year. On the performance standards that we have here, it does not appear to be. It says current target is 60, current value is 64. Yes, in the current year against the current measures, we have seen a slight movement, but we continue to keep that under review and we are still confident that we can maintain our performance here. Have you met it? We met it in terms of the last financial year, where it is where the end of year measurement in terms of heat are in your performance. I think that, convener, that is the data that you are referring to. We are slightly above our target, our local target at this time. In relation to that, Mr McKee asked you about specific actions that had been done to improve that. I have to say that you could not really tell us what those specific actions are. If that is the case, then how can your board help others to learn if you cannot tell us what those specific actions were? I do not have the specific detail at my finger, so I think that I would be happy to provide that for the committee. That is cool. M Dells wants to come in on any of the performance standards issues at the moment. We may come back to that then. Good morning, convener, and good morning to you late at the panel. There are a number of areas in the performance standards where there is red alert shown and that you are not meeting, for example, in treatment time guarantees, 18-week referral time, GP appointment booking and all of that. What is your response to those issues where performance in some areas is considerably, you know, looks pretty poor in terms of, like, a 12-week treatment time guarantee 20 per cent below what should be 18-week referral time is 15 per cent below? What is your response to that and how are you going to address that? In terms of the 18-week referral treatment time, we have detailed demand capacity models, so we understand what we need to do. We have some challenges in the system around workforce. What does detailed demand capacity mean? We have looked at the referrals that we receive in each of our specialties. We have looked at the capacity that we have in our clinics and in our workforce. We have tried to match to understand whether we are able to meet those referrals, that activity, coming through the system. So is that recruitment then? Some of it is in recruitment, and that is why we have been working. We have had to bring in some local staff. Some of it is capacity, where we are looking to adjust our capacity. For example, we are looking at new appointments versus return appointments and working with our clinical teams to see if there is a way to rebalance some of that activity. We know that there is evidence that not all return appointments are necessarily need to be made with someone attending hospital, so we are looking to redesign to improve our capacity where we can. This year, we are looking to reduce in our review attendances by about 7,500 reviews and convert that into approximately just 3,000 new attendances. That tends to be the broad ratio that we would see in Ayrshire. We are trying to enhance our capacity for outpatients. We have access funds from the Scottish Government that we are using to impact and reduce the outpatient waiting time. We have made considerable change in the last year, but I agree that it is an area that requires further work, and we continue to keep that under very close review. In terms of the treatment time guarantee, the issue is primarily around orthopedics. There are one or two other areas that we are addressing, but orthopedics is our main area, and we are bringing that down gradually over time as we try to put more elective capacity into our orthopedic service. That might be helpful, so we do not dwell on this. For each of those, you could write to the committee giving us an indication of what action is on going to improve that and what improvement you expect is because of that action. Is that okay? I am happy to do that. Can I follow that up with a specific question about one performance indicator in particular? What explanation can you give for the fact that the NHS Ayrshire Naran's performance against the 62-day target for cancer referrals has fallen from 92.8 per cent between January and March 2017 to 88.5 per cent from April to June 2017? What was the reason for that fall and what action are you taking to improve on that target? The main issue that we face is diagnostic capacity. We work with other boards, so we work with Glasgow, as well as our own diagnostic teams. We know that, within our own position in Ayrshire, we have radiology challenges, particularly around CT scanning, and that is predominantly a workforce issue in terms of radiologists and radiology vacancies. We keep that under very close review, because cancer is one of those areas that we strive to ensure that we are managing referrals, diagnostics and treatment as effectively as we can. That is an area that we are very focused in trying to improve. You say that you have diagnostic capacity. Is that staffing problems? We have consultant radiology vacancies, so the reporting capacity is a challenge for us. We work closely with our radiology team to ensure that we are prioritising and focusing in on cancer services, and we will be looking to do everything that we can to make sure that that figure improves. The one thing that you have not mentioned is the review of chemotherapy services that has been carried out by the board. You started that review in 2014. You said that you would carry out an options appraisal in 2015. What exactly have you been doing for the past two years? I have looked through the health boards papers for the past two years. I cannot find it mentioned anywhere. I cannot find it mentioned on the website, apart from the fact that there have been options appraisal in 2015. Why is it being trickled out that you are currently considering the closure of chemotherapy services at Ayrhos, but why is that not in the public domain, and what exactly have you been doing since you started that review? As you said, we have done an option appraisal with the involved staff users and other interested groups. That was a detailed option appraisal. We concluded that and then there was a consideration as to whether that would be significant service change. We worked with the Scottish Health Council around that. In order to come to a view on that, we were asked to do a transport impact study, which we did, and that took a bit of time. Having done all that, we did get to a point where it was agreed that that was not a significant service change. In the meantime, I accept that that has taken a long period of time. I want to clarify that that has not impacted on the service that we deliver, because we are delivering our chemotherapy services in Ayrshire, and I would say that it is highly effectively delivering our chemotherapy services in Ayrshire. However, what we are now considering is that, in the west of Scotland, there has been some work around systemic anti-cancer treatment work. We are taking account of that, because I think that it gives some other opportunities to look at the model for Ayrshire. We will be continuing to have a discussion with staff and patients in the months ahead. We will take a full paper to public board meeting in January, setting out what we would now consider as a model of service, and then, in the spring, we would intend to consult on those proposals widely across Ayrshire. Why is none of this information being in the public domain? You mentioned a transport appraisal. That is the first I knew about that. You talked about the options appraisal. We still do not know exactly what those options are, apart from what is being trickled up. Why is this not being carried out in the public domain so that the public can have their say on it? We have worked with our staff and users of the service. What we have not done is to formally consult on any change. We realise that we need to review our chemotherapy services and how we deliver them. We want to deliver the best services to our residents in Ayrshire. Given the further work that has been done, it would be wrong to consult on what we have done, and we should bring into that consideration some wider learning from that west of Scotland work, review our proposition and consult on a revised paper. At the moment, the public perception is that you are going to centralise chemotherapy services on a single site in Ayrshire. Are you saying that that is currently under review that that might not be the proposals that you bring to the board in January? What I am saying is that we will bring proposals to the board in January that will be built on the best evidence available for delivering chemotherapy services in a way that provides that service to our residents in a safe way. We will take account of all the evidence. It would be premature for me at this stage to say what that final proposition would look like. You mentioned a minute ago that the performance was good and yet it has fallen from 92 down to 83. Does that reflect a good performance? I would draw a distinction between the cancer, the diagnostic and treatment target, so that is a 60-day target. No, I am not saying that is a good performance. I am saying that in 62-day performance, which is diagnostic and treatment, we need to do much better. We have had a very good, looking at the trend data in Ayrshire. We have had very good performance in cancer. We continue to have very good performance in the 31-day target, which is once there is diagnosis, delivering treatment and chemotherapy, which is then the next stages in treatment. I believe that we deliver that service very effectively, but we need to keep all services under review to make sure that we deliver them safely and to the best evidence. You said that you want to do better. What are you going to do and how long is it going to take, given what Colin Smyth has just referred to, that other changes seem to be taken in a very long time? The trend that we have—our cancer performance over time has been performed well, and we will do everything that we can to quickly get back to that standard. We recognise the importance of this. Can I ask again what—I am hearing repeatedly, if I am making as well, a lot of words—what we need to know is practically what you are going to do. If any of the other analysts would like to comment on any of this, feel free. What practical steps are you going to take? We need to address the capacity issue and the reporting issue. What does that mean? I do not have that answer in terms of the specifics. We have been very aware of this. This is our recent issue in terms of the drop-in performance, and we are looking at what action we can take to improve that. Just on back to the delivery of chemotherapy, in the recent annual review, there was quite a strong cry for consultation in terms of delivery of chemotherapy treatment within Ayrshire to be a public consultation. You seem to be quite open to that idea. Are we still in that position? Absolutely. The paper that we take to board will seek that approval for formal consultation and public consultation, and we will do that in a public board meeting. Just to clarify, that will not be a selected number of the public. That will be an open public consultation. Just for the record, it appears that, in the last two years, the cancer target has been met once. My question is about recruitment and retention. NHS Ayrshire and Arran has a higher consultant vacancy rate in terms of whole-time equivalent than the figures are nationally, so 16 per cent versus 8.5 per cent nationally as of June 2017. In written evidence to the committee, Parkinson's UK Scotland stated that there is a critical shortage of consultants in medicine for older people in Ayrshire with nearly half, 47.6 per cent of post-vacant. I would like to ask why the consultant rate is higher in Ayrshire and Arran. What is going on? Secondly, what are you doing in terms of attracting people to work in Ayrshire and Arran? Are there any specific things that you have been doing? I know, for example, NHS Fife goes across to Ireland and they do recruitment drives. What are you doing to attract people in to fill those vacancies? The consultant vacancy issue in medicine for the elderly is seeking to address. We have recently recruited a new consultant into our older people services, particularly with a focus on acute care. We think that that is an important step. We are also redesigning the team around the consultant, so we are looking to bring in acute care of the elderly practitioners to support the medical team and deliver that service. It is about change. We are also looking at how we deliver our older people services to ensure that we are delivering a service that is modern and will attract consultants to come and work in Ayrshire. In terms of attractiveness, across all consultant vacancies, we are looking firstly to promote Ayrshire, because we think that it is a good place to come and work and live. Secondly, we are looking to engage in any national initiatives that there are in terms of recruitment. We are looking to learn from other boards. Other boards, as you say, have been looking beyond our shores for recruitment. We are looking to learn from their experience to see if there are different things that we can do in terms of attracting consultants to Ayrshire, because it is a critical and significant issue for us. John Lennon mentioned acute care of the elderly ace practitioners. I think that, in recognition that it has proved difficult to attract a full complement of geriatricians, what we have sought to do in collaboration between the partnerships and our acute colleagues is to recruit a number of these practitioners who are essentially senior nursing and AHP staff with additional skills who can fulfil a number of roles to prevent and support at the front end of the hospital. John Lennon mentioned the combined assessment unit working within that to prevent admission to hospital after initial assessment and also to support the discharge, working hand in glove with social work and senior clinical staff. I think that what we have sought to do is to recognise the difficulties that there are in recruitment and adapt where appropriate. However, as John Lennon says, we are fortunate recently to have attracted a consultant to come and work with us. There are still vacancies, but we are making progress on that. I think that one of the other things to recognise is that there is some evidence, albeit anecdotal at this stage, but increasingly clear that young consultants prefer to live and work in the central belt and attracting them to go down to rural Ayrshire is becoming an increasing problem. I appreciate that. I represent a constituency in Fife and I recognise that it is difficult to get people into those areas, particularly young graduates. However, with regard to the geriatric medicine that you alluded to, in terms of the statistics, it shows that over half of the consultant posts for geriatric medicine were vacant and had been vacant for six months or longer. Is that pattern changing? If you get job vacancies sitting there for six months, it suggests that there has not been a culture shift. I appreciate that you are trying to put things in place, but that is June 2017. Have things improved in the past six months? Yes, I think that things have improved and that we have recruited a very good consultant as clinical leader for the service. We have worked very hard with our health and social care partnerships to redesign our older people's services so that we are clear about the focus in community and front-door assessment. We have a very different model that we would be offering, and I think that that will be attractive to consultants to come and work in. We know that, when we can bring potential candidates to Ayrshire and when they meet the clinical and other teams, they like what they see and hear about Ayrshire, and they are keen to come and follow through on their application. Thank you, convener. I will come on to the issue of delayed discharge in a minute if I may, but I have a couple of follow-ups. First, on Colin Smyth's question around cancer waiting times and the broader issue of waiting times, we have learned that, in recent weeks, in NHS Lothian in particular, there has been a culture of under-reporting of waiting times and delays of misindicators. First, in St John's in the last 24 hours, we have also seen that in the ERI and the SIC kids. Do you have 100 per cent confidence in the fidelity of the statistics that we are seeing before us today? Secondly, in picking up on Ivan's question on improvement, in the issue of, for example, cancer waiting times, you talked about diagnostic capacity being a principal reason for those delays. Is that something that you capture as a matter of course? In terms of right across all of the indicators that you have given us today, do you routinely capture the reasons for those delays? Yes, we do, and we report them through our board reports to board every public board meeting. And when you have that sort of risk register, as it were, in terms of the reasons for the delays, the catalysts for the delays, do you then, is there a follow-up process where you talk about how you can mitigate those specific reasons? I'll pick that up, if I may, in the governance side of it. The answer to that is yes. We ensure, through the healthcare governance committee and then reporting into the board, that there are quality improvement plans or improvement plans in place to mitigate against any of those cases. There's a very high degree, I would argue, very high degree of scrutiny through the healthcare governance committee, and then reporting that into board. Uniquely, we have a slightly different setup. After that, we have the chairs of all the governance committee meet as a group called the Integrated Governance Committee, where we further look at the key issues of the period. Thank you. Are you happy for me to come in on delayed discharging? Not just now. We were trying to stick to retention of the recruitment, so that was a bit cheeky, I'll explain if you want to come in on that. Thank you, convener. It is a recruitment question. Last week, Jason Leitch talked about how he worked at Greater Glasgow and then spent a day doing clinic and a day doing surgery in Auburn. I'm aware that the urologists from Ayrshire and Arran also support NHS and Frees and Galloway, and the same with ENT for Glasgow as well. Is there enough opportunities being explored to share the skills across different boards? If we can't recruit for one specific area, can we maybe get people out for two or three days at a time, over a month or whatever? I think that we need to think more about that type of arrangement. Regional working, regional delivery will give us a chance to do more of that, but we are already doing some of that in Ayrshire in limited ways. We are also looking to work with neighbouring health boards, and you have just given some of the examples where we are assisting some boards, but we work closely with Lanarkshire and Glasgow, where they provide support for us in terms of delivery of service to support some of the challenges that we face. However, that is not always a practical solution. Can I give a couple of examples around that? In terms of Glasgow, consultants come down around neurology and neuro-rehab services, where we do not have our own consultants. With Lanarkshire, there are shared arrangements for support of the hyperacute stroke unit, which is across the house. Those are examples where we are working with neighbouring boards. We have been able to achieve that. The other thing that I wanted to mention was about skill mix and so forth. We mentioned our challenge around consultant radiologists, and we have had vacancies for a long period of time, so we had to look how to redesign those services. We have trained a significant number of radiographers, and they are able to do a proportion of the work, which otherwise radiologists would have done. That is an example of redesign and skill mix change. Because of our PAC system that is national for radiography, it means that you can take x-rays by a radiographer, but then it could be interpreted by somebody in another board, for instance, on a Saturday night at midnight. Does that work happen as well? The PAC system allows the images to be shared on the back of the national shared services work to improve that radiology activity. We need to have a common radiology information system to allow those reports to be transferred back. That is part of a national programme, and we are involved in that. In relation to recruitment, when there is a vacancy in Ersin Arn, what happens? How does that get advertised or how is someone recruited? If it is a medical vacancy, for all vacancies, the department needs to consider if it is a straight replacement. There is a natural review of the job. If it is a straight replacement, we would go to advertise for those posts. Where is it advertised about? We will advertise on the show website for all appointments, the Scottish Health and the Web. Do you do anything more inventive than that? Anything more creative? I think that the area where members of the committee have touched on where we need to be more creative is around medical workforce. For other skills, we continue to be able to recruit to nursing posts, to allied health professional posts and others reasonably well. The area that is most challenging for us is medical workforce, and that is where we are trying to look in different ways and learn from others to see if we can embrace some of their work. What kind of good examples could you give us then? Maybe just an example around nursing is that we work very closely with the University of West of Scotland to do nurse training, so a high proportion of the people who are going through the University of West of Scotland nurse training end up working for us, and that is a good link in a feeder system for nursing. In terms of medical, we have tried a number of things, one of which would be using an agency rather than bringing in a doctor on a short-term basis to ask them to go and see if they can recruit for a shortage area. That has had limited impact, but those are a couple of examples. Just from the papers that we see, there are big weights and things like for musculoskeletal complaints. Are you doing anything creative or inventive to get professionals in that discipline? Anything different? I will pick that one up for a start, trying to give John a bit of a rest here. We recognised that at the board several months ago. I forget which board meeting was discussed at, but we picked that up. The whole musculoskeletal unit has been redesigned over that period of time and performance is improving significantly. I think that the latest figures that John will give you do not have them to hand. Yes, there was a recognition through the Healthcare Governance Committee, and the MSK unit recognised that they were underperforming. There has been a full redesign and significantly better outcomes. Part of what you refer to is that financial constraints have been at the core of that, and the waiting times are increasing because of financial constraints. Does that mean that you are not able to recruit staff? At 1 NHS board, we noted that there was improvement in relation to the MSK service. I can report that we would expect to meet a 90 per cent treatment within four weeks, probably by March this year. That is the trajectory that we have. I think that what we did note was that in order to achieve some targets in relation to savings and efficiencies, there were potential risks in due course. However, in the interim, what we have agreed is not to seek to apply the same level of efficiency to the MSK service. Having undertaken the redesign, we have seen significant improvement in that. I think that next week at the board we will see that we are now at a 50 per cent achievement of the four-week target. I think that the issue was one of future risk rather than the actuality. Were vacancies not filled because of financial constraints, that is what is referred to here? There have been occasions in which we have sought to reduce spend by not filling all vacancies. However, we agreed that, at the end of the day, that was counterproductive. Thank you, convener. We are aware of the fact that you have had a consistently high rate of emergency admissions. During the past five years, you have had the highest rate of emergency admissions of all 14 territorial health boards. I appreciate that you have an older than average population, high levels of smoking, obesity, drug and alcohol use, low physical activity and low levels of wellbeing. You have a lot of challenges, which may lead to that initial admission. I understand that, but you also have particularly high levels of multiple admissions, where people are returning three or more times. I wonder if you could let us know why that might be the case. As you have described, we have a range of challenges around the health needs of our population. One of the areas that we need to do more work on is around multiple re-admissions. We have high levels of chronic conditions in Ayrshire, and there is no doubt that, when we look at the data, that causes and is a driver for those multiple admissions. Working with the partnerships, Tim might want to say a bit more about technology-enabled care. There is strong evidence that, if we can use some of the digital technology, we can support individuals to have more ownership of their health using home health monitoring as an example. I think that there is quite a bit of opportunity for us in Ayrshire to work more closely with those with chronic conditions and to see how we can support them to manage their healthcare differently that would avoid multiple hospital admissions. Obviously, having support at home is absolutely key to prevent admission in the first place to ensure a swift recovery when patients return home. Do you think that there is any link between the multiple admissions and the fact that NHS Ayrshire and Arran have, amongst the shortest stay of any of the health boards in Scotland, where patients seem to be in hospital? Are they leaving too quickly? There is no evidence that they are leaving too quickly. We have looked to re-admissions quite carefully and, often individuals—well, there is an element, as I have described, around chronic condition and exacerbation of their condition. The multimorbidity or the nature of that often causes people to be admitted for a different reason. We are looking and continue to look closely at re-admissions because we recognise that re-admissions as an indicator, as a measure of how we manage care through our hospital system. However, there is nothing coming forward that would suggest that people are being discharged too early. You will be expecting increased admissions over this winter period. What measures have you got in place to deal with that expected increase? One of the partnerships has a range of measures, and Tim will touch on those in a moment. In the hospital service, particularly around University Hospital Crosshouse, we have done a lot of change in our combined assessment unit, which is a key part, and provide—I say turnaround—there is never a good way to describe this. In managing the care of individuals, they are able to return people back home and avoid admissions, with quite high levels of success in doing that. We are going to introduce, with referring back to the older people's physician that we have just recruited, an extension to that assessment unit process, with 12 extra assessment beds specifically for older people to give the new consultant and those practitioners that we have described the space to provide that rapid assessment and to seek to avoid unnecessary admission to hospital. We think that that is an important aspect. However, maybe Tim would like to talk about some of the work that the partnerships are doing. Maybe at two or three levels, just in terms of responding perhaps to the earlier query about supporting people at home and the whole issue around about self-management. At the end of the day, the issues around about winter and delayed discharges and so on—what we need to do, it seems to me, is to work with local communities, with individuals, to assist them with self-care. John May mentioned, for example, of the work that we are doing in relation to home and mobile health monitoring, the use of technology to enable people to self-care, anticipatory care activity with GP practice, where what we are seeking to do is to use a variety of indicators to enable the multidisciplinary team meeting within the GP practice. That includes social work and other staff to identify people early who may need support. Clearly, there are circumstances and we haven't cracked the issue of people turning up at hospital more frequently clearly than in other localities. What we obviously need to do is to seek to manage that demand as effectively as possible. Clearly, from our perspective in South Asia, I imagine that, in relation to my colleagues in North Asia, we have concerns about delayed discharge, because that impacts on the system's ability to manage that demand. For us, a significant strand of our winter planning is trying to identify some additional capacity for home care, which is where we are struggling most in a South Asia context. Perhaps in relation to the earlier questioning in relation to recruitment and retention, we held a job fair recently seeking to attract as many people as we could to a job fair to come and work as home carers within South Asia. That took place two or three weeks ago. We have been able to speed up appropriately the process of recruitment. A number of people are already in induction over this weekend and next week. We have also sought additional capacity from our private providers. We have put out a further tender contract to them. I am hopeful that a provider will start to provide additional capacity in January. Over and above that, we have a range of initiatives and activity that are designed to support people to return home as quickly as possible. We have capacity issues both in terms of home care and care homes. Our care homes are running across largely private sector and are running at almost 100 per cent capacity at the moment. Our objective is to maintain people within their homes. However, there is a range of activity. One area that I did not mention is the intermediate care team. I think that most partnerships will have a multidisciplinary team working—alied health professionals and social work—working within the hospital to support, discharge and minimise admissions. We have a range of activities for the winter. I think that there is a complement to that. Tim is talking about South Ayrshire and rightly. North Ayrshire is also in the process and has recruited additional resource. I think that they have taken 21 or 21 additional people in for home care. That will help to address the problems in the north as well. Thank you. Moving to delayed discharge, we know from meeting with the Royal College of Emergency Physicians for example that delayed discharge is often the principal cause of delays in A and E. In fact, it represents an interruption and flow throughout the healthcare journey. What are the barriers in social care in your territorial area that cause problems in getting people out of hospital? What are you doing to mitigate them? The two main issues for us at the moment are capacity downstream in terms of care homes. We are, I think, as of yesterday, year on year. We have seen an increase in the numbers of placements that we are funding in care homes. We obviously have a good relationship with a ranger provider or all of the providers in South Ayrshire. We work hand in glove with them to manage as best we can the capacity and demand, but largely the places are full. It had been certainly our strategic ambition to try and manage down the number of people that ended up in care homes. There are circumstances in which we believe that if we were able to intervene more quickly, we could prevent deterioration. I think that there is good evidence to suggest that if older people are in hospital any longer than 72 hours or so, their risk of ending in a care home is higher. To some extent, our ability to achieve that ambition to speed people's discharge has been as a consequence of our inability to provide home care to them. As I said earlier in response to the earlier question, we are seeking to increase our capacity within home care and to manage that capacity more effectively. We have introduced a reablement service. Most other questions were about learning from one partnership to another. I think that there is good learning across Scotland. Reablement is a way of supporting people early in their time within home care with a view to helping them rather than simply, for instance, being helped to bathe or toilet or whatever to support them to do that for themselves and therefore need less service moving on. We recently introduced that service and we still need to see the full effects of that. Two things are going on. One is trying to use our home care capacity more effectively but also adding to the total home care capacity. For us, in terms of our thinking strategically moving forward, in terms of commissioning plans, I think that we need to understand better the data in relation to the local population, particularly in South Asia. I think that the demographic characteristics are quite unusual, I think that we are beginning to establish. There is relatively high deprivation but a relatively high number of older people as well and a much smaller group of people of working age. The dependency ratio is very high in South Asia. As we begin to reflect on what to do with the entire system, delayed discharges are simply a symptom of the system not working in the way that we want. What we would want to do, I think, as we look at commissioning moving forward, is to understand what the future demands are like to be and manage our service in that way. I fully understand that your situation is replicated across all the 14 health boards, particularly residential care capacity. In terms of home care, I am always struck by the tension that still exists, even despite integration, between the willingness of a health board to spend £400 or £500 a night to keep somebody in hospital but then social care directorate not willing to spend £150 a day or night for care at home. Is that attention that you are familiar with? Is that a reality? Secondly, is there a capacity issue in terms of recruitment and retention of social care workers being able to provide that care on the ground? If I deal with the second issue first and then move on to the first issue, in terms of recruitment, it is an issue. I think that we were pleasantly surprised, though, at the recent job fair that we held that so many people came forward to work in effect at our in-house council managed service. The risk, of course, is that we attract people from the private sector. We do know that a number of the applicants are coming from the private sector, so all they are doing is moving the capacity from potentially one place to another. However, that is not only the case. I think that moving forward, and we will not be unusual as a partnership, perhaps some of our thinking needs to change. I think that there is much more that we will need to do as a community and families to support people. I think that using the assets of communities in the widest sense is at the forefront of what health and social care partnerships will want to do. However, some of the traditional models are simply not going to have the bodies to do the work. I do accept that, and we will, obviously, as with other partnerships, continue to monitor that. The point in relation to the resourcing of beds and, as opposed to care homes or care at home, I think is understood. I think that we have made progress. For instance, in South Asia, we have recognised, for example—we have one of the community hospitals in South Asia—where we underdid some quite significant demand and capacity work and looked at the role and function of the community hospital and determined that its best function, given that NHS continuing care really now does not exist, was palliative and rehabilitative capacity. As a consequence, what we have done is to close a ward there and use the resources from that for care at home and care home provision. I think that it is more difficult when we are talking about acute hospital care. John and Derek may wish to come in on that. I do not think that it is easy to simply take the resource out and move it to social care, but where possible, those changes can be made. Anyone else when John Doe wants to come in? I think that Tim makes a point about it and well around the work done in the community. I think that it is more difficult when you get to acute care and when we look at Ayrshire as has been commented on, the levels of need are high. I think that what we are striving to do with our partnerships is to manage that need, to bring the demand down. I think that as this evolves and strategic plans develop, if we start to see in the future that there is a substantive shift from hospitals into community provision, we can start to address that issue. Just now, the risk and the demands are so great in managing acute care that we are not in a position where we are having that discussion about shift from acute hospital to partnership. Ryan, do you want to come in on that issue? The whole financial premise of integration is about moving that money from acute into the community. Are you saying that that is not realistic? Is it not happening? It will not happen? Or will it not happen without transitional cash? I think that I am saying two things. Firstly, we need to stabilise the acute system and transform how we work and how we deliver care. When we look at the population need, what we are trying to do is identify with our partnerships and work together across the entire Ayrshire system to understand what changes could be made. We have touched on some of them around technology and the use of digital to help to support individuals in their home. At this point, given the demands, I do not see the opportunity to shift money from acute hospital provision into community. However, as we go forward, one of the challenges that we have is to make sure that strategic planning that partnerships are responsible for takes a very close view of demand. If, over time, we can see that shift, we would respond accordingly. However, I do not see that as an immediate issue. Anything that we do needs to be risk-assessed, because to destabilise the acute system would put too much risk into patient care. The second point that you make, convener, is about transformational funds. We have the integrated care fund, which provides some of that transformational opportunity, but Ayrshire is developing a transformational plan. We need to see some transformational funds to make that step change into the community, because we need robust and resilient community services before we can consider those shifts. Can I add a rider to that? The chief executive has made that point clear, but I would like to emphasise that the chairs group that we meet has made a very similar point on transformational change. Transformational change will only happen effectively when there is sufficient resource put in place to support that. I am going to focus a wee bit on complaints and complaints procedures. Last week, Tracy Gillis, who is NHS Lothian's chief medical officer, talked about patient experience. Poor experience is what leads to complaints. I know that we have implemented changes around the complaints procedure so that feedback is more of a focus, because there are complaints, concerns, comments and even compliments now and again. I am looking at the complaints document that the NHS Ayrshire and Arun experienced annual report. It talks about things that you have put in place, such as what matters to you and the compassionate connections programme, and obtaining feedback in different ways. I would be interested to hear your thoughts about why there is a 20-day working day response that is not being met. I am just reading that some of it is because the complainants are requested in face-to-face meetings and that can be a challenge for diaries and bookings, so that might be one reason why the 20-day resolution is not being met. Ayrshire has, before the new model complaints procedure was brought into to being, been reviewing its complaints processes. We wanted to be more responsive to patients whom we introduced as a fundamental premise. Wherever someone complains, we should seek to afford them the opportunity of a meeting, if that is what they wish. The evidence that we had showed clearly that if we enabled a face-to-face discussion with the individual and staff, there was a greater chance of resolution for the individual and learning for the team. That leads to two things in terms of the 20-day target. First, I think that I would agree with you. It is important that we do this at a time that is appropriate for the complainant or their family and that we do not rush it just to meet a deadline. There can be challenges around trying to bring staff and given clinical commitments, but we commit to that and we look to do that as quickly as possible. It can contribute to delay, but I think and believe that as long as it is done in conjunction with the patient and their family or where that is appropriate and that they are happy with that, that is the right thing to do to have that face-to-face conversation. The second reason that we should always strive to meet and keep the communication with the complainant is that often complaints that are written can be quite complex and therefore it can take a bit longer to give a full and comprehensive response to a family or an individual. Again, we would always seek to do that within the target and if we can't, to then keep the complainant informed so that they are aware of what is going on and when they can expect a response. The top five complaint themes are communication, attitude, behaviour, clinical treatment and appointment date. Obviously, there is a range of feedback or complaints right from the wrong-site surgery type thing, which is really rare, but looking at the communication and attitude, can you tell us a wee bit more about some of the aspects around the complaints that make it really difficult to meet the deadlines for the complaint response? I think that the themes that you have referred to around communication are ones that we would seek to address within the 20 days. The ones that I think take a bit longer is where an individual is concerned about the clinical care that they have had and there may be a range of issues within that where we need to speak to a range of professionals to be able to bring together a comprehensive response for that individual. I am very clear that, where we can respond in 20 days, we are absolutely committed to doing that. As I said, things like communication are areas where we should be able to do that. OK, Miles. Thank you, convener, and good morning to the panel. One of the areas that you highlighted is information that you gave to the committee was the higher-than-average levels of smoking in Ayrshire and Arran. I think that you specifically said that 22.7 per cent smoked compared to 20.2. I wanted to know what work the board was doing to increase uptake of smoking cessation. Again, this is an area led on by our public health team. Through the smoking cessation programme, and indeed working in health improvement, Tim might have something to add to this, but through local activity to support individuals who want to stop smoking, the smoking cessation programme is the key focus. I do not have detail with me on the specifics around the smoking cessation programme and, again, I would be happy to provide the committee with that detail. That would be helpful. I will look into that and provide information afterwards. The big one thing to mention is things like nicotine replacement therapy patches and so forth, and using those and making them available to patients and patients as well. If you could provide us with that detail, it would be helpful. The Government is continuously telling us that the health boards are working towards making a parity between mental health and physical health. Looking through the information that you provided us, I found two paragraphs totaling 119 words outlining many of the problems. I wonder if you could outline to us how big an issue is mental health for you in your board and what work are you doing to deliver that parity between service? In terms of mental health and wellbeing, clearly that is a very significant focus of the work that we are undertaking within localities within each of the three partnerships in Ayrshire and Arran. Again, in terms of the specifics, I suppose that they have gone out of my head at the moment. I looked up your heat target, which suggests that 76 per cent of people in June were only seen within the 18-week target. What works going on to try to improve that? I think that there are two issues that are foremost in my mind here. One is mental health wellbeing. Obviously, there is a mental health service for people with severe and enduring mental health problems. That, I have to say, is largely led by my colleagues from North Ayrshire. I am not absolutely clear in terms of the achievement of target at this particular stage. We could provide you with some more information after the session. The two targets around child adolescent mental health and psychological therapies. I can advise the committee that in terms of child adolescent mental health, they have been performing above target in terms of the 18-week measure and they have been improving. I have to say that that is very much a good example of where integration has seen child and adolescent mental health services work with other agencies, other partners, and redesigning work differently to contribute to that improvement. We see strength across Ayrshire in that area. Psychological therapies. We have been conducting a review of our psychological services. We were concerned at the performance, not just the performance, but we felt that we needed to review and change that service. That work is under way. The latest figures that I have for psychological therapies, which covers a wide range of interventions, is a performance of 87 per cent. We are seeing a marked improvement in that area. It is still not at target and therefore there is still work to do. In terms of the wider mental health, Tim is right that mental health and wellbeing is a priority issue in Ayrshire. We know that it is one of those areas that is raised consistently by citizens in terms of an area of concern. There is work going on in the partnerships. Importantly, we have a pan-Ayrshire approach to mental health services. We opened a new inpatient facility recently, which has transformed the inpatient experience for those who require an inpatient stay, but we have also been continuing to develop community services. Primary care mental health is a particular area of focus and a continued priority for us. In terms of the things that went out of my head before, one of the significant areas of focus for us is clearly within the localities where isolation and loneliness have been raised as concerns. Clearly, what we will be looking to do is to work with local people to identify opportunities for people to come together and have social interaction. At a slightly more clinical level, each of the partnerships within Ayrshire and Arran with funding from the Integrated Care Fund and the Scottish Government have put in place community link workers that will be called different things in other places, who support GP practice with the needs of people who have relatively low-level mental health needs and so on. Perhaps the other area that I would mention from an Ayrshire and Arran perspective is that we have recently been rolling out the use of electronic CBT therapy. For people with relatively low-level mental health issues, encouraging GPs to prescribe, if you like, or to refer on for that type of online assistance and so on, rather than necessarily clinical therapy, medical, sorry, pharmaceutical therapies, drugs in the first instance, and I think there's some really good evidence from across Scotland that that's likely to improve people's well-being overall. Just have a very small supplementary. In terms of every GP in your health board area, are they trained and have access to the ALIS system? In that case, if that would be where the referral was being made. To the which system? The ALIS network. Yes, so the ALIS system is a, I assume that you're referring to the directory of services and so on. Actually, each of the partnerships in Ayrshire and Arran have, I think, certainly sent you to the case for us and I think for East and North. We've been working with each of our voluntary sector, third sector interface organisations to develop, I think, more bespoke or more local access directories and so on that fulfil the same function as ALIS. Whether or not GPs have direct access to it, I'm not, in all honesty, clear, but certainly the community link workers are the people who are probably best placed to put people in touch with local services at that sort of more informal and non-statutory level. Okay, thank you. Brian. I should have declared at the start that I have an interest in a close family member who works within Ayrshire and Arran, so apologies for not doing that at the start. I'd like to touch on the reporting of significant adverse events. Forgive me if I've got the years slightly out of kilty here, but I think between 2010 and 2013 there was 54 reported and that's running roughly at 18 a year. For the next three years it went to 0, 3 and 4 and that's a significant change and I wonder who monitors the significant adverse event numbers, an important investigation with those changes in a shade. The adverse event review in Ayrshire perhaps just give a little bit context in terms of answering the question, if I may. Since 2012 we have had a continuous improvement process around significant adverse events in Ayrshire. On the back of our review by Healthcare Improvement Scotland in 2012. That's the basis in which we have continued to look to review and learn from our process. In terms of taking the point around who monitors, we have different levels in the organisation where adverse event reviews are regularly reviewed and monitored. The first is at the directorate level at the adverse event review group, where directors and members of the directorate team have a responsibility for reviewing the progress and delivery and improvement around adverse event reviews. That is then reported through our risk management committee, which is chaired by myself, so that we look at the number of adverse event reviews. We are looking at the learning that comes from adverse event reviews. That is reported to the healthcare governance committee. Each significant adverse event review is reported to the healthcare governance committee. The action plan is reported and the committee holds myself and fellow directors to account for the delivery of that improvement and to demonstrate learning. One of the things that we have been developing is the use of learning notes as a way of sharing more widely the learning from adverse events. Thank you. For such a significant drop in the report or the instigation of adverse events, there are only two things in my mind that can happen. That is either you have implemented a change that has hugely improved outcomes, which would be fantastic, or you have changed what constitutes an adverse event. We, as part of our review back in 2012-13, looked closely at the national definitions of what categorised a significant adverse event review, as opposed to an adverse event review or an adverse event. We brought in clarity to Ayrshire on those definitions, and that had an impact on the total numbers of significant adverse event reviews that were initiated. It also meant that there was an increase in other reviews that were as part of the wider definition. Everything is recorded through our data system. We are able to look at how all adverse events, however scored and rated, are reviewed and addressed. Significant adverse event reviews in our process or where one was requested would be submitted to the medical or nurse director for a final decision on whether that should be a significant adverse event review. Since 2012, we have kept that under review and we continue to keep that definition under review, but we believe that we are working in line with the definitions that exist for significant and other reviews. Do you accept that there is a huge disparity between health boards in terms of the numbers of adverse events, the significant adverse events that are reported? Does that suggest that there is an autonomy within health boards to define what a significant adverse event review is? As I said, there is a definition, but we would then look to score. We would use a scoring method to determine whether that adverse event is merited. I cannot speak for the other territorial boards. I assume that they will have similar systems and processes to the ones that we have in our show. If I could just do a related one to that. I know that there was a health improvement Scotland review of the neonatal unit in Crosshouse, and one of the outcomes of that was looking at a sort of a reading of the CTG monitors was a major contributor to preventable baby deaths. Now at the back of that, there seemed to be an indication that mandatory CTG training across the neonatal unit would be implemented twice a year. I just wanted to confirm if that is the case. The review into the Ayrshire maternity unit concluded, and certainly CTG training was an aspect of that. Our response to that has been to a full training needs analysis across our maternity services of which CTG training is part of that training needs analysis, and to introduce and make sure that we comply with the recommendations that were brought through in that report, including CTG training. So is it mandatory now that CTG training is taken apart by all neonatal unit workers? CTG training was carried out in Ayrshire, but what this was, if I recall the recommendation, and I am happy to provide the detail, was how teams come together, the clinical teams come together and train together. So we were doing CTG training, but this was to, I think, develop that further. I am happy, I just can't recall the detail to mind, but I am very happy to provide that detail for you because I know we have it. I can help you this year. Although CTG training was available, the report suggested that that was not taken up because it was supposed to be done within the private time of healthcare professionals, and the recommendation was that CTG training would then be available during working time, and that it would be mandatory to all neonatal workers twice a year. That is the information that I have been given by the Cabinet Secretary, I think, to have to check that up. I just wanted to clarify if that is actually the case. We are implementing the recommendations, and CTG training is part of that, making sure that all our maternity staff undertake appropriate CTG training. That will be part of our training needs assessment. We have a suite of mandatory training, and each discipline has its own mandatory training. We are very clear that CTG training in Ayrshire needs to be addressed and delivered and provided for all of our maternity staff. I will clarify the position— If the position is as Mr Whittle suggests it is, or whether there is a difference from that. I just can't recall it, but I will clarify it. There are a number of things that we need to follow in our exchanges today, so we will include that in the list. In relation to finance, the board has a requirement to deliver cash efficiencies, as you would describe them cuts, as I would describe them, of £20 million. Will you achieve that? The target for cash releasing efficiency savings in the current year is £25 million, and there are challenges around that. We have already secured about £18 million or £19 million. The remaining balance of that is not yet secured. For example, we talked earlier about the musculoskeletal service and the number of the numbers. The cash releasing efficiency savings planned around that area have been deferred because of the potential impact on services, so in some areas there are replanning around some of the areas of cash releasing efficiency savings. Audit Scotland has identified quite significant unspecified savings. Is that a sensible way to proceed where you just stick a number in and say, well, we hope to get it somehow? Ideally, we would identify the savings in advance of the start of the new year, and there is on-going work in a number of areas. For example, around prescribing, working on-going this year will identify next year's savings and within individual directorates and teams as they go through a year. It was mentioned earlier where a vacancy arises and assessment is carried out to say, is it necessary to fill that? If it is not necessary to fill it, then that can contribute towards next year's efficiency savings. Ideally, you would want them all identified before the start of the financial year. The reality is that we have not been in that position. Indeed, in some occasions there has been non-recurring savings identified, but then they need to be found on a recurring basis in future years, so that is a challenge. In the report, it says that the revenue plan approved by the board was for £13.2 million deficit. It is now projected to be over £20 million. You might be commenting on that. The £13.2 million deficit was projected in our local delivery plan for 2016-17. In 2016-17, there were significant recurring cost pressures related to a change in national insurance contributions, which cost about £7 million extra for us. There was about a 10 per cent increase in prescribing costs and we also invested in a number of areas that have been touched on. For example, radiology, we invested in extra £1.5 million to increase the capacity based on demand and capacity analysis and we also identified £3 million extra for nursing, of which £800,000 went into mental health services, £1 million into maternity services and the rest into acute services. We had a very big challenge in 2016-17 and projected that we would have a £13.2 million deficit in that year. Through non-recurring means, we were able to get back to a break-even position in 2016-17. However, in 2017-18, the investments that I mentioned earlier are having their full cost. Although, at the beginning of the year, we projected a deficit of £13.2 million, things have moved in the wrong direction this year. One of the major aspects of that is the additional unscheduled care beds that we have had to open in both of our acute hospitals because of the demand. That will increase our overspend by an excess of £6 million there. What we are projecting is a deficit in the current financial year. Your target was £7.5 million. According to the performance standards, the target was a £7.5 million deficit. It is now going to be what? No, our target was £13.2 million, but it may be the phasing of that in terms of where we would be at a particular point in the year. Perhaps at the date that you are looking at, that may have been at the end of September of October that we projected to be overspend by £7.5 million. We expect that the final outcome to be around £20 million of a deficit this year. What happens then? We are in discussion with the Scottish Government regarding brokerage. That is a mechanism whereby the Scottish Government would effectively loan us money to cover that £20 million. We are continuing with our efforts to address the deficit, so we are minimising expenditure where we can but without impacting front-line services. We have a transformation programme, which is identifying areas where we could further cash-releasing efficiency savings. There is on-going work around all that, striving to minimise the level of deficit and working with some of our nationally, in things such as sustainability and value, which is a national area that is looking at workforce, looking at prescribing, looking at shared services, etc. The assurance to you as a committee from the board that the board looks at this in depth in a number of ways. We have board workshops, we have various other mechanisms, we have one of our non-executives at the vice chair on the transformation group, and so we have a number of ways where we are monitoring this together with the chief executive and his executive team. On behalf of the board, I can give the assurance that we are working hard to try to make sure that we continue to deliver the safe service that we want to deliver within the resources that we have. Is it a failure of financial planning? Or do you simply just not have enough money to run the service? I think that the director of finance has indicated the areas of financial pressure for us. If you want just to reiterate those again. What I am asking you is, do you have enough money to run the service straightforward, severe yes or no? I will let the chief executive answer that. He is the accountable officer for the organisation. I do not think that it is as simple as a straight yes or no. What we are clear on is that there are pressures, and Derek has alluded to unscheduled care that we need to change. I think that what this is about is recognising that we are at a position where we need to address some of the underlying pressures around medical workforce, around unscheduled care. We also understand that, with the demands on our system, we need to redesign and deliver that differently in a way that delivers better value for the money that we have across the whole system. We need to continue to look at areas of best value. It is more difficult than it has ever been, but that is not to say that we should not be still trying to drive through efficiencies and change where we can. I do not think that it is, for me a yes or no, it is very much about what we as a board are trying to do to deliver improvement and change whilst at the same time trying to continue to deliver a service. I have a very brief question. Just to put it all in context, can you tell me how much your budget was in 2016-17 and how much it is in 2017-18? Our cash-limited budget is about £680 million, and that would have increased by about £10 million in 2017-18. Most of that increase is earmarked for social care services, so that is passed across to invest in social care. Do you say that, in cash terms, there was no increase? About £10 million of an increase. I just want to ask you about any work that you are undertaking around the preventative agenda, because we know that this is a very important area, particularly considering the deprivation profile of Ayrshire. We know that, if we get it right and spend the money preventatively, that could not result in effective savings into the medium term. In your paper, you said that you are intending to implement a range of high-impact, targeted interventions. I wonder if you can explain to us what areas you have identified and what programmes you are planning on undertaking. I suppose that, earlier on, I referenced the fact that, for example, where people have long-term conditions, there are ways of managing those in a more effective fashion than we do at the moment. We are looking, for example, at self-management, the use of technology and so on in order to prevent them requiring the use of hospital services. But, even before that, there is a wide range of activity that our colleagues within public health and health improvement are supporting each of the three partnerships with. I suppose that, for our purposes in South Ayrshire, it is probably this case in eastern north as well. The community planning partnership has a significant role, it seems to me, in looking at prevention. In the South Ayrshire context, I chair strategic health and wellbeing group as recently as last week, we heard proposals that have been jointly developed by the partnership and our colleagues within the leisure services within the council to develop a healthy activity programme across partners. We expect them to come back with proposals within the next two or three months in terms of how each of the contributors to community planning might make a contribution to active citizenship and so on. It seems to me a number of levels at which we are trying to undertake prevention, trying where possible to prevent demand, manage demand in a more effective way, reduce circumstances in which the state needs to intervene. I mentioned before the work of the community-linked workers within GP practice, for instance, seeking to get people involved in more informal activities. One specific example that I might mention is the dementia-friendly towns in Prestwick and in Trun, where local people, the local locality planning group and other businesses are seeking to support people with dementia, include them, increase and improve their resilience and that of their carers. Those seem to me to be the sorts of activities that we are going to need to major on over the coming period to reduce demand down and manage it more effectively. I will say that, in terms of preventing avoidable illnesses, can you tell me which illnesses you have identified and what specific interventions regarding them and your planning? I might just make an additional point. The point about community planning is incredibly important. Across Ayrshire, I sit on all three community planning partnerships. There is a very strong prevention agenda looking across a whole range of inequality and change. That is important. The area that we have been talking about in Ayrshire with our public health team of latest diabetes needs to have a very key focus around gestational diabetes and trying to work with and improve the type 2 diabetes. That is an area that, within our work, we are looking to bring forward because we believe that there are significant benefits in the short and longer term if we can work to address some of the challenges that we have around diabetes. The other area that my public health colleagues are working on again, we have some good examples of where we have been greening our estate as physical activity and supporting and encouraging physical activity. We believe that that is one of the key companies. Through community planning, that is a strong feature of our approach. We are well over time. I say thank you very much for coming along this morning. It is greatly appreciated. There are a number of things that we will follow up with you and will correspond with you and some information that you will provide to us as well. I thank you this morning and will briefly change the panel. The third item on our agenda is an evidence session on the final report of the expert review group on targets and indicators. I welcome to the committee Professor Sir Harry Burns. I invite you to make an opening statement. When I was asked to do this, I think that there is an expectation that what I would be saying is that certain targets and indicators should be dropped and others should be brought on board and things like that. As I began to tease the whole issue out, not just targets and indicators for waiting times and so on but across the whole landscape of health and social care and the indicators that are already out there, it became pretty clear to me that just dropping some and pulling in others was not going to change anything. I mean, I think it was Einstein that defined insanity as carrying on and doing the same thing and expecting different results. It seemed to me that the problem with targets and indicators was not what they were but how they were being used or not being used. A number of reports published outwith Scotland confirm the fact that when you apply targets, yes, you can see some change in the way the system works, but very often it produces problems. Problems in terms of all the attention is focused on the target but the target is just one slice of activity in a complex system. The length of time people wait in any department is largely determined by the number of people coming in and the number of people going out and yet we don't seem to pay too much attention to that. The focus is, did you make the 95% or not? My recommendation therefore was let's keep the existing suite of targets more or less with one or two alterations, but let's use them for improvement, not simply for judgment. Use them for continuous improvement in pursuit of an aim. That was the other thing that I wasn't clear about. What's the aim? What's the purpose of health and social care? The only thing that was out there was the stated purpose of the Scottish Government, which is to ensure that all of Scotland flourishes through things like inclusive economic growth and so on. If we are wanting a more flourishing, economically prosperous, successful Scotland with low crime, high educational attainment and so on, let's step back and think about what is needed to achieve that and let's put targets and indicators in. Let's put indicators primarily in that would show progress towards that. The one thing that I would want to say however that I have recommended that I think is extremely important in pursuing that aim is to collect data on adverse childhood experiences. The evidence coming from a number of international studies of long duration and large numbers is very much that if you want a population that is educationally successful, that's successful in the jobs market, that has low offending rates and so on, you need to pay close attention to the lives of children living in adverse circumstances and I can go into more detail on the data on that but that is a problem advocating collection of data and adverse childhood experiences because we've got no system to do that at the moment and therefore I would hope to be able to work with officials to design a system for collecting data and for developing responses to situations where children are living in adverse circumstances. Those were the main points that I wanted to make. This is about collecting data on processes and outcomes, not just slices of data that tell you where in a process someone is achieving 95 per cent compliance or 85 per cent compliance or whatever. Okay, thanks very much. There's a number of people who want to focus on the early years issues that you guys, and that's very appropriate. Initially, I think that for a number of people who have followed some of the work that you've been involved in throughout your career, we were looking at this with great interest but I kind of feel a sense of being underwhelmed by it that it took quite a long time and we kind of wonder what it's really saying and I think you expressed that at the start where you said that people had expectations of what the report was going to be but it's kind of turned out something different. I'm wrong to feel a bit disappointed. I'm quite excited because actually there are very few systems in the world that are looking at health and social care as a complex system. It's an opportunity to take things further forward and if folk were saying that we're thinking that I should advocate dropping the four-hour A&E department then they're very much mistaken that that is going to change anything of any significance. Apart from anything else, the four-hour A&E target is one that has at least some evidence behind it. If I give you an example using that target, let's say there are two hospitals, one achieves 95% compliance, one achieves 85% compliance and everyone looks at the 85% compliant hospital and says, oh, they must be bad. Actually, if you then look at the system, if the 95% compliant hospital A sees 1,000 patients a week in its A&E department and hospital B achieving 85% compliance sees 3,000 patients a week at its department with only 50% more staff, which one's more efficient? And if you look at the next bit of the system and see how many people are admitted, if hospital B with the 3,000 patients is admitting more patients and they're staying longer, then it tells you that hospital B is seeing sicker patients probably. But at the moment, we don't collect that data that tells us how hospitals are functioning. It just look at that 85% compliant and the newspapers go crazy about it. So, this is an opportunity to do something that's rational for a change, rather than just picking numbers out of thin air. And I can tell you that numbers are picked out of thin air because 20 years ago, almost when I was lead clinician for cancer in Scotland, someone came up to me and said, we want a target for cancer care. Does three months sound about right? And that tends to be in the past how targets were achieved. So, this is an opportunity to move beyond that. Either we have the will to do something really quite radical around improving performance in health and social care or we just want to sit back and say, you know, we're going to stick with the original targets. But you are sticking with quite a lot of the original targets you're keeping. Well, at the moment, until we have the data that shows that they are influencing outcome, very few of the targets are to do with outcome. We don't measure. Again, go back to the four hour A&E target. The main data that says four hours is the right time comes from an Australian study, quite a big study that showed that mortality declined and was at its lowest in the three and a half to four hour waiting time period. And then, as patients waited more than four hours, their subsequent mortality increased. Now, is that because they waited in the A&E department or were they in the A&E department getting investigation and resuscitation and therefore they were sicker and therefore they were more likely to die? We don't know that. So, you know, there's a kind of, if you were managing a business, you wouldn't manage it with this kind of data. Ivan, is it on the generalities that you wanted? Yeah, okay. Thanks and thanks for coming along and talking to us this morning. I think I share some of the conveners' concerns of what's in the report in terms of what you've pulled together. I suppose coming in, you mentioned business, come from my background, this stuff's kind of sick nature because this is what you do in business. The process you've outlined in paragraph 37 or started to outline makes sense. You need to know what your objectives are and your outcomes, then you need to know what your indicators, your KPIs are, then you set targets. There's a whole thing there about how you align organisations so that the right people you know who's responsible for hitting those targets, but that's probably at a scope. There should be a hierarchy of those indicators, so which are the important ones, which are secondary, which are feeding into those, and then it drives improvement plans, which is the whole point, and we obviously had a session earlier this morning with Eishan Ardern about how they were doing that. That kind of structure all makes sense, and I think to my mind that that's kind of well understood. I think what you're saying is it isn't well understood in the health service and further work needs to be done to kind of drive that understanding before we even go forward with actually reviewing the indicators, which is kind of what I think we all thought we would get to next. Just to take your point of—I think it comes out now—what you measure and you talked about A and E, so yeah, you're absolutely right. If you measure a waiting time, that might not be the right thing to measure, but there are things that should be perhaps measured, flow through demand, et cetera, et cetera, and maybe the issue is not that they were not measuring something, they were measuring their own thing. No, if I thought we were measuring their own thing, I would have said so. I mean it's important to measure that for our waiting time, because that's where the evidence that we've got points, but we need much more evidence about— All things as well, please. Yeah, we need to know what the process is in each hospital. I think what I would say is if you—most businesses are far less complicated than society, because that in effect is what we're looking at here. What is it that drives people into A and E departments? I discovered recently there is one A and E department that has about 12 people who, between them over the last five years, have accounted for 2,000 attendances at the A and E department. That's telling you something about the way those individuals are—the circumstances in which they're living. The answer is not about doing something to the A and E department. The answer is about all the other things that can support those individuals. Therefore, what we're looking at is an immensely complex system, and we're trying to bite off small chunks at it. We're not doing the population any service in just narrowing it down that way. It's complex in one sense, but business problems are complex as well. I suppose that the concern that I would have is that you're saying that it's too big and scary that we can't do anything—not do anything at all. I suppose that the question is if that's not what you're saying, then what happens next? Who should do what next? That's a good question, and that's a matter for the folk up the hill. What was your recommendation? What would they do next? What we have seen using an improvement-based approach in terms of patient safety and in terms of early years over the past few years, is significant reductions in infection rates, significant reductions in hospital mortality, significant improvements in stillbirth rate, and infant mortality in Scotland, by applying a co-production approach in what the front-line staff work to see what changes indicators that they themselves think are important. The line I've used in this is that the data should be used for improvement, not for judgment. We should create—instead of creating a blame culture that says, okay, you guys are obviously useless because you're only achieving 85%, we should be creating a culture in health and social care partnership areas that says, okay, what are the drivers of demand? What's stopping people from being sent home so that beds are available and all this kind of thing? I don't have much sense that that's being done systematically because all the focus is on these hard targets that folk know they're going to get a thick ear for missing. So do you think there's not an understanding that that culture needs to change? I think there are plenty folk who understand that that needs to happen, but the focus from the press, from politicians, is all on youth failed, therefore, you know. Politicians don't understand that. It's the old thing that says what's counted is what counts, and therefore, people put all their attention onto the numbers that are being counted rather than trying to think about changing the process. You think that politicians don't understand that? I don't think that politicians do from the way in which they respond to some of the data. I'll pick up on a couple of other things before we finish. You hinted, just to clarify, that a general sense is the very first part of this, obviously setting your objectives, what you're trying to achieve. Do you think that there isn't clarity there from a top level as to what it is that we want the system to achieve? I took in the report the stated purpose of the Scottish Government, which I think is pretty broad in terms of its appeal across the political spectrum. And that seems to me to be as good as you can get. There are a few other countries, I think, that have set themselves a purpose in the way Scotland has. But it's very broad and very top level. It's broad, but it's got enough in it. You know, this notion of flourishing population, one where the kids do well at school, where they get into jobs, where they're creative, where there's low levels of offending, and all of that adds up to the definition of well-being. So, I would be content to go with that as a purpose, but the statement in the report that this should be the overarching aim, which all the targets in the case that it should lead towards, is the first time I've ever seen that. At least three frameworks you mentioned. There's a national performance framework, there's a local delivery plans, and there's health and social care indicators, I think, as well. Is there a need? Do you hinted at that? Is there a need just to get that into one? We should see how it interacts. The health service targets are one sliver of a broad system that, if managed appropriately, could enhance well-being, lead to decreased demand, could lead to better outcomes in the national performance framework. So, those should all be crunched into one? They should be seen as part of one system. To be perfectly honest, national performance framework, I would mention it. I don't know what the mechanism for changing that is. Again, health will focus on health. What can be measured as what counts? National performance framework, they measure outcomes in every year or every two years. It's clear that you're advocating a greater focus on the early years, as you did in your previous role. I suppose we've had a real, well, I think the new CMO, there's a different focus there. We've been speaking a lot about care for the elderly, chronic illnesses, the realistic medicine agenda, but you're really advocating this life course approach. I'd just be interested to learn how you think that might help us address some of the challenges that we face. You note that Scotland is the lowest life expectancy out of 16 western European countries, and that that has only happened since the 60s. I'd just be interested in what that life course approach might look like and how you think it would help us address some of the unintended consequences of the targets. The evidence around adverse health experiences which comes predominantly from a very large prolonged American study carried out in Zealand, some work done in England and so on, shows that children who experience very clearly defined adverse events, and that's things like experiencing physical violence, experiencing emotional neglect, experiencing parental absence either through parental imprisonment or parental mental health problems, postnatal depression, for example, is a very significant adverse childhood experience. Four or more adverse events, when those children grow up, the evidence is they are eight times more likely to become alcoholics or other substance misuses, eight times more likely to be arrested for violence, significantly more likely never to work, significantly more likely to be a, to require healthcare and so on. The English study showed that four or more adverse events in early life, you had, if you had no adverse, none of these nine defined adverse events in early life you had a 35% chance of having a chronic illness by age 60, if you had four or more it was a 70% chance. The American study has calculated that one year's worth of child neglect in the US brings with it a lifetime cost to the American economy of $124 billion in terms of demand for support and care, failure to pay taxes because those individuals never work and so on. Now pro rata, the Scottish equivalent of that is one year's worth of child neglect in Scotland may bring with it a lifetime cost of £1.8 billion. So you get that early years right, the children do better at school, they're less likely to fail when they move into the workplace, they're less likely to go to jail, so the life course begins to move in a different direction. There was a report published a few weeks ago where they pointed out that the greatest number of deaths from drug abuse and alcohol in Scotland was that were in 40-year-olds. Well 10, 15 years ago the highest number of deaths from drug and alcohol abuse was in 20-year-olds and what we're seeing is a cohort effect. The people born in the 60s round about that era are moving through the life course and they're acquiring all sorts of problems. The way to begin to fix it is to change the life course at the beginning. Yeah you've got to do the things to the rest, you know you've got to support them, you've got to provide services for them and so on, but we better start getting it right in early years if we want to have a flourishing population. I mean if we know that that mortality relates greatly to young people or those young people are now carrying those conditions throughout life, what can we do to make sure that we address that because all the targets we've been discussing here they seem far removed from that life course approach? Well the work that I've done over the past 10 or 15 years has been to demonstrate the biological consequences of adversity in early life. It always seemed to me that if you just expressed an opinion that adversity in early life led to all sorts of problems later on, yeah folk might recognise that, but if you can show that there are biological changes that lead to problems then nobody can argue with that and we have shown that. We've shown that through studies carried out in Glasgow that involved measuring neurological function and so on and fundamentally children who experience adversity in early life, brain development leads to reduced ability to learn, reduced ability to suppress inappropriate behaviour, increased emotional ability so you've got kids at school who are you know more anxious and aggressive and fearful, less able to suppress those tendencies and less well able to learn. We've shown biologically different brain patterns in affluent and deprived Scots, what measured psychological function and so on. Can you change that in later life? Yes the evidence is emerging, this is relatively new science, but the evidence is emerging that there are certain things that can be done to reverse some of those brain changes. One of the most important and this is what you see in the third sector, the third sector is particularly successful is one of the most important is mentoring, is supporting individuals living chaotic lives. I give you an example of a jaw dropping outcome, I recently gave a lecture to English chief constables at one of their CPD days and afterwards a chief constable of a county in England came to me and he said that his force was currently doing a randomised controlled trial of criminal justice so if you were arrested in his county they went through a screening programme so that serious offenders, murderers, no question they were charged and they went through court, but medium and low risk offenders were randomly allocated to being charged and going to court or not being charged and therefore not acquiring a criminal record and having a support package of mentoring and so on. He said the two year follow-up within two years the reoffending rate of those that go to court was 65%, those that got the support package it was less than 10%. So there are all sorts of different ways of doing this but follow those folks through the life course and support them in ways that keep them involved and engaged in society and we'll begin to get that bulge of low life expectancy throughout. We I'm recently heard I think it was an informal session but I know the convener will know the person I'm talking about but we had a session with ex-prisoners and one of them had been in prison I think several times said that those in prison had changed markedly over the years and he felt they now resembled it felt more like a mental health ward and one of your suggestions is reporting the incidence and prevalence of mental health problems by the SIMD index. I just wondered why you think that would be so useful when it comes to identifying the impact of other interventions. So when you look at things like domestic violence and incidentally the American study given all the focus that's on education just now, the American study showed that the single biggest predictor of educational failure was witnessing domestic violence in the home. So adverse childhood events are not exclusively associated with low socioeconomic status but they tend to be more common in areas of low socioeconomic status and that will largely because of worries about money, worries about alcohol consumption and there's a cyclical effect I've referred to this as the cycle of alienation. When I talked to young people in prison you know an 18 year old has been in Pullman or whatever and he's about to get out so I talked to him and I said what are you going to do when you get out? I'll never get a job I've got criminal records so what are you going to do? I'll sit at home I'll watch telly and I'll drink that's literally what I've been told but what they don't factor into the equation is the girlfriend will have a baby and that baby's then born into a chaotic household that's where you begin to break that cycle intergenerational cycle. So I think it's hugely important for us to focus on that life course but that the focus begins with adverse adversity in families and focusing on them and you will see that bulge of dysfunctionality moving out of the system. Alex, then Jenny. Good morning, Professor. Your section on adverse childhood experiences with music to my ears having worked in the voluntary sector for 15 years, 8 years of that for an organisation which delivered trauma recovery for children of all ages. I was delighted to see that and delighted to see your push towards a more trauma informed approach. The NSPCC report right to recover identified that 15 out of 17 local authorities that they examined did not have any trauma recovery services for the under fives and a further 11 of those 17 had nothing for primary school aged children either. In your recommendations you suggest that we should set up a protocol for the management of such cases but that's as close as you come to calling for the widespread introduction of trauma recovery services. Why did you pull your punches? Because that wasn't what was asked to do, I would anticipate and I earnestly hope that some group is set up to consider the collection of data on adverse experiences and the management of it. So we start off by identifying the problem and then I would love to be involved in further discussions on this and I have been looking at this. One of the most interesting things in this area is the Barnahouse system in Scandinavia.  The way in which our current system treats them because of legal requirements reinforces the trauma. The accuser has the right to be there, if they're having their evidence filmed then the video is often been an instrument of the abuse and so on and therefore the trauma is reinforced by the way we manage it and we have to start looking at alternatives and the Scandinavian system as is often the case has a far more sensitive and rational way of collecting evidence that allows abusers to be dealt with but it wasn't my job, I wasn't asked in this to come up with the solutions, I was there to say well actually our targets and indicators system is probably not fit for purpose. No I get that and I understand that it would have felt like mission creep to then start calling laying out other recommendations which perhaps might have been more linked to your work with the early years collaborative. On that though I mean I think I support it because I absolutely believe that we still have this cultural reality of what gets measured gets done so if we're measuring childhood trauma and lack of trauma recovery then perhaps that will pump prime local authorities, health boards and everything to build those services around the children. I'd like to take you back to the national performance framework which looks at dental health, cams, waiting times, babies with a healthy body weight and then in the report you go on to mention GERFIC and you say that it is not clear how this system identifies ACEs and it would be helpful to see if there is a standard approach to identifying and managing neglect in babies. So in terms of those processes and outcomes, do you think there's a disconnect between education and health? No I mean I talk a lot to probably talk to more teachers than I talk to doctors. I know actually the last time I saw you were in front of my higher class and actually get more sense out of teachers than I get from doctors. So there is an understanding of the close link but there's no real understanding about how you manage that, how you do it. The fact is that, well I was speaking recently to a head teacher who'd just been given £500,000 for his school to spend on what I really liked and his comment to me was I don't really need this, I'd far rather spent giving the kids a decent breakfast before they came to school and that is part of the, you know people have different ideas and if we were to we're a small enough country to sit down and say okay what is the link here? The link is absolutely cast iron that adversity before you go to school leads to failure when you get to school and if we're serious about a flourishing inclusive economy then we've got to get that link built more strongly. Now things like Girfech and so on all well meaning policies and so on have all arrived but it's time someone sat down and looked at a system to create success at school and pulled all of that together. On page 18, 71a, one of the recommendations you state, analysis of school attainment rates should routinely consider the effect of adverse circumstances arising from socioeconomic deprivation on attainment. Obviously, school attainment data is a very narrow measure, what other factors then specifically do you think should be taken into consideration? What are the things that influence attainment rate and we've already mentioned things like adversity in the home, exposure to violence and one of the most complex things here is this notion of mentoring. I keep you know I keep seeing people who you know all of us here have some person in our family who was the first person to go to university. I mean we've all started off coming from a difficult you know a probably a poor background and emerged and so on and so and I keep coming across stories of a mentoring process for example that bumped into a former medical colleague of mine who was volunteering as a mentor and the boy who lived in Possil Park that he was mentoring had just got a place in medical school.  Now there are guys from Lindsey and Bearsden that don't get into medical school coming from the best schools in Scotland. So it's that kind of thing that we need to be focusing on more supporting people who might not feel that they have any place at university and convincing them that they should and there are a number of projects out there developing the Young Workforce. The school in Bullens in Glasgow that takes troubled children and trains them very effectively to go on and go to university or succeed. There are ways of achieving success that we should collect data on and try and do it more consistently but to do piecemeal approaches just fragments it all. Thank you. Good afternoon. I find this topic fascinating especially around the link between as Jenny says, education and health. With that in mind and with early intervention in mind, are we looking at targets? Why are we not linking targets with health with educational targets and should we be looking more cross-portfolio? I'm really interested around this idea of access to opportunity at the early age or lack of access to opportunity, understanding that access and perhaps with education in mind, do we have an opportunity around the 30 hours of free child care to have a more positive intervention around early because it seems to me if you're 40% likely to be 40% behind the time you get to primary school, why are we focusing on primary school? Why are we not focusing on that? It comes back to this idea of the life course approach and the life course begins as soon as the pregnancy test is positive, basically. It's that whole thing seeing children, you know, when the UK chief medical officers a few years ago sat down to consider recommendations on alcohol consumption during pregnancy, I was the only one that said, I do not want, I want the recommendation to be no alcohol during pregnancy that I said, oh maybe one or two drinks and so on. You know, drinking alcohol during pregnancy has impact on brain development and so we start there, we look at the whole life course that way, we don't start at aged five, in fact the adverse childhood events study calculated cognitive performance at aged two and at age ten by socioeconomic status and you had a group on the 90th centile, very high performers, from both affluent and deprived backgrounds. By the time they reached 10, the affluent ones had maintained their cognitive functioning, the deprived ones had just deteriorated over that period. So the evidence is that there are things that we need to do throughout childhood to support these kids, achieve their very best possible educational outcome and what I wouldn't want and I think you're absolutely right when you talk about a holistic approach to this, you know, pulling it all together. At the moment you will have groups working in different silos all trying to do something similar and at the end of the day you're not going to get a harmonious result, you're not going to get a result that you can apply indicators to effectively. So I would really want to see us co-producing with teachers, with children's carers, with third sector organisations and so on, a programme for leading children to the best possible intellectual place over the first 10 years of life because if you get them to that point they'll do quite well thereafter. So at the moment we don't have any way of doing that and that's why I was saying we should have a set of indicators for this but it's not up to me to say what they should be, it's up to the whole system to design them. So I could extrapolate that a little bit then, are we talking then or could we realistically state that educational intervention has such a huge part on health outcomes later in life that we should be looking at education much more?  So they get to that point in life where they have no sense of purpose, no sense of meaning, no sense of self-efficacy in life and that largely comes because they've had a difficult childhood that's sent them on that road, this cycle of alienation. The kids, so a kid who's experienced adverse events is more emotionally labour less able to suppress it so he's badly behaved so he gets excluded from class because he's disrupting education, a policy which I think is nuts and when I asked a school at an education department could they provide me with data on who was excluded from school they couldn't, they didn't know who was being excluded and how often they were being excluded.  That's the life course that adversity sends them on often and unless they get picked up very early on and get mentored and supported and so on we're you know to talk about it in purely economic terms and that's not my nature to talk about it in purely economic terms but it's a huge waste of human capital. These are the kids who should be the doctors, the lawyers, no I'll leave the lawyers out of it, they should be the doctors, the engineers, the you know the inventors, the artists, the musicians and instead they're ending up in employment. I could talk about this all day, I'll give some. Happy to talk about it all day. Pick up on a couple of the issues you've raised there. On a number of those areas in early life or throughout a person's life, the group of people who would have picked them up would have been either youth workers, child development workers, third sector organisations either employed by or funded by local government. Now how can we address these very serious issues that you're raising when local government services are disappearing through your fingers? I know that your previous word that you worked very closely with local government so you know this stuff inside out. Now we're not in danger of exacerbating this problem but what's going on at the moment? Well in the process of working with five or six local authorities and their associated health boards I'm just in the process of pulling this together where we are thinking about applying a different pattern of service to people living in difficult circumstances and measuring it just yesterday I interviewed for four PhD students who would help me assess the impact of all of this and there is no doubt that we have to work differently with public sector organisations not just public sector but public sector and third sector organisations who are confronting this kind of problem and my hope would be that that would give us the evidence that we need. I think youth workers might be too late you know I think it really needs to start workers and nursery staff nursery staff the the health visitors you know the family nurse partnership for example one of them one of the most inspiring things I've ever witnessed was seeing family nurses who had worked with six pregnant 16 year olds I mean again one that I met where I watched this young girl with the baby the attachment between her and the baby was absolutely secure the father appeared and he was similarly attached and the family and the girl then said right I have to go now as a taxi waiting to take me back to school and she was sitting five hires and she wanted to be a lawyer and I said to the family nurse if she hadn't been if you hadn't been there what would she be doing just now she said she'd be wheeling the pram down to the shopping centre and drinking with her mates you know that kind of intervention yeah it's expensive but it's gold dust one year's worth of child neglect £1.8 billion lifetime cost but doesn't it these services don't run in fresh air they don't so um ash thank you convener it's been very interesting discussion unfortunately i'm going to change the topic slightly and go back to the targets so you recommended keeping most of the targets but one that you suggested maybe should be dropped was the 18 week guarantee you said because possibly that alters clinical decision making could you say a little bit more about that yeah so someone comes with them a complex problem um you know they may have complex abdominal pain they may have um anorthopedic or whatever for a start it can take a good few weeks to run down the diagnosis um it might be that as you are narrowing down the diagnosis with different tests and so on different options for treatment appear you may well offer a treatment to the patient who would ask to go away and think about it and if the clock's ticking it kind of puts pressure on both the clinician who's trying to come up with the right management strategy and the the patient themselves who may want to take time to go away and do it now okay you can come up with all sorts of strategies like the clock stops whenever the patient decides they want to think about it and so on but but that's not that's not um it doesn't build good clinician patient relationships you want to build a relationship with a clinician is trusted and feels he is supporting the patient through this I would not want to go back to the days I mean when I was a consultant surgeon I used to manage my own waiting list and like all the other surgeons in their oil and firmware had a waiting list where every week you would take patients off it for the next week's surgery and this more serious ones came off and the ones waiting for varicose vein surgery or hernia repair or whatever it might be waiting two years and all of that was swept away because of a big investment in waiting list initiatives and I may say I never did any private practice but I may see my colleagues who did were driving big flash cars at the back of the waiting list initiatives they made a lot of money out of it so yeah patients shouldn't have to wait but imposing a target where that target might actually interfere with the clinical decision making and the doctor patient relationship is not a good thing to do and especially not a target that is legally enforceable and you also said that it might also affect patient choice as well patients need time and decision support tools you mentioned in order to make an informed choice about the treatment that they want so I suppose where we're going with this is if we're saying that the 18 or if you're saying the 18 week guarantee is maybe not you know is cutting across these kind of issues can you how would we decide on a better target that would lead to the right outcomes the outcomes we're looking to develop so there is once the decision is made then you've got the 10 week target so that's there is the backstop what I'm talking about is that process between referral and deciding that this is what is clinically indicated and what the patient wants to accept and that can take longer than eight weeks you know all things working smoothly it can take longer than eight weeks to do that you know complex problems shouldn't be rushed at you need to stop and think and discuss with the patient what the options might be and you know i'm seeing things like decision support tools things like the internet and so on are making patients much more aware of their options and that's a good thing so in the old days when you would see a patient and say I think you need such and such an operation and they'd say I okay and they'd go away and they'd you know things have improved a lot and patients the word empowered is an overused word but patients should feel more in control of of their these big decisions okay thank you Miles thank you I want to pick up in terms of what impact our target based approach to health is having on people working on health services and specifically this week it's been reported but across NHS Lothian's A&E units for example there's been the under-reporting of people within 18 within that target but specifically do you think that's become in common throughout the health service of massage and figures or under-reporting? I have no factual insights into that so anything I would say shouldn't be taken as as gospel but it wouldn't surprise me because what gets measured is what counts and it's not right to put you know people who work in the health service genuinely want to do a good job for their patients and putting them in a position where they might have to behave dishonestly is not a good thing and you know that's why I'm suggesting that look at the whole system so that if there is if there are a lot of people waiting in an A&E department is it because there aren't sufficient beds in there is it because there are too many inappropriate you know folk just pitching up because they have problems that could be more effectively managed elsewhere and so on we need to understand that and not put the blame on hard pressed A&E staff and that's why I'm suggesting co-production involve people in designing what the process is and and indicators should be and what you'll find is they will go much more much further than what a bunch of officials would do they will want to do the right thing I mean that the patient safety program I am absolutely stunned at the results of that because the frontline staff got the bit between their teeth and they eradicated whole swathes of infections that when I worked in intensive care units 90% of people ventilated for more than a week had ventilator acquired pneumonia in some hospitals it's years since they've seen a ventilator acquired pneumonia because the staff changed the way they worked so involve them and you'll get outcomes far better than you ever anticipated and how can I just come in briefly that how do you think we can move to that outcomes focused in HS then because there's lots of pilots we hear them all the time there's lots of good working in areas but that doesn't get rolled out and there doesn't seem to be that learning and you talk about this systems thinking but you know how can we make sure that professionals can have professional responsibility and and how you then aren't measuring that when we ran the early years collaborative every five or six months we would get 800 people from every local authority and from every health board in Scotland into a room who were involved in early years care and they would sit down and they would share ideas and you know it's it's like athletics athletics without the drugs or maybe more appropriately the UK cycling team you know lots of marginal gains so um so you tested things and you got two or three percent improvement in performance and you found the earliest collaboratives there were what we counted 1500 things that were tried and maybe 60 of them actually produced a benefit and where you did all 60 of them consistently and collected a data that showed you were delivering it you got a standing in performance and 18 production and still both rate over a matter of a few years is unheard of so it's about bringing people together and making it plain that we want to hear what you are doing we want to hear what works and crucially we want to hear what you've tried and doesn't work there is no shame in failure except not telling people you've failed him we tried this and it didn't work so don't waste your time and gradually you build improvement that way uh colleague up in st Andrew's house jason leach professor jason leach he's the guy that can do this he frightens me so so uh Emma thank you thanks um i think you've covered a lot of what i was thinking about but last week dr macintosh talked about um the paternalism of healthcare originally and then um if you can count it it counts which you've talked about as well and then looking at um a more professionalism approach or a moral approach is where we need to be at but also not forgetting that targets do inform us about where we need to go so i'm you know i was directly involved in the scottish patient safety programme as a clinical educator nurse at nhs and freezing galloway and we had a multidisciplinary team approach because that's where you get all the views so i'm interested to hear about what your thoughts are about the whether we should be moving to a less target driven culture and a more professionalism moral approach as dr macintosh outlined i think a less target driven approach but a stronger indicator driven approach targets delineate the end of a journey okay we've made the target right we can stop trying there but indicators tell you the direction of travel you're on and you know so a 15 reduction in infant mortality is a good thing but we should keep going um so indicators understanding the way you want to go the earliest collaborative things like ensuring that 90 percent of children attain older developmental milestones at the 30 month health visitor assessment for example was something that the front line staff identified as an indicator on the way to improving intellectual performance so we need indicators but the indicators need to be feasible they need to be pragmatic and they need to be co-produced and we need to be able to say okay we've done that now so what's the next thing i mean at the moment some of these targets seem to be cast in stone and the thought that you know you would move away from them is just you know we should be aiming high with them so indicators tell you that you're shooting for the stars but you don't want a target that stops you trying it and bringing people together a critical thing about bringing people together is you have to bring the front line together but the bosses have to be there the heads of health boards and so on have to show the front line that this is important by their presence you know in what I remember front line staff in Tayside health board when Jerry Marr was the chief executive up in Tayside they were really impressed because he came on ward rounds the chief executive of the health board was there on ward rounds to show that the hand washing and so on was important he was taking an interest in what they were doing so leadership from the top but front line staff being there to create the change it's the way to do it and all the co-production that you're talking about and all these masses of programmes and integration of joint boards they're so much happening yeah will we see a tipping point eventually do it obviously it's constant constant hard work that the front line staff and everybody has to engage in yeah but surely there should be light at the end of the tunnel I mean you get this and integration between health and social care is really important as is integration we've talked about integration with education and all this kind of stuff that's important but creating new organisations you know organisations will tend to have their boundaries and cross boundary working become you know the more you fragment the system the less well label you are to get a coherent strategy so that's why this report starts off with talking about how we achieve a flourishing population in Scotland let's start off from there and let's see how we design a system that takes us all there and when I think about I mean I've never been a member of any political party nor would I ever want to be um but uh there's something in this that goes right across the political spectrum there's social justice there is excellence in outcome there is economic development and so on it's about creating a society that we all feel proud of so if we put that in the forefront how do we design the indicators that shall we get there I mean if you want me to to go back and do phase two of this then I could design something but this has to be co-designed with the people who have to deliver it it takes us to well what is the next stage of the process where you would have to ask colleagues up the hill um who are these people up the hill tell us who they are I've never met them I was asked to do this by Mr John Conaghan who was director of performance who is now no longer up the hill he's directly a chief operating officer of the health service in Ireland now and was that because his performance was good or not so good well I think he would see it as good because he's still going to be in the the European Union I think but but let's not go there so my fear is that this gets taken away in the traditional way and designed by civil servants this needs to be designed by people who are actually doing it and so rather you know so a year's gone by and I'm just getting out there and doing it I got money from various sources and an American charity heard about what I'm doing and they said we'd like to support this because we want to do the same in the US ask us for some money so ask them for half a million quid and they came back to me and said no you haven't asked us for nearly enough so so we're beginning to get a group of local authorities who are expressing an interest in trying different things trying to integrate things differently but is that being done by you on your own yeah right so we need to then as a committee find out what the next stage in this process is that's what we really need to do that would be very helpful to me that's probably probably a good place to finish yes okay okay can I say thank you very much as always it's good to have you before the committee always provokes a very interesting conversation and there's much for us to think about so thank you very much and as agreed previously we'll now go into private session thank you