Gwladdech chi i ei ddweud i gael ddechrau y 27 wrth gwellig cymdeilig y Dysgrifesbydd ac yn 21 licwyr ar gell yn 2017. Rydw i'n gymryd ei chlym ar gyfer allu', yr galiad aeth gael gwellig yn teimlo fydd ddaethau'r cyfnidol, ond yn yr dydymae'r gwellig yr yddydd. Rhywodraeth unrhyw, mae'n gwneud hyn bydd hwnnw yn gwerthiedig y ddymeidig, wrth gwrs o'r gael fwyaf ac rhywetrain ar gael. Rwy'n meddwl gwympRRF yn gychaf yr auditor general â'r gynllun o'r NHS wath, ac rwy'n meddwlningo carillongardner, auditor general o'r gynllun, Clath Sweeney, ysgolwyr gysugiau cyllidog acolydd cyst-dweithredu peth o audit carillongardner. B disgrwmp am y cyst-dweithio ar gyfer carillongardner. Sgolwyddon yw'r anioedd yw'r NHS yng Nghymru. Mae'r Gwladau'r NHS yn 2016-17, yn y cyd-dyn nhw'r unigau a'r ysgolwyddon yng Nghymru, ac yn gweithio'r progres yn gweithio'r cyd-dyn nhw'r cyd-dyn nhw'r cyd-dyn nhw'r cyfnodol. Mae'r gweithio'r gweithio'r NHS i'w cymaint i gyd wedi ddysgu'i cyfrifiadau yn gweithio'r gweithio. Gyda'r NHS yn 1948, wrth gwrth Scotland a'r oedden nhw'r newid iawn o'r gwaith yn gweithio'r bwrdd. Mae'r population oedd yn gweithio gael yng Nghaerffordd Llywodraeth, rhai oedden nhw, gyda maen nhw ddifuig iawn ac mae'r pethau ddweud o gweithio'r gweithiol yn ei gweithio. O'r NHS, mae'r gwaith ei hideb yn gweithio ar gyfer y gwaith yma sy'n ddwylo, ac mae'r cymdeilio'r cyllid yn gweithio'r gwaith. Fy hollwch cyngorau bwrdd yn cael that healthcare can't continue to be provided in the same way, but there's no simple solution to the challenges facing the NHS and previous approaches are no longer sufficient. There is a lot of activity underway to achieve the Government's vision that everyone should be able to live longer, healthier lives at home, but some crucial building blocks still need to be put in place if healthcare is to be transformed. NHS staff remain committed to providing high-quality care, and patient satisfaction is at an all-time high, but there are warning signs that the NHS's ability to maintain high-quality care is under pressure. Patients are waiting longer to be seen. There was a 99 per cent increase in the number of people waiting more than 12 weeks for their first outpatient appointment. Patient complaints have increased by 41 per cent over the last five years, and a number of surveys have found that staff are worried about the quality of care they can provide. The challenge is facing the NHS continue to intensify. In 2016-17, NHS boards had to make unprecedented savings of almost £390 million to break even, and they are finding it harder to make these savings. Cost pressures are continuing, spending on drugs rose by 7 per cent, backlog maintenance remains higher at £887 million, and spending on agency locums increased by 6 per cent. Demand for services also continues to increase, and significant health inequalities remain. People living in the most deprived communities are still likely to spend longer in ill health and to die younger than people living in the least deprived areas. We found that urgent action is needed in several key areas. The Scottish Government needs to set out how existing and future funding will be used differently to move more healthcare into the community, workforce planning needs to improve urgently, and staff and the public need to be properly engaged in developing new ways of providing health and social care. As always, convener, we will do our best to answer the committee's questions. Thank you very much, Auditor General. Can I turn first to Colin Beattie? I think that Audit Scotland probably has the best independent view of the overall NHS of anybody. What I have been seeing recently is NHS chiefs and indeed the Government starting to talk about is not a case of more money and more people anymore, because that is an unsustainable model. I am looking at the fact that the share of the Scottish budget spent on the core health service has gone up from 38 per cent to 43 per cent of the national budget, and that is unsustainable. Are we at a point where we need a complete re-engineering of the NHS? First of all, you are absolutely right that we cannot spend our way out of the challenges facing the NHS now. We are seeing the difficulties of continuing to try to meet the targets for access to acute care, for example getting harder, cost-rising demand increasing. In the report, there is a broad consensus that I share, that the vision for delivering healthcare differently in the way that you are hinting at is the right one. We need to make sure that services in the community, particularly around primary care, are able to look after the needs of many more people with complex care conditions, avoid more admissions to hospital and help people to get home more quickly. We have the vision there, but what we need is building blocks around a financial framework, thinking about what workforce is needed to do that and making sure that the capital investment decisions are supporting it rather than investing most of our capital resources in acute hospitals. You mentioned lack of detail in areas such as GPs and so on, and that has come up before. I understand that there is, in the past few days, under the new GP contract. There is provision in that for getting information from GP surgeries. Do you have any more detail on that? You are right that it is covered in the proposals for the new GP contract that we have published this week. I think that Clare Orl Cursing may be able to give you more detail. Some of the issues previously have been about a lack of information on parts of the system that are not in acute hospitals and getting better access to patient information. We have seen improvements in that regard over the past few years, but there clearly is something more that needs to happen around access to information through general practice and community services to get a much more rounded feel for how patients are accessing the system and what needs to change. There are provisions in the new contract that should help with that. We have talked on quite a number of occasions about lack of data from the national health service. It has always been a bit of a juggling act because there is a lot of data being collected, but maybe not in the right place or in the right form or in a consistent form. Are there indications that we are starting to get better data now? I think that there are two areas where that is the case. One, as Clare Orl said, in the new GP contract, there are specific proposals about GP practices providing data on their own staffing and on the demand for and the activity numbers of patients that they are seeing, which will help to fill that. Beyond that, as Clare Orl said, the overall information about services provided in the community is not nearly as strong as information about hospital activity. The review that was published by Sahari Burns this week makes a very good point that healthcare information needs to look at the whole system, not just one part of it, or else you risk skewing attention and resources towards the part that you are looking at and cannot manage or balance the system as a whole. Given where we are with the NHS at the moment, and obviously it is coping but showing some strains, we certainly do not want to be in the situation as they have got it south of the border. We need to maintain our NHS here. Are there any quick fixes that can be put in place now? I think that there are never quick fixes for a system as important and as complex as health and social care are. As we say in the report, there is a lot of activity already going on. I think that the three things that we have highlighted are the things that will make the difference around a financial framework that makes it clear how current funding and potential future funding would be used, better workforce planning, and the committee has heard over the last couple of weeks about the problems in knowing the way in which NHS staffing needs to change in future to be able to make this shift into community settings and then making sure that the capital money that is available is being invested to support that rather than investing in more acute care where that is not needed. I will come back to indicators, because clearly they are key to redesigning the NHS or effectively making the changes that are needed. It seems to me that, in paragraph 34, 35 of your report, you seem to be indicating that probably the NHS itself is producing better indicators, but where it is the community side, where it is primary care, the indicators are less good, less efficient, and maybe they are just not even there. I do not know where to pick up the detail of the community indicators. I would like to make the broad point, first of all, that I think that it is useful to distinguish between indicators and targets. I think that there are lots of parts of health and social care that we need good information of and we need to be monitoring as auditors, as the committee and as people with an interest in healthcare right across Scotland. I think that the danger of turning that into targets is that you run the risk of skewing priorities towards those targets. I think that the review that was published by Sir Harry Burns helps to move that debate on what we want to know and what are the relatively few things that we should be setting targets for. Can the committee drive the targets? I think that I see indicators as things that you are measuring and monitoring and seeing how they are changing and where there are indications of pressure points in the system. For example, the fact that we know that the number of people waiting more than 12 weeks for an outpatient appointment doubled is a good indicator that pressure is building up in the system all the way through. I think that focusing just on that number as a target runs the risk that you are not thinking about what is happening in primary care and in the community that actually would have a longer term effect on the number of people waiting to be seen in hospitals. I draw that distinction. We know a lot about what is happening in terms of our acute hospital system, particularly in terms of how long people wait for certain individual parts of the system. What we are much less good at is understanding how that is interrelated and the connections between different parts of the system, which is why in the report we say that there is no simple solution to some of the challenges that are facing the NHS. It is a very complicated system. It is interrelated to things like social care services. The way that GPs work increasingly is thinking about things that are not just necessarily related to the health system itself, so there we are talking about things like social prescribing, access to green space, exercise, things that really can make a difference to improve people's well-being and long-term mental health. We are very well sided on the acute system in terms of waiting times, less so in terms of the rest of the system. We are also interested in the extent to which the Harry Burns review will lead to a review to help us to focus more on outcomes, the impact that the services actually make on people. We also make the point in the report that we know far less about quality, so lots of what we are talking about are throughput measures. It is not about the quality of the system that is provided, the care that is provided to people, and we would like to see more around that, too. Looking at some of the statistics, the increase in people attending as outpatients, for example, is going up 12 per cent between the first quarter of 2013 and the first quarter of 2017—that is in paragraph 33. Those are very big increases. Is there any indication of it levelling out? If we carry on as we are, all the indications are that it will not level out. If you look at Exhibit 6, we show indicators of demand for NHS services going back to 2012-13, so across a five or six-year period. All of the indicators for emergency admissions, numbers of procedures, outpatients, a number of people waiting for inpatient and day-case treatments and GP consultations are going up by different amounts. We know that, to a large extent, that is driven by an ageing population where more people have complex care needs and by the fact that, for many of those people, although they could be cared for in their own homes and, often better, if we had a good primary care system around them, at the moment of need, there often is no alternative button, admission or referral to hospital. That is absolutely what the vision for healthcare is founded on. It is what the GP contract proposals that were published this week is trying to build capacity for. I think that our message is that the urgency of building that capacity and being able to see what effect it is having is the only realistic way of dealing with these continuing increases. It must be a projection that shows that, at some point, the demographics turn because we have got this bulge of older people and, yes, they need more services, but that is going to reduce in the future, so we should start to see a down curve. At some point, yes, but I was looking at statistics yesterday for a speech that I am giving tomorrow, and the latest projections are that, by 2030, the number of people over 65 will increase by 50 per cent. If you plug those numbers into what we have seen over the last five years, it starts to look unsustainable. I think that that is why there is general consensus about the vision for the future to deal with that need and also because what many of us want as we are getting older and have a wider range of needs, rather than something that is easily fixed, such as needing a knee replacement, we would much prefer to be in our own homes, but we can only do that if we are building the strength and depth of capacity in primary care. Alex Neil. Can I begin by asking about the waiting times? Obviously, with Harry Bunz's report, which seems to me a very good report, it raises a whole host of issues. One of the issues that I do not think that we have ever properly addressed is just the cost of implementing and trying to reach some of those targets, particularly on waiting times and the extent to which it possibly distorts decisions on other matters clinically. Have you ever sensed that, if supposing that we suspended the waiting time targets, the ones in statute for a year, what impact would that have in terms of performance and finance and a better allocation of resources within the health service? We have not attempted to estimate the impact in exactly those terms, but, 18 months ago, we published a report on changing models of health and social care that aim to get under the skin of what is happening with demand and what the successful responses to it look like. The main message coming out of that was that there is a real risk in looking at one part of the health and social care system. If you have people working to not just a four-hour A&E time, but a 12-week target for inpatient or hospital care and a reducing target for discharging people safely from hospital after their treatment, without looking at what is happening in the community, you run the risk of building up pressures elsewhere that cannot be dealt with. For example, we are seeing the number of people waiting more than 12 weeks for their outpatient treatment doubling over the past year. That is a sign of pressure building up elsewhere. We do not know how many people are having to wait longer for a GP appointment because we do not collect that information routinely, but there is a real risk that, by focusing on this bit of the system, you have pressure building up elsewhere that you are not aware of and that you are potentially having a more significant impact on people's health and wellbeing than getting right the treatment time guarantee or whatever other indicator of the acute system you are focusing on. The A&E targets were actually driven by the clinicians in that case. The four-hour target was driven by them. It was not a political invention if you look back to it. Even if you ask emergency consultants today, they will say that the four-hour target is absolutely the right thing to do. The problem was that when that policy was introduced 20 years ago, nobody looked at the impact and how it related to the flow of patients through a hospital sector. A lot of the problems in achieving the target were related to the lack of flow of patients through the wards in the hospital. As I read Harry Burns' report, what he is suggesting, and I think that correct me if I am wrong, does this equate to what you are suggesting. That is that we need a new performance and impact measurement framework that looks at the totality of the patient pathway and the relationship between the different sectors—primary, acute and so on. Is that basically what you are suggesting? I think that it is what we say in this report and have been saying for a while. I need to be careful because I am precluded from commenting on the merits of policies, so I cannot talk specifically about targets, but we have been saying that there is a risk to looking simply at the acute sector and you need to pull that focus back to understand all of the things around health and social care that are leading to somebody arriving at RNA. At the moment, we are not doing that. We tend to look at it in silos, in chunks, rather than in the relationship between the different parts. Secondly, we tend to look entirely at performance against stated targets rather than impacts. The point that Clare was making is that impacts are at least as important as performance. Also, if you look at impacts, it differentiates between what the health service can do and what outs external factors over which the health service has no control. What we want to know is what is the added value of the health service and is it maximising added values? We do not have a framework—performance and impact monitoring framework—that does that. Is that a fair comment? I think that's right. We focus very much inevitably on the work of the territorial boards and, within that, the GP sector and the acute sector. We would include the jubilee for the purposes of this discussion in that. There are seven other special boards, because the jubilee is a special board. The seven other boards play, to different extents, an important role—the Ambulance Board, the NHS 24 Board, the NSS, so on and so forth. In looking at the financials, are we getting value for money, in your view, out of those seven boards? You are absolutely right that they play a very significant role or, potentially, play a very significant role in addressing some of those challenges. I will ask Claire to pick up some of that in a moment. We have seen, though, that because of the overall financial pressure on the NHS, the territorial boards having their funding protected in real terms in a way that hasn't been the case for the specialist boards. They tend to see significant real terms decreases in their budgets over a period for very understandable reasons. That suggests that they are playing their part in value for money. For me, the question is probably more about whether they are able to fulfil their potential to really start to change some of that. We have seen NHS 24 gradually moving to a point where it can help with redirecting patients who don't need to go to A&E into other forms of service. We are seeing NHS Education Scotland thinking about new professional roles. I think that there is probably much more potential there to be playing their part to make the system as a whole more effective. I will just build on that. If you look at Appendix 2, which sets out all of the territorial and national boards, you will see from the national boards listed at the bottom the very wide range of different services and support that they can offer. Some of the examples that we have pulled out in previous reports are things like the role of the Scottish Ambulance Service in responding to patients' need in very urgent situations. We have seen some really excellent examples of how that has helped to reduce pressure on other bits of the health and care system, right through to the role of NSS to Healthcare Improvement Scotland to help to drive the improvement agenda across health and social care services. All providing really important services that can help to achieve the goal, which is about making care better for people in Scotland. As Caroline says, it is the extent to which they are able to fulfil that to its full potential given the context that they are working in. As we see in the report, the sense of a need for a longer-term horizon, a move away from focusing on individual bits of the system and a short-term focus, a longer-term planning horizon and a longer-term financial planning will really help those boards to make the maximum impact. In terms of the new regional structure, has the time come to maybe, with at least some of those functions, devolve those to the regions rather than have them run at a national level? There is a conversation to be had about that absolutely as part of regional planning. We are very interested in the extent to which the planning arrangements for health and social care across Scotland will work in future. You will see that we have had exhibits at the beginning of this report that start to draw out how we think that that will work in practice. There is a need for more thinking about how the connections will be made from a regional focus on planning through to some of the focus of the territorial boards, all the way through to integration authorities and the role of general practice and localities. There is a little bit more work to do to think about how all of that connects up so resources are used most effectively. We have tried to be as clear as we can at the start of the report, making the point that there is a need for more thinking there. Just on the data issue, in looking at the GP contract draft that is out to consultation with GPs, clearly, in previous evidence, you have rightly indicated that one of the problems in trying to look at the primary care sector is the absence of data, particularly from GPs and GP surgeries. In looking at the draft contract, are you satisfied that that kind of black hole is going to be filled? We raised the issue in the report that, in terms of the new primary care data around GPs that is being developed, the SPIR system, we raised an issue that there was a potential that GPs would not have to provide that information to local IGPs because they are independent contractors. I understand in the new GP contract that they will have to provide that data either through the SPIR system or through their own system, so that would certainly help IGPs to help with their planning, to fill those data gaps that are there, to help them to do when they work out what their local needs are and what their services need to look like. So, the new GP contract proposes that that should help to fill some of those gaps? Fill some of them, but we should not be trying to fill all of them. This is an opportunity that will not arise for at least another five years. I start by saying that we have seen progress around this over the last few years. Certainly with the introduction of integration authorities, there is a lot more targeted support from some of the national boards to try and help focus attention at a local level on what the data tells you. For example, I focus on things such as the number of people who make very intensive use of health and social care services. They are responsible for accessing lots of different services across the system, acute services, right through to general practice. It is really important that there is a focus on how they are using services to help start to make sure that they get the care that they need as early as possible in the right place, so that they are not then bounced around the system to different bits. We have definitely seen improvements around the data that is available. One of the consistent messages from us over the last few years has been about gaps in terms of understanding provision in community and primary care services. We are not really understanding enough about the numbers of GPs that are there, the way that they work, the services that they can provide, and certainly the new contract starts to make some progress towards a better understanding of that. My final question is, the improvement service does a fine job in identifying improvements in best practice, which is my experience as a health secretary, but very often that is where it stops. You might pick up a good practice. For example, there was a computer pen that was used by community nurses in the Western Isles, which was developed locally on their own initiative. That was about 10 or 8 years ago, and it still hasn't been rolled out. That is a very good example. The lack of spread of good practice, the lack of drive from the centre to basically ensure that good practice is adopted reasonably quickly across the board. I know that it is a frustration for a lot of people working in the health service, and we hear a lot of anecdotal stuff last week from the chief executive about what might happen in Cowdenbeath. That is fine, but why is it not, if it is good practice, now happening across the whole of Scotland? One of the things that we say in the report as we pull together the action that we think is needed is the tightening of the governance arrangements for the change that is required, given its scale and complexity. We would all recognise that, in a system as complex and as people-centred as the NHS, a sort of top-down direction is not likely to be successful. I think that the approach has been very much about letting people develop good practice locally and hope that it will spread. We now know that it is not spreading, as you say, as quickly as it needs to. I have recommended in the report that we need to look again at that governance and maybe think about some of the approaches that have been used for the patient safety programme for the early years collaborative about building that sense of understanding locally across Scotland about why change is needed, what change might look like and how we will know that it is happening. Claire, you might want to add to that. I think that there is also another dimension. We have made a lot of this at the end of the report that not only does staff working across the NHS system need to be bought in, to understand, to truly live the values and to make those changes, but there is also another key aspect to it, which is the involvement of patients and the public in Scotland. We have said a lot in the report about the need for more transparency, clarity about the services that are provided, the quality of them and true engagement with the public about how the services are delivered in future, because there are difficult decisions that need to be made and we do see some examples where that has been done very well, but we think that there is scope to improve how the health service engages with the public around some of the difficult decisions that need to be made in future. Liam Kerr, you give some key messages early in the report at page 11. What you say, and I am quoting from this, is that the majority of key national performance targets were not met in 2016-17 and wider indicators of quality suggest that the NHS is beginning to struggle to maintain quality of care. That is then drilled into at paragraph 40, where you give examples of where the various pressures that you have isolated may impact on the quality of care. Is it clear to anyone exactly why those pressures have arisen in terms of the cause and effect? Assuming so, how do the health boards intend to respond precisely to those pressures? The circumstances will be different in different parts of Scotland, but across the country we know that we have a population that is ageing fast. Many of us are living longer, which is a good thing, but age tends to bring with it complex health conditions, complex care needs that are not easily fixed by one admission to hospital, as is often the case when we are lucky enough to be younger. We have the ageing population playing in, and we have also got the fact that health care costs tend to rise more quickly than general inflation. Although the Government has been committed to maintaining the health budget in real terms, we know that drug costs last year rose by 7 per cent against general inflation of two or three per cent. Drugs are one example, but that happens more widely because of the innovations in health technology that is available. The two of those together are behind the recognition that we have in the report that is shared more widely, that we cannot just spend our way out of this and it is not just a matter of being more efficient in what we currently do. Health policy over the past few years, in terms of what is visible in the public domain, has tended to be about the targets that you have drawn attention to, about how long people are waiting for acute care for admission to hospital for treatment. However, the only way of speeding up that part of the system is by taking away some of the pressures of people who could be treated better if there was a good primary care team near their home who could stop them being admitted in an emergency by treating their chronic obstructive pulmonary disease better, by helping them to recognise when their health is deteriorating to take action to respond to it, rather than mending up in A&E on a Saturday evening because those signs have been missed. The point of our report is to try and focus attention back on that end of the system to capitalise on things like the proposals for the new GP contract and the review of targets and think about how we can see the system as a whole rather than just that one dimension of it. That makes sense, of course. I wonder, though, do you get any sense that the individual boards, because you say that there is a kind of macro picture, but then there is also the more micro picture where each individual has its own individual pressures? Did you get any sense that the individual boards understand the individual pressures pertaining to them and they have the bespoke plan to deal with that? I think that it varies, Clare. Do you want to pick that up? It does vary. We say in the report that there are a number of big issues affecting the NHS in Scotland that are common across all, so some of the things that would be included in that list are difficult these in recruiting and routine and in certain specialties. That is something that is widely recognised as a national issue. There are also similar issues around the social care sector, which again has an absolute knock-on effect in terms of health, so there are many, many things affecting the system that are common across Scotland. We would go further than that. Many of these issues are affecting health systems across the world, so that is not unique to Scotland. Of course, there are particular issues affecting individual boards, and they will be aware of those. That might be difficulty in recruiting and in retaining staff in health and social care in the central belt, where there are many other employment opportunities for people. There are particular pressures in the island boards, for example, of recruiting and retaining GPs, but generally speaking, yes, there are consistent issues across Scotland that need to be addressed. Some very local specific areas, but in the main, these are broad issues affecting the system across the nation. This was not where I was going to go, but you raised the point that these are not unique issues to the NHS in Scotland or the NHS in the UK. You say that it is across the world, which begs the question, has anyone successfully solved these sorts of issues across the world? If so, what are we learning from them? I have opened a can of worms, haven't I? There are some very good examples of individual bits of practice that are starting to change the way health systems operate. Some very good examples from the rest of the world in terms of access to things like primary and community care services. They fit with the general shift in Scotland about a focus on providing care closer to people's homes, about supporting and enabling practitioners to make more independent decisions about care, to put the person at the heart of the treatment that they receive. There are a number of really good examples across the world. Scotland is trying to learn from those examples. I think that the issue that we would highlight is how do you find there are pockets of examples and some really innovative practice starting to be taken forward. What is needed in terms of the financial picture is more of a plan, more of a financial framework, as we call it in the report, to give us a sense of how we are going to get from here and now to this ambitious view of the world as it will look in a few years' time. We need something to bridge the gap between the two. Examples of where some systems have started to overcome some of those challenges, but they are incredibly complex and difficult. I would like to focus on that financial aspect, and Colin Beattie rightly raised the issue of savings. Obviously, it is very difficult for the boards to make particular savings. Do you especially comment in your report that NHS boards' use of non-recurring savings is unsustainable? Just to delve into that, you explained that the non-recurring savings accounted for 30 per cent of all the planned savings in 2016-17, more than double the level of five years ago. It seems to me, first of all, that it cannot be sustainable to continually pair a service. That begs the question, how concerned are the boards themselves with the current approach to savings? Secondly, have they proactively suggested alternatives to the current programme of non-recurring savings that they are going through? Yes, that is a very good point. We have said for a number of years that the level of non-recurring savings is unsustainable. Every year, the boards managed to generally make their savings. This year, they did not meet the target that they had set themselves. In terms of the actual non-recurring in 2016-17, it was just over a third, at 35 per cent of all the savings that were made when non-recurring was made. What is interesting as well is that the level of unidentified savings is all so increasing over the past few years. So, in 2016-17, it ranged from Shetland, where all its savings were coming from, up to a third at NHS Fife, so 33 per cent of its savings. At the start of the year, they did not know where those savings would be coming from. Alongside that, we are seeing an increase in the level of risk attached to those savings, so boards know that a number of their savings are high risk. Some of that will be related to that. Forgive me for interrupting, but I just did not quite follow that point. I am suggesting that, at the start of the year, the NHS board will say that we intend to save X amount by this time next year. I cannot remember the phrase that you used, but the unidentified savings is saying that we are going to save X amount, one-third of it, and you said that we do not actually know where that is going to come from, we are just going to save it. Is that correct? Did I read you right? Yes. The 33 per cent was particular to Fife. In terms of 2016-17, it was 17 per cent at a national level. In the LDP's boards set out that they agree with the Government that we will make X amount of savings. They will then try to identify those savings, but what we have seen over the past few years is an increasing trend towards the boards do not know where those savings are coming from or where they know where the savings are coming from. The savings are increasingly high risk. A lot of that is attached to things such as closures of facilities where they may identify at the start of the year that we would like to close X facility. However, as the year goes on, public political pressure means that it becomes very difficult to do so. The final question that arises from that is, do the boards both project the impact of those savings on patient care and do they retrospectively assess the impact of those savings on patient care and the staff, particularly if, at the start of the year, they did not know what those savings were going to be? The boards should assess savings for clinical impact. Before the information goes to their own boards and they make those decisions around savings, the board should be identifying exactly what impact those savings will have on the clinical element and the link on patients. I am not aware that boards retrospectively look at the impact. Obviously, some of that impact will come through in terms of impact on, say, existing performance indicators. They may see drop-offs or improvements in some of that. I would be happy to come back to the committee with more information on that. That would be useful.  Have you seen any evidence of them saying that this impact could be considerable? Let's not do this. Let's find another way to make the savings. Is there evidence of that? You will see from the way that we have described the savings picture at pages 15 and 16 about the differences in savings. We were able to see some of the trends in recurring, non-recurring savings over the past year, but you will notice at paragraph 26 that we have drawn out that there are differences in terms of how savings are reported and that message changes throughout the year. We are very interested in whether there is scope to make that much clearer, not just in terms of planning the services and understanding the way that the resources are being used. That is important, but also what that says to the public. Is there clarity about how the savings agenda is being planned for throughout the year? Is it being done in a meaningful way to try to improve efficiencies, to try to get to the aspiration of how services will operate? We have made a recommendation that there is scope to get much sharper at how the savings issue is being dealt with. Although that does not speak to the detailed point that you are raising, that shows the context that we are working with here, that there is scope to be sharper around the reporting of savings. We know that boards take the issue of savings very seriously. That is why some of them fail to meet the level of savings that they have planned because they are not prepared to put patient care, patient safety at risk. One of the things that drives the way of planning that Kirsty has been describing is the need for them to break even every year. One of our recommendations here has been to give boards a longer-term financial planning framework so that they can be thinking about how they invest to save and how they make changes in a way that are not just about cutting at the margins, as we have seen. That is reaching the end of its usefulness. Liam Kerr referred to paragraph 40 on the overall pressures and so on on the health service. Why is it that we have got all this doom and gloom out there as it is built up on the pressures on the health service? In paragraph 39, you say that inpatient satisfaction is at an all-time high, patient safety indicators are continuing to improve and the Nuffield Trust 2017 report said that there is a strong culture of continued improvement or continuous improvement. It seems a bit of a conflict there. I think that it reflects in part the great efforts that staff go to to continue delivering high-quality care for patients and perhaps the fact that patients recognise that. We all are exposed every day to concerns about the effects of austerity on public services, and I think that patients know that staff are working very hard to maintain care. We have also seen the Government making very significant commitments and investment in the patient's safety programme, and we have seen some real results from that in terms of things like the rates of hospital or healthcare acquired infection, which are very positive. Across the page, we also highlight some evidence that is going in the other way. We see patient complaints increasing, and we see staff responding to surveys with concerns about the time that they have available for delivering the quality of care that they want to. I absolutely want to recognise the huge commitment of staff in continuing to provide the best care that they can, and I think that we need to put that in the context of other signs that it is getting more difficult for them to do that. I wonder if I could just pick up on the point about targets and meeting targets that were made earlier. If you look at Auditor General at Bendix 3, there are a whole series of tables there showing how the various boards have met all the various performance targets. I am looking particularly at the 12-week treatment target. Only one board met that particular target, so your impression of that is that it is disastrous, bad or far wrong. What is the impact of demand on those performance figures? If there are simply raw figures about meeting a 12-week target, how do we know what the impact of demand is in the various communities that might be pushing those numbers down? It is a really good question, and it goes back to the questions that Mr Neil was asking earlier about the effect of targets on the system as a whole. First of all, we have said before that there is no evidence to show us that these targets were set with an understanding of the capacity of the system to manage flow through them. Our report last March 2016 tried to set out some of the modelling that suggests that it is going to get harder and harder to meet those targets because of imbalances in the system across the piece. Hospitals are getting much better at managing the flow through their hospital, and the four-hour A&E waiting time target has been a driver for that because they have had to manage as actively as possible patients going on to the right place quickly to do it, but they cannot manage the things that are outside the hospital system. They cannot easily manage the number of patients who arrive in A&E, who could be better looked after in many cases in primary care if the capacity were available there, and they cannot directly manage the number of patients who are medically fit to be discharged but cannot safely be discharged because social care is not readily available to make that transition safely. That is a really good example that you have pointed to of why just focusing on the acute service and access to it does not give the whole picture, and it runs the risk of simply speeding up and speeding up to the point where the system cannot cope because the real drivers are outside. Do you think that we need to do something about that to show the impact of demand on those targets, not to conceal bad performance where it may be, but to give a more accurate reflection of the performance of the service that is going on? If you look at that table again, the poor fourth valley is at 63.5 per cent, you might think that what on earth is going on there, but perhaps they are performing really well and they have had a doubling in demand. We do not know that. Should we try to reflect some of this within the stance that we produce from year to year? I think that that is a good point. I think that also on page 20 and 21, we have tried to draw out how demand is interacting with what is happening around the waiting lists. The sense of waiting lists just getting larger and larger and larger is not always that more people are getting treatment. There is something about that starting to see the effect of potentially being very difficult to fill vacancies, that the fact that the system is being driven so fast is very hard for it to continue to improve in that way. There is a need for a more understanding about what is really happening because of those waiting times figures. That is absolutely true. That is when we will start to see some differences across the boards. I do not know if there is anything else to add to that. One of the points that we make in the report is the need for better and more information around some of this area. Some of that relates to the length of waiting times for patients. The number of GP referrals coming in and coming back to that point is about the need for data around the primary KLM element and what is driving that pressure into the acute system. For example, NHS Grampian, in the past year, started writing to patients saying that they have been referred for treatment. Those are the amounts of people waiting. That is your likely length of time that has happened just to try to be more transparent about what are the pressures around the system that we are facing. On the stick with the same column, we are thinking beyond the target. Do we collect data on when people were actually seen? For example, in the fourth valley, 63.5 per cent were seen within 12 weeks. When did they reach 100 per cent? Is it a week later or is it months later?  What is the clinical impact of that, if there is any? Individual health boards and hospitals are using that data actively. It is another example of where having the data and indicators is more useful than having targets. If you have a target that says that 100 per cent of people referred to outpatients need to be seen within 12 weeks, you are going to try to drive everybody through that 12 weeks because that is what the target says. We have seen that getting harder and harder to do. The number of people waiting more than 12 weeks doubled last year. If you are looking at it in a more nuanced way, you can say that we are still managing to see everybody within 16 weeks. While we manage the pressure in GP practices and in patient or day case treatment, that is acceptable for us for now and will work on the system as a whole. Alternatively, we have some people who are actually waiting 26 weeks or a year and that is not acceptable, so we will focus on those specialties. It helps you to understand what is going on and really manage the system in a way that is much likely to lead to better outpatients for outcomes for patients than a target that says that 100 per cent should be seen within a particular point of time. It is quite a sort of nuance thing, but I think that difference between measuring it and having a target is a really important one in being able to manage the system and get the best outcomes for as many patients as possible. Just to build on that slightly, we have looked at this in some detail for certain bits of the system in the last few years. We carried out some work looking at accident emergency services, and it was very interesting looking at the time if we looked at it, set the clock from people going into A&E and looked at when they were receiving treatment up to the four hour and beyond. What was really interesting was that it was quite difficult to do that, but it was quite illuminating in seeing, were patients waiting longer in some instances because they were being tracked just before they tripped into the four hours. There are all sorts of issues that front-line staff are dealing with in terms of being able to treat the right people at the right time, in terms of clinical priority and need, but also with an absolute eye to those targets, and that is why it can really have an effect on the way that people are experiencing the health system. I turn to your main recommendations in the report of Auditor General. You clearly talk about things like better financial planning, capital investment, workforce planning, governance, transparency. Those issues are not uncommon. We have heard many of them before. What is your sense of having made those recommendations and making those recommendations that you as the Auditor General will be able to follow up on progress with those? Do you see the NHS various departments for delivering that service? Do you see us being able to structure ourselves in terms of making real positive gains in delivering those key recommendations? How will we know that we will be sitting together next year saying the same things? Are you confident that there are structures and management processes in place that will begin to deliver on those? I am more hopeful than I have been. I was looking back at the report that we published in March 2016, where we talked about the need for stronger national leadership to deliver the vision. Since then, we have seen big progress on the proposals for the new GP contract. We have seen the review of targets and indicators coming through. We have seen some of the things that you heard about workforce planning starting to gather pace. In the report, there is a lot of activity happening. I think that the things that we set out—those two or three key recommendations about the financial framework, the workforce planning and the capital investment strategy—can help to bring that together, along with the forward look in terms of demand and responses to it that the committee has been exploring over the past few weeks. I think that lots of the building blocks are there. Those recommendations will help to bring those together and make sure that everybody is moving in the same direction and that it is possible to measure progress and to respond where progress is not happening as fast as it needs to. Presumably, you will be following up on the recommendations. Will you be here again next year? I wonder if I could ask you a question about something that you said in paragraph 45. You are telling the committee about particular areas of deprivation and the gap is not closing healthcare issues and areas of multiple deprivation. The gap is not closing and some areas are widening. Have you made any particular recommendations to try to assist government in the NHS to begin to close this gap? I think that it operates at two levels. One is what the health service can do and one is what society public services as a whole need to do. Claire, I know that you want to pick that up. Yes, we produced a report a couple of years ago on health inequalities and as part of that work we were asking questions about not just universal provision of services and everybody's expectations that they would receive the same level of care but to understand what efforts were being made to try and address the gap, to address the needs of people who perhaps found it really hard for whatever reason to engage with their GP or to get into the system in terms of things like screening. We have made a series of recommendations in that report to try and help the service to focus in on addressing the gap. It is not just enough to provide the same to everybody. There are some parts of society where people need a little bit extra support to get into the services that they need and probably they need more than some other people in society. It is that extra work that goes in to try and help to support people into the system. There are good examples across Scotland but we absolutely saw through that piece of work that there was a need to do more. Last question, Jackie. On telehealth, do you see an increasing role for telehealth in shaping the whole service delivery for the NHS and where do you see it making its greatest impact? I think that it has got huge potential and we see some really good examples of that. The attend anywhere pilot that is happening in Grampian is a very good example of it. I would also echo what the chief medical officer said last week in evidence to you, that we should not underestimate the very straightforward technology that everybody has got like the telephone. You have heard examples of GPs using the phone to be able to make early contact with people to understand what their problem really is, to either bring them in quickly if that is needed or to point them towards somebody else if that is a better response. I think that we can think in much more flexible ways about the way the health service is a whole response. Technology makes that more possible but we do not need to wait for the magic technology to come along. Do you think that it is consistent enough? I think that you mentioned that about good practice exists in pockets. How do we make sure that good practice, for example in areas such as telehealth, is spread right across? I am sure that it is not consistent enough at the moment. Again, I think that there are some pointers in the proposals for the new GP contract that help with that. The recommendation that we have made is about the stronger governance of this to be clear about what is expected of people and how we know whether that is happening or not is also an important part of it. I will flick back to your recommendation page. The one that has not been mentioned is at the back of the report but it is still important. I have lost my page completely now. It is basically about everyone working together. I think that that is the part that we are still not seeing real evidence of. If we can go to paragraph 87, it is interesting to note that what you are seeing in your report is that although public health has traditionally been seen as the business of the NHS, as little as 10 per cent of the population's health and wellbeing is linked to access to healthcare, a lot of what we are talking about today is not for the NHS alone to sort out. You are talking about the need for a shared commitment across the public sector and perhaps beyond. Where is the evidence that there is that shared commitment and that people understand that we need to work differently and to work together? I will kick off by saying that it is at the end of the report because we think that it is very important, not because we think that it is not. I will ask Claire to pick up what we see the stage for players being. We mentioned in the report the introduction of the integration of health and social care being part of the key here. We are going to carry out more work. We are just starting that work now where we are reporting next year around the progress that has been made with integration and some of the challenges that we are already seeing coming through. They represent an opportunity for an integrated approach beyond just the health and social care system to think about the needs of the local population. As I mentioned earlier, that might be access to green space. It might be about making sure that children are eating healthily, that everything is being done to help them to succeed in schools and find work after education. There is an opportunity through the integration of health and social care to think much more broadly. We are starting to see some really good examples of that happening. It is challenging. One of the other messages in the report is about the long-term nature of a lot of the things that we are talking about today, that there is no quick and easy fix, that some of this takes an awful long time, that we need to have the right measures in place, the right workforce in place, that we need to have an open conversation with the public about what is possible. There is also an onus on the public in terms of their own health, and we are starting to see conversations about that happening across Scotland now, which is really encouraging. There are some green shoots that things are starting to move forward, and there is a mechanism through which that should be a little bit easier in future, but we are yet to report on that. Health and social care, the integrated joint boards, still operate at quite a high level. What I am thinking about is that we are listening to evidence today. You have people working in housing departments, in roads departments, in planning departments, people who deal with leisure centres. How many of those people do you think have a focus on what we are talking about today and think that they have a part to play in that? There are working groups, there are other things being set up, but day-to-day there are thousands of people across the public sector and other sectors who have a role to play. Are people sitting back waiting to get some direction from the top? How do we get this working from a bottom-up approach? Without predicting what that report might say, because we have yet to do the work, we know that it has been recognised that housing, the example that you gave there, is absolutely vital to this working. We have produced some work in the past that has talked about the role of housing in the context of health and wellbeing more broadly, so I do not think that it would be a surprise that there might be more that needs to happen out there across Scotland, but there are some really good examples where housing is starting to be tied in, but I am sure that we will find that there is a need to do more around that for sure. The opportunity with health and social care integration to have a real meaningful conversation within local areas about their needs, the services that are working very well, but whether there are gaps and whether there is an opportunity to do something different for local communities. For example, with the voluntary sector and with the housing sector, it is really important that that is front and centre as part of that development, but we will be doing more work that will touch on that and we will report next year. Are you using any evidence of health impact assessments being carried out to look at the impact of decisions on budgets or on policy and strategies? For that joint-up approach to work, people have to understand the consequences of any decisions that are taken. Is that something that is happening? We have not looked in detail at that as part of this piece of work. I am trying to think that there are some particular examples that we have seen just in the course of this. We have not included it within the reporting, where there are examples where that has worked, but I am sure that there is scope to improve that. It is not something that we have looked at in any great detail as part of this piece of work. I know that there are opportunities coming up with the planning bill and so on to embed that kind of good practice. Going back now to the NHS, looking at the cost pressures in Exhibit 5, one of the things that you highlight is that the NHS estate, 70 per cent of it, was rated to be in good physical condition. There is a slight improvement there, so that is good. Looking at the backlog of maintenance across NHS boards, it is £887 million. It is quite significant, but a high element of that is classed as significant to high risk. What kind of decisions are boards having to make? If things are being put on the back burner, what are the risks and what are they concerned and attached to that? There is probably a broad point to be made, and then I am cursed that we will probably want to give some more of the detail around this, but because of the introduction of health and social care integration and a different way of delivering services to meet people's needs, we recognise in the report that there is more work to be done around this. Backlog maintenance on existing estate, some of that estate will not be in the right place, will not be the right facility, so there is a need for the planning arrangements to catch up with some of that. While we have a figure at the moment for maintaining the current estate, we know that there is a general recognition that things need to change. Services will look different. That is bound to have an impact on the estates and facilities that are there, so there is a little bit more work to do to fully understand that, but I know that Custor will want to say more about the detail. Just to pick up on Clare's point, that global sum of £887 million is not a sum that all boards and the Government will have to find and spend in the next few years, because, as Clare says, the estate needs will change and boards and the Government need to work together to identify how the NHS needs to change to make sure that it is fit for purpose for the future. That is one of the recommendations that we make around the need for that capital investment strategy. Around the high-risk backlog that exists, boards will identify in their asset management strategies the extent to which the backlog maintenance is high-risk. They will then decide their appropriate strategies to decide how to deal with that. Some of that might be that we know that we are about to open a new hospital, so it is fine. If we look at the picture next year, the condition will have completely changed. It is board responsibility to prioritise the capital investment that it has and how it manages its estate and makes sure that it is in good condition, suitable and functional for patients. From the work that you have been doing in the audit, are boards showing that they have the skills and the capacity to do that well? I know that your recommendation is to develop a capital investment strategy, but has that been lacking or has it not been adequate so far? Boards have had asset management strategies for a number of years now. The data that exists around the NHS estate is much better than it used to be. What we are seeing is that there is a need at a national level for a strategy to pool together all those board strategies that exist. Boards will identify on their own where their estate needs to go and the amount of money that needs to go into it. Obviously, there is a limited pot of capital money at a national level, so the Government needs to pool that together and work with the boards and the IJBs to identify where the estate needs to move. That brings in the new elective centres as well. What regional working will look like the facilities around that, the facilities at a local level around and enhance GP services and pool that altogether to make sure that the amount of capital money that is available is able to deliver the estate that is going to be needed in the future? In the report, you said that there has been a 7 per cent increase in backlog maintenance classes significant and high risk. That is setting at 47 per cent. That does sound quite high. High risk, what kind of circumstances is that covering? High risk can cover a range of things. Some of it may be the basics of wind and water tight. A lot of it will be to do with safety compliance of regulations and how well the facilities are able to actually meet the regulations that exist for patient care. Have you got any sense of what impact that is having on staff morale or whether there has been an increase in patient complaints? Does it have any sort of connection to that? I know how people feel in an environment that can really affect their wellbeing and that they are moved as well, so if people feel that it looks like it has fallen round about, that might have an impact. Do you get any sense of that? We did not have a look at that in any detail in this report, but I know that the national report on the NHS estate that was published in the summer does have an indicator around patient satisfaction with the estate, and that has improved slightly over the past few years. I was going to ask a question that Colin Beattie came in on, but I will ask it anyway in a slightly different way. You said that the levels of overall patient satisfaction continue to be high, but in the same breath you more or less said that complaints were up, and we see in the financial statements that there are hundreds of millions of pounds set aside for medical negligence claims. Is there something counterintuitive there? How robust is the statement that levels of overall patient satisfaction continue to be high? We have taken the statement from the national inpatient experience survey, which is a very large robust survey that is carried out on a regular basis. It is what patients are saying in response to questions and in large enough numbers to give it credence. In response to a question that perhaps Mr Coffey asked earlier, I said that we know that that is not necessarily a straightforward thing. We know that patients rate the NHS very highly anyway, and that, if they recognise that staff are working harder than ever to provide their care, that may be reflected in the levels of satisfaction that they are reporting. For completeness, we have shown the range of different indicators of quality in the NHS and highlighted that they are not consistent in that way. Claire, do you want to add to that at all? I do not think that there is much more to add. I think that what we are saying is that we understand why those things might look counterintuitive, but that is the fact, as we see them. Because people are consciously engaging with clinical staff and feel the care and support that they get is good, it is not necessarily counter to all of the challenges that we know the NHS is facing. It speaks to that message right at the start of the report about the commitment and the hard work of staff. The information is valid. We say in the report that it is becoming increasingly difficult for staff to continue to provide that level of care. The survey only asks a limited number of questions. I am not familiar with it. It does not sort of look beyond that you had a good experience with the front-line person. It asks quite a wide range of questions. We go on to say in the same bullet point that a significant minority of patients did feel that they were less involved in discussions about their care than they would like to be. There is some nuance there, but nonetheless the headline about overall satisfaction is what people reported in response to the survey. On another comment that you made, you said that there was no quick fix. I do not know what analogy is the appropriate one for the NHS, whether it is a supertanker or a convoy. By the time the slow fix comes in, it is somewhere else in different circumstances. How do you fix it then, if there are no quick fixes? What I would say is that because the health service is about people and because we do have very good demographic information and information about some bits of the health service, we can see what is likely to happen over the next 30 years. The population forecasts give us a very good indication of how much the number of older people is going to increase in that period. We know what is happening to life expectancy and we have seen some very significant increases that have reduced slightly. Recently, we can play all of that in. There is increasingly strong evidence, as Clare was describing from around the world, that moving our focus away from just what is happening in acute hospitals to what happens near people's homes in primary care and in the wider public services can address some of that. The point that I am trying to make in the report is that some of the building blocks are in place. We have the proposals for the new GP contract. We have the review of the targets and indicators. We have general commitment to the vision. What is needed now is the key things to make it happen around a financial framework that makes sure that we are investing in the right places, better workforce planning that makes sure that we have the people that we need, doing the new jobs and the new types of services that are needed in the future and that we are making sure that our capital investment is building an NHS for the future, not just running to keep up with what we have right now. I think that there are a number of small things that can be done that will help it on the way. I do not think that there is a quick fix. Coming back to something that Liam Kerr asked about, you were talking or mentioned unidentified savings. Is that just the way that boards make their budgets? They just take the difference between what they know and what they do not know to make it balanced and then sort it out later? I think that Kerstiol wants to talk you through it, but if you look at the case study on page 19, that gives you an example from an NHS grampion of how they go about it. They are taking, as you would expect, what they think they will have in terms of money to spend, what they think will happen to the commitments that they have for workforce drugs and other pay pressures and that gives them a gap that they need to close and they then work on planning how they will close that gap. Kerstiol, do you want to pick that up? Yes, there is not much to add to that, because Carling gave a very good explanation. As case study 1 shows on page 19, the boards will make assumptions about certain things. They will know certain things that will make assumptions about certain things, such as funding over future years. They will work that all through, look at the funding and the other income that they are receiving, and then identify where they need to make savings. In terms of identifying those savings, they will work through where they think those savings can be made. As I mentioned earlier, it is becoming increasingly difficult for boards to do that. We have seen over a number of years the slicing element, but that is not sustainable. The reason that we have got to a point of quite high levels of unidentified savings is because we are getting to that point of service redesign that things really need to change. There are not just small amounts that can keep coming off. You write very carefully crafted reports. We get very carefully worded replies from the Government. In the past few sessions, we had three chief executives saying that there were no workforce plans, and then we had the chief of the NHS coming along saying that there were. If you look through the words and from what you said, there are a lot of changes to come. There is a lot of thinking that needs to be done working together. Is the system fit for purpose for that? We say in the report that the signs of pressure are increasing. I think that the sessions that you heard over the last two weeks on workforce planning are a subset of the bigger problem that we are describing here. I think that the recommendations that we made in the reports that led to those sessions on workforce planning are what needs to improve there. I said in response to an earlier question that I think that this can be done, but I think that it does need, first of all, a very concerted effort. It needs the three key recommendations that we are making in the report to be addressed urgently. We have got the building blocks there. There is a huge amount of commitment to make it work. It is about pulling all of that together and making sure that all of that effort is pulling in the same direction on the things that will make the biggest difference. I would say that that is a carefully crafted answer that change needs to come. Colin Beattie? I just wanted to come back here on one thing about savings. Obviously, the non-recurring savings are a worry.  One thing that I was concerned about, which has come up in previous reports, is that a proportion of those savings were generated in some boards by delaying filling posts. Now, I know that there is a problem in getting people to fill posts, but is there any indication of deliberate delays? That is one of the ways that boards are trying to make those savings. Not just in the past year but previous years, there is a range of ways that boards are trying to make the savings around the non-recurring element. Some of them have been delaying filling posts until a few months on, a year on, just to try and make those savings. How significant is that? In terms of the non-recurring costs? I do not have the level of detail with me around that. We did not go into that level of detail, but I would be happy to have a look at it and come back. That would be good. That would be very helpful. Alex Neil has a very brief point. A very brief point about complaints and the increasing complaints. To be fair, over the past three or four years, the NHS has introduced the patient opinion system, which was deliberately designed to elicit information about where things were going wrong, so could it be that the rising complaints are at least partly, if not largely, due to a better system and a deliberate attempt to get that kind of feedback? Exactly that in the report. At the top of page 24, we say that NHS boards have worked to raise awareness of their complaint system, and that may account for at least some of the rising complaints. We cannot break it down, but we recognise that it may be a factor. I just wanted to get it on the record here as well.  Auditor General and your two colleagues, thank you very much for giving evidence this morning. We will now have a brief pause to allow witnesses to change over. We will now take evidence on the Auditor General's report on NHS Tayside, and I welcome Caroline Gardner, Auditor General for Scotland, Fiona Mitchell Knight, Assistant Director of Audit and Bruce Crosby, Senior Audit Manager for Audit Scotland. I invite an opening statement from Caroline Gardner. For the first time in five and a half years in this job, I cannot find my speaking note for this morning, so I will make it very short to introduce your questions to us. As you know, I have reported for the last two years on questions about the financial sustainability of NHS Tayside and the action that the board and the Scottish Government are taking to try and return to financial sustainability. The report that you have in front of you is the third of those. It is under my powers under section 22 of the Public Finance and Accountability Act which enabled me to bring to the attention of Parliament and this committee issues that have arisen from the audit of the accounts of the board, which I think are of interest to you. Fiona Mitchell Knight has given the board an unqualified audit opinion again this year, but she has highlighted that the concerns around financial sustainability continue, and that there is a lot of action going on within the board itself to try and return to financial sustainability. They made a significant amount of efficiency savings in 2016-17 but still required an additional £4 million in brokerage last year, and the savings were still below the target that they had set themselves. As you know, the Scottish Government has appointed an assurance group to work alongside the board to provide assurance about the quality of the work that it is doing to change the way it works and bring itself back into balance. The latest report of that group has recognised the extent of the work that is going on and the extent to which it focuses on the right areas, but has also highlighted that the next period will be critical in moving from developing plans to actually implementing those plans, and we will be continuing to work alongside the group as part of our audit work to understand what that means. Fiona and Bruce Crosby from the audit team are here to help me to answer questions that the committee may have. Thank you very much for this general. Alex Neil I just tried to clear up the debt and the brokerage issue, because there seems to be still some confusion around what is actually going to happen. We have had the letter from Paul Gray indicating that the board will not be required to effectively repay their debt until it is in financial balance. What is your understanding of the phrase financial balance? Secondly, given the timeframe that will be required to reach what I suspect to mean by financial balance, that debt will become quite a challenge that I would afford for the board to repay. Would it not just be better for everybody to recognise that, particularly if we are going to make sure that services are not going to decline significantly in Tayside, that we should just write off the debt and allow them to make a fresh start? As I understand it, as you say, the chief executive of the health service has made the commitment that NHS Tayside will not be required to repay it until the board is back in financial balance, and that a decision will be taken at that point about whether it needs to be repaid or not. Financial balance means meeting the resource limits, both revenue and capital, which are set for NHS Tayside as for every board. The board itself identifies that in order to be financially sustainable, it will need to make savings of £205.8 million cumulatively over the next five years. There is little doubt that the outstanding brokerage of £33.2 million at the moment will increase further by a small amount, and Fiona will be able to give you updated indications of that if that would be useful. It is a policy matter for Government to decide whether it wants to write off the debt or to suspend it as it has done until the board is back in balance, but, as my report says, there is no doubt that it will be challenging for the board to return to financial balance. How achievable is £200 million of savings over the next five years, particularly if there is to be no reduction? In fact, one would be arguing that there should be anything but, there should be an enhancement of service provision. If you look at all the Government strategies and so on, they will say that further demands on resource allocation within Tayside to meet national targets and so on. What are the realistic prospects of achieving a further cumulative £200 million worth of savings? That is the key question. The committee knows from previous work that we have done, that Tayside itself has done and that the assurance group has done, that Tayside costs more relative to other boards to deliver like-for-like services when you are taking hand of its population and so on. It is still costing more. The assurance group has said that the areas that the transformation plan is working on are the right ones to address that higher cost. They are looking at the big areas such as cost of workforce, realistic medicine, cost of prescribing and all the areas where Tayside is more expensive for the same level of service. There is no doubt that it will be challenging to do it. In some ways, Tayside is facing a more acute version of the problems facing the health service as a whole. Understanding how the change can be made, what it costs to do that, what the impacts are on staff and patients and other public bodies, is a key part of what needs to happen in Tayside over the next few years. Fiona, do you want to add to that at all? Yes. It is the case that it continues to face extremely challenging financial position and the challenges to make financial balance continue. In 2016-17, the board delivered significant efficiency savings of £45 million. That was double what they had achieved in the previous year, so that was significant. However, it was still below the target that was needed and, as has already been mentioned, brokerage was received for that year. In terms of the 2017-18 financial position, the financial plan for the board showed that it needed nearly £50 million of savings to achieve balance. It was recognised that the board could not achieve that in one year. The local delivery plan includes a target for £45.8 million savings, with around £4 million to be met from brokerage this year. It is further brokerage to be achieved. The latest outturn position that is being reported by the board is that the shortfall in efficiency savings is in the region of £5 million, but the board is taking extra actions to draw that in to the £4 million that was included in the local delivery plan. The board recognises that, to achieve financial balance into the future, it is not enough to just keep making efficiency savings and that more fundamental service redesign and transformational changes are required. That is the objective of the transformation programme that is now in place and under way in the board, but it is yet to deliver on those savings, the level of savings, and we will hopefully start to see the impact of some of the initiatives that are coming through that programme into the longer term. Ultimately, where we are at this point in time, based on the evidence, is that there is a high risk that the financial plan 2017-18 will not be achieved, but it is something that will continue to monitor and report on through the audit. I think that it would be useful if we could get a copy of the actual transformation plan that they are working to, if that was possible. I think that it is possible. I think that it may have been provided previously when the committee was taking evidence from NHS Tayside, but we can work with the clerks to confirm that. The final question is, who is making sure that these savings are not being made at the expense of the patients? That is obviously mainly the responsibility of the board, the chair and the chief executive, and I know in assurances that they have given to this committee that they take that very seriously. The role of the advisory and assurance group is absolutely to test that and to make sure that the effect on patients is being planned, measured and that any adverse effects are being dealt with as quickly as possible. That is one of the reasons why the Government put the group in place. From your report of the late targets, three have improved, four have remained the same, a couple have gone down the way or something of that order. At the moment, there is no indication that that is leading to a reduction in the quality of service, but presumably that is something that you are going to keep a close eye on in terms of those performance targets. We say in paragraph 18 of the report exactly as you said that eight were not met, eight were met or exceeded and that TASIDE is by no means an outlier compared to other boards, but we take seriously the need to look at their financial performance in the context of their performance overall and the safety of patients, and we will continue to keep an eye on that. Just to pick up on what you said there, if we compare the performance from year to year, there is no clear picture about whether a performance is improving or declining, four have improved, eight have declined, three are the same and there are two for which no targets are available, so there is very much a mixed picture and there is no clear direction of travel that can be taken from those indicators at the moment. Thank you. Colin Beesie. Just to be a little bit nitpicking, what is the definition of net expenditure for NHS TASIDE?  That is the net expenditure that comes from the annual accounts that are published and audited by us, so that is the bottom line figure, which is the net position of income less expenditure. Does that take into account any income? Is there any income? Yes, it does. How much income? I would need to look at the accounts on that, Bruce. I tell what I am interested in knowing what the gross expenditure is and seeing what the savings against gross expenditure are, because it would be interesting to see how much income they actually have. It is not that simple to take out of the accounts because the accounts show income and expenditure over different natures of cost, so that is not a figure that we can easily provide. The £205.8 million that has to be saved over the next five years, that is in addition to the 2016-17 figure of £45.5 million, is it not? I echo what Alex Neil is saying. Is that possible on that level of budget? It is challenging. We do not think that it is impossible and the advisory and assurance group do not think that it is impossible. It might be worth looking at the savings forecast for the next five years, which is set out in Exhibit 3. What they are showing is that the percentage of the baseline funding that needs to be made in savings is declining over that period. For reference, in 2016-17, the year that this report was about the savings that was achieved was 6.5 per cent, and it is reducing down steadily to about 5 per cent. We do know, as we have said, that the costs in NHS Tayside are higher than in other boards for like-for-like services, so there is scope to make savings, but it is a very significant amount to be taking out, and it can only safely be done by transforming services, which is what the board is trying to do. That is why we highlight the risks to achieving them. Has anyone looked at it? It is quoted here about work for cost, for prescribing costs and clinical supplies. Has anyone looked at it and said whether that is appropriate spend for Tayside, given its demography and all the other things that come into this? In other words, is it actually not excessive, given what they are trying to deal with? No. When I talk about like-for-like spend, it is taking account of exactly those things. It is taking account of the demographic size of the population, the demographic make-up, the extent to which there may be particular challenges for delivering because of rurality and so on. As far as it is possible to make comparisons on a like-for-like basis, they suggest that Tayside is still more expensive than other boards, largely for historical reasons, due to the number of large hospital sites that they have been operating with over that period, and the referral and treatment patterns that have historically been seen in Tayside. Again, it reinforces that point that it is possible, but it is not easy and it just relies on transforming services. Previously, when this first came up, a large part of the projected savings revolved around disposal of fixed assets. I know that some fixed assets have been disposed of, and I see that they have reduced the anticipation of what they will get from that source. What is the cost to NHS Tayside of maintaining those fixed assets that they are waiting to dispose of? That is something that I do not have to hand, but clearly there will be a cost of the on-going maintenance while the board is waiting to dispose of those assets. It is something that is recognised by the board and they are taking action to dispose of surplus assets. They monitor and report back on progress to the board on a regular basis on that. It is possible for us to know how much those maintenance costs are, because I think that previously they were significant, but not overwhelming. That is not something that we would be aware of part of this work, but you would need to ask the board about that. The history of this with NHS Tayside has not been an easy one. There have been failures in terms of management and the board over the years. Are we satisfied that, currently, the governance and management of NHS Tayside is adequate to the task ahead of them? I mentioned in my introductory remarks that this is the third report that I have produced on Tayside in consecutive years. I think that the real difference this year is that there is not just a recognition of the problem that we saw last year, but a much fuller understanding of it and of what is needed to address it than was initially the case. I think that you may be the only member of the committee who was on the committee at that time round. What initially triggered my report on NHS Tayside was the fact that their annual accounts contained over-optimistic assumptions about the proceeds of the disposal of assets in the following year, which had the effect of appearing to minimise the scale of the financial challenge that they were facing. I think that we have moved beyond a situation where the focus was on how to minimise the problem to a situation where it is now much clearer what the problem is and the plans for addressing it are developing all the time. As we say in the report, the challenge now is to turn those plans into action and to do it in a way that does take patients and the people of Tayside with the board to reach a situation that is not just sustainable in the future but that is potentially providing better healthcare than it has been able to so far. Has there been much change in the composition of the board itself and in the management of NHS Tayside? Since the initial problems came to light, we have seen the appointment of the new chief exec and some turnover among board members, and I think that that has contributed towards that recognition of and grasping of the problems that I have just described. Fiona, do you want to add to that? Yes, the director of finance has now been in place for about a year, the current director of finance, so that has been a change in the management team. Certainly, our evidence of working at the board we see a clear commitment from that senior executive team to the level of change that is required. Is the chief executive an internal promotion or is it someone who has come in from outside? He was an internal promotion and that is something that the committee explored in its previous evidence sessions with the board. The board itself is essentially the same board that was overseeing the situation over the last few years. I do not want to mislead the committee by focusing on specific terms of appointment. There has been turnover and I think that the chair is a new chair since the problems built up before my first report. Bruce, can you shine any light on that? We have only taken on the audit for this year, so I am not really sure about the composition of it before then. I do not think that I could add anything to that. I guess my concern is to ensure that those who failed previously are not building us up for failure in the future and that there are people in there who understand the issue, have their hands around it and are managing it efficiently and successfully. I recognise that concern. It is obviously what I am aware of in reaching my audit conclusions in the report that you have before you. The board and the senior management team now have a full understanding of the issue and a commitment to resolving it for the challenge of doing so is the next step. I think that the staging report that was done by the transformation support team can get some comfort from the commitment of the executive team at NHS Dayside. I think that the support of the transformation support team will be crucial in providing the sort of advice that they are able to give to ensure that they get balanced position in the coming years. Very briefly, just to clarify something, you said in response to Colin Beattie that the direct finance had only been there for about a year. I have in my mind that the direct finance had been there for about 33 years, so what have I missed? No, he has worked at the board for a longer period of time, but in that post, it is direct just for over a year. It is the same chap that has been there for 33 years, isn't it? I do not know exactly the exact term. The point that you asked about the level of income. I have had an opportunity to look at the accounts and that is of the order of about £600 million. That is what brought the net expenditure down to just over £800 million. Okay, I am resisting the temptation to ask a follow-up to that. Willie Coffey. I wonder, it was not part of the previous discussion on this issue at NHS Dayside, but could you just elaborate a wee bit about what the differences are in Dayside that might be given rise to some of these cost pressures? What is different or special about Dayside? We know that the level of staffing costs relative to the population that they serve and activity is higher than the average for boards across Scotland. We know that their prescribing costs, both in hospital and I think in primary care, are higher, and I think that that is due to both higher numbers of prescriptions and higher costs of prescriptions around there. We know that their estates and property costs are higher than the average for NHS boards around Scotland. They have a lot of analysis as to why that is and where the costs are arising, but they are higher in those three key areas. Bruce, are you wanting to add to that? No, I do not think that that is a good comment. What matters is not wildly higher. Prescribing costs went up by an extra £2 million in your paragraph 14, as the general said. Prescribing costs overspent by £6.7 million compared to an overspend of £4.7 million in the previous year. In one year, prescribing costs went up another £2 million. What on earth could the reason for that be? They are not alone in that. Their overall prescribing costs are higher than Scotland as a whole, but, as we were saying in the earlier session, drug costs nationally UK-wide are rising faster than inflation. Part of that is straightforward inflation and the cost of drugs. Part of it is new drugs becoming available that tend to be very expensive. Part of it is an ageing population where more people are getting prescriptions, so they are not alone in it moving in that way. They are unusual in that the baseline is higher for Tayside than for other boards, and that is having an impact on their overall financial position. The board has commissioned some very detailed exploration of where those higher costs are arising, how much it is volume and how much it is price and whether it is hospital prescribing, GP prescribing, which specialities it is happening in, to let them drill down and address it. In terms of getting their arms around the problem, they have a much better understanding now, but their starting point is higher than other health boards across Scotland. There is good evidence that they are taking out their worn. They are tackling that directly now. I was just looking at the performance figures at the back in some of them from the previous sessions stuck in my mind. The section on psychological therapy, and I see that there has been a number of vacancies and maternity leave care breaks and so on. Is that an area where it is possible that posts have not been filled deliberately? That is quite concerning, looking at the drop in standard. I do not think that we can answer that specific question. We know that psychiatry is one of the specialities that can be hard to recruit to across Scotland, so they are not alone in that. Fiona, is there anything that you want to add to it based on your local knowledge? No specifics. Where the board is struggling on issues of recruitment, they are looking at their attraction and retention policies across the board as part of their workforce planning through the transformation programme, but no specifics on that. In terms of NHS T side, I have been in a number of these sessions now and it has been a very challenging picture. What are the wider lessons that are being taken from T side? It has not escaped our attention that the health secretary herself is local to T side. How can we be reassured that the challenges that T side have faced are not going to start to keep into other boards? I have, as well as the report that you have in front of you, and Fiona is a very close engagement with NHS T side. I have tried to keep a close eye on what the Government is doing to manage the situation to support the board to protect the interests of patients and people across Scotland. I genuinely think that the approach of having the advisory and assurance group to test their thinking and challenge it and to do that robustly, but in a way that is constructive, and the transformation support team, which is helping them to draw on expertise elsewhere in Scotland, is a very positive model for dealing with the problem of this scale. I think that senior people within the Scottish Government are taking the opportunity to think about how elements of that approach can be applied elsewhere, so to really use the benchmarking to understand where costs are higher or where performance is lower than elsewhere, to use that as a way of sharing good practice, sharing expertise, tapping into new ways of doing things to help peers to learn from each other across Scotland. I think that there is a good start being made on that. I think that there is scope to take it further, and I think that it can also be used to inform some of the things that we were describing earlier around better workforce planning and better capital investment planning. Again, although this is a very difficult situation in T side, I think that there is an opportunity to learn from it for other parts of Scotland and to use it as one of the levers for encouraging people to adopt good practice where it is developed elsewhere. The assurance and advisory group is looking at the report recommendations. There are some points of concern there. One of the things that you highlight in your report is that the group reports insufficient evidence of progress with the key elements of the transformation programme. There is still a lack of confidence that T side can achieve its financial plan. There are a few warning signs in here, and we have heard a lot of optimism from the board, from some of the witnesses before. How can we be sure that things really are on track? What you have got is my assurance, which draws on the views of the advisory and assurance group about the balance between absolutely the scale of the challenge and the progress that is being made. I hope that we have been able to give you a thorough and balanced view of that. The assurance group genuinely feels that a lot of progress has been made in understanding the problem and drawing up plans, and it is clear that the next stage of implementing those plans is going to be the key one. We all know that that is not going to be easy. It means taking a wide range of staff right across T side with the board and the management team to do it. It will mean some changes to services for patients, some of which may in the longer term be better than what is currently provided, but change is always uncomfortable. There are cost pressures pulling in the other direction around drug costs, as we have described, around pressures on the property market where disposals are part of the plan. Progress is being made, and the problem is understood better. There is a much stronger commitment to what needs to happen to address it, but it is not plain sailing. There is still quite a lot of unknowns there. My final question is that the board is expecting the percentage of recurring savings to increase to 60 per cent. That is a big number from 19 to 20 onwards. Are you satisfied that that is achievable? Since I am comforted by the fact that the recurring savings are going up at the expense of non-recurring savings. Recurring savings are an indication that they are genuinely managing to reshape services in ways that can be sustained for the longer term, whereas non-recurring savings are often made by selling properties and not filling vacancies. It is a good sign that the challenge is whether they can achieve it and maintain the quality of care at the same time. There is some evidence about the percentages of recurring savings on a positive trend. In 15 to 16, only 35 per cent were recurring savings, but in 16 to 17, it was near to 50 per cent. That is a positive direction with that from the board. Are you happy that there is more measurement to patients? As we said earlier, based on the indicators at appendix 1, it is a very mixed picture and there is no clear evidence either way of an improvement or a decline in performance over certainly the last year. That is something that we will need to monitor going forward. Liam Kerr, thank you convener. I will try to be brief. A number of matters are rising, it seems to me. First of all, there has been a great deal of non-financial support given to NHS Tayside over a considerable period of time. Other than providing brokerage and reviewing the NRAC allocations, are there any other feasible ways that the Scottish Government can actually be assisting the board? Are there any other non-financial things that they should be doing? Are there any other financial things that they should be doing? I think that, for very understandable reasons, the focus of the Scottish Government has been on helping the board to understand the problems and to address the underlying causes of it, rather than to continue providing short-term funding to close the gap. I have said previously in response to questions that I think the approach of having both the transformation support team, which is there to provide support and advice, and the slightly arms-length assurance group, which is there to test out and challenge progress, is a good model and one that could be adapted and used elsewhere. If I had any criticism of the approach that has been taken so far, I think the focus on one-year brokerage to fill a gap this year, rather than a longer-term view of what the financial situation is and what is needed to address that, took a while to put in place. I have been reporting since 2013 when I took this job that we need a longer-term approach to financial planning and financial management. I think that that is a good example where a real over-focus on the annual situation made it harder to get a grip on the longer-term position and really start to address it. I will come back to the financial piece and then the financial management in a second. Has there been a significant cost—by which I also mean an opportunity cost—to the Scottish Government and other parts of the NHS as a result of providing this extensive support to NHS Tayside? Specifically, the thing that I have in my mind is—I recall and you will correct me from wrong on this—that NHS Grampian needed about £15 million to get it up to its NRAC. The funding formula required to be met would require an extra £50 million to go to NHS Grampian. Is there any suggestion, any possibility that money is being pulled from other parts of the estate to support NHS Tayside? In the sort of micro-picture not, I think if you look at the amounts of brokerage each year as set out in exhibit 2, they are very small in the context either of Tayside's overall funding or the £13 billion that is spent on the NHS overall. I think that the bigger opportunity cost is the one that we were describing earlier, that NHS Tayside costs more on average to provide similar services than other boards. Tackling those sorts of differences will free up resources that can be invested right across the country. It has taken Government longer than it initially expected to get all of the boards to the NRAC position, the National Resource Allocation Committee formula, but I don't think that Tayside itself was a significant element in that. Is there a suggestion that NHS Tayside will require permanent additional support, whether it be financial or more likely permanent like support from the AHEG, for example? The intention is not. Mr Neil asked an early question about what financial sustainability means. It means being able to manage within the resources that are available to it under the national funding system and provide the level and quality of services that the people of Tayside need within that money. Getting to that position is the challenge. Just staying finally on the financial position, we heard Fiona Mitchell-Knight earlier on talked about the deficit forecast of £4 million for 2017-18, and there will be additional brokerage required. The AHEG, the Assurance and Advisory Group, believes that that is an underestimate. You said earlier that previous financial estimates have been over-optimistic about the disposals, and now there is a recognition after four years of reporting on that that there is a need for long-term financial management. Does that concern you at all that whoever is responsible for this situation is still underestimating the size of the whole and is still in a position to try to fix a problem that some might suggest has been caused by those who are currently on watch? I will ask Fiona Mitchell-Knight to give you the latest financial position as we understand it. I think that we have touched previously on the extent to which there is a new board and changes in the senior team at Tayside, which has got a fuller understanding and a very strong commitment to dealing with what needs to be done here. I think that there is genuine complexity in trying to make changes on the scale that are required in Tayside. That is not to say that I do not think that there is a risk of optimism bias in anything of this nature, partly because of the commitment that people have got to fixing it. I think that that is the value of having the Assurance and Advisory Group there to be applying that very detailed examination and challenge to the plans that they have. Fiona, do you want to just provide a quick update on the current position this year? Yes, the current forecast stout term position for March 18 is currently that there is a savings gap of £5 million compared to £4 million, but the board is working on measures to close that gap and is anticipating being able to do that, but we will obviously have to wait and see. Is there a commitment to dealing with it? Yes. You know this organisation better than anyone having looked at it. Do you think that they will deal with it? As you said, there is definitely a commitment to do so, but the important thing is the shift away from short-term efficiency savings to real service design and transformational change. The actions that the board is taking through the transformation programme are driving that forward. We are starting to see some initiatives coming through at the board meeting in December. The board is due to discuss the overarching clinical strategy, which will set the direction for the board going forward, and then the workforce plans will be aligned to that clinical strategy. So there are some really important milestones coming up for the board, and we can see them in the near future, but they are yet to deliver financial savings that are reported in the accounts today, and that will be something that we will be looking for in the future. Will they deliver in your view? We say in both of our reports that it is challenging. I cannot give you a guarantee that it is challenging. Again, Colin Beattie and others have touched on topics that I was going to speak about. I do not have the detailed experience of this board that others do, but just looking at the history over the past five years where an organisation has effectively had to go to its banker and ask for more money and then keep on refinancing it, and then not unusually the banker or the lender has put in its own team to try and see what is going on and oversee it, and not only that has put in another team to actually see that its recommendations are worked through. It is, of course, worrying. The discussion around it has spoke about whether they recognise that they have yet to deliver. It has not really—I suppose that Liam Kerr has asked the question about whether they would do it. When you, Fiona, were finalising your audit, I presume that you were concerned about the future viability of the organisation and you would go to the Government as a lender to get some comfort that they would continue with the existing funds and future ones, and you would speak about the future plans. The key thing is not just the recognition and yet to deliver, it is the competence of the management. Did the Scottish Government have a view on the competence of the management? The Scottish Government certainly haven't spoken to me about the competency of the management. In terms of the work of the Assurance and Advisory Board, they have reported the same level of commitment that I have spoken about from those senior executives, but what they have recognised was that the capacity of the executive team was under stretch because of the scale of change that was required. That is why the transformation support team was brought in to work alongside the executive team to support them in that, but there has been no indication of capability issues with that senior executive team. Would you not expect there to be a discussion like that? How can you be satisfied that the future plans will work if you do not know how competent the management are? Fiona is taking comfort from her own experience of the team and the views of the Assurance and Advisory Group, which are there. There is also an important difference in public services compared to the corporate sector in that the Government can continue to fund at the level that is required, as it has done in the past. The assurance that it will continue to do that carries more weight than the need to take a view on the competence of the management team. Having said that, I share Fiona's view that the main question here is not the competence of the team, but the scale of the challenge and the scale of the change that is required in a system as complex as healthcare. I am concerned about the issue that Liam Uncoverd said that we are talking about a new finance director when, in fact, it is somebody who has been there for a long time and is presumably carrying on as before. He has certainly been in the board for some time, but he has obviously been promoted into the director of finance posts more recently, over the last couple of years. In terms of the financial management of the board, our annual audit report reports that that is effective in terms of the processes that are in place, but clearly the size of the challenge in meeting the financial forecasts of the future is something that they are working on through the transformation programme. I think that I will leave it there as the competent situation as it is. Perfect timing. I thank the witnesses for their evidence this morning. The committee is now going to go into private session and I propose a three-minute break. Thank you.