Ddiolch i chi gael iawn i'w maes y 26 o'r gwaith yn y cyflawniol cymdeithasol, ac yn panfio'r cysylltu y Sgrutinid Gaeliad yng Nghymru yn 2017. Dwi'n ddweud i chi'n gael iawn i gael iawn i'r gaeliaethau cymdeithasol, oherwydd gofynu'n cytuniau'r cyfrifoedd o'r ddweud o'r cymdeithasol, oherwydd ddweud i chi'n ddweud i chi'n gael iawn i'r cyfrifoedd, oherwydd ddweud i chi'n gael iawn i'r cyfrifoedd? Reoli i gael items 3 arifnig i gychwyn. Yr iawn, cadw i chi'n gwybod gyda'r items 2, i gael ynddaeth gydag o'r partyniad, y dyna'r gweithio gwybodaeth o'r NHS Gwfran Unedig. Their cysyllt yma'r pen yw Paul Grey, director general health and social care i gael Gwyrgu Cyffredinol o NHS Scotland, Surally Rogers, director of health workforce and strategic change i'r Cyfrin Cogdorydd, chief medical officer, all from the Scottish Government. I invite an opening statement from Paul Gray. Thank you, convener. I propose to just say very briefly that I'm grateful to the committee for the opportunity to present evidence today. We will, I trust, share the questions appropriately between myself and my colleagues. If there is anything to which we don't have a factual answer, we'll seek to provide it as quickly as we can. And if there are any issues on which we require to take further advice from other professionals, we'll do that and again provide the evidence to the committee as quickly as we can. I really don't want to take up the committee's time with a long speech, so I'm happy to hand to you, convener, for questioning. Thank you very much, Mr Gray. I wonder whether I could kick off because last week, when I wasn't here, unfortunately, we heard from some of the witnesses that there appears to be no coherent plan in place. If you were to kind of gauge the importance of having a coherent plan, is it something that you regard as kind of nice to have or absolutely essential? So I think I would like to begin by saying that there is a coherent plan. We have already published phase one or part one of that plan. There are two parts still to come, one already well forward in preparation and the other on the stocks. Is it nice to have or essential? It's essential. That's why we're doing it. We wouldn't be doing it if we didn't think it was essential. I think in the present context in which we operate, focusing on the essentials is important. Can I therefore ask then, given that workforce planning decisions were made before and previous ministers have taken decisions to cut numbers or increase numbers, on what basis did they do this if we're now only arriving at a comprehensive plan? I'll ask Shirley Rogers to come in on that in the moment. Ministers in different contexts and in different administrations would make their decisions based on the best advice they had at the time and in the context in which it was made. A decision made 5, 10 or 15 years ago would be different from one that might be made now. There have been significant changes over time. I would offer three areas, although they're not meant to be exhaustive. The first is changes in clinical practice. So, for example, things are now done differently from how they were done 5, 10 or 15 years ago. Changes in our approach to multidisciplinary teams, so the spread of work across different disciplines is different and we need to be planning for that. I genuinely don't want to pull us off on this, but contextual issues such as Brexit, the decisions made there do have an impact on how you might plan for a future workforce if your stock of people is likely to come from different sources. All of those considerations and many others would apply at the time at which decisions were made. If you had such good planning tools and such a positive approach to planning in the past, why then do we have such acute shortages? Given that it takes 15 years to train a consultant, surely we should be horizon scanning in a way that allows for that and that we don't simply think in five-year bursts? I think that your point about thinking not just for the medium but for the long-term is fair. We have seen changes in the way in which clinical practice is delivered, but it is a fact that in some specialties—again, the chief medical officer could speak to this—there are worldwide shortages. We are up against the same situations as other health systems in developed countries face. I don't say that as an excuse, but it is nonetheless a fact that in some specialties it is difficult to recruit beyond national boundaries and internationally. I also think that, having come to the point of developing a comprehensive workforce plan, we are drawing together significant strands of work that have always been done. We are not inventing some great newness here, but what we are doing is bringing coherence to work that was always done perhaps on a more narrow basis. I think that that is all to the good. The inclusion of the social care workforce in this plan is another important contextual difference from what might have been done in the past. That is why we are working closely with COSLA and SOLIS and other partners to make sure that we get that aspect of it right. I do not know whether you want either the chief medical officer or the director of workforce and strategy to say more about any of these issues. We will probably pick that up in questioning from other members. Colin Beattie. For how long have you been working on a national workforce plan? That is surely to give you the detail, but in terms of what we have now produced, we have been working on that for at least a year. I am happy to help you further if there is a more specific point that I can follow. The point that I am coming to is that this should not be something new. I presume that the different boards and yourselves have been working on a national plan for some years. I am looking at the evidence that you gave to the committee. I am struggling here to see anything other than jam tomorrow. There is nothing firm in here. It is all things under way, under active consultation, being considered and we are going to recirculate guidance. There is nothing firm here. There are approximately 156,000 people working in the national health service in Scotland at the moment. They came from somewhere. They came from the planning that we did. They are still coming from the planning that we did. If we had no plan, there would be no people. Universities do not train people on the basis of speculation that something might happen. I accept that what we are doing is drawing together strands of work that we have always done, but I do not accept that this is all jam tomorrow. There are doctors, nurses, physiotherapists, pharmacists and other allied health professionals working in the NHS in Scotland today because of the planning that we did. You say that you are drawing together all those threads that already exist and that are already giving you the information that is necessary for a national workforce plan. Is that correct? We are doing that. We are augmenting it by further work that we are doing on data, for example. I know that the committee took evidence about data. That is an area where we have some substantial amounts of data, but we need to improve the way that we draw that together and present it so that there is an improvement, in my view, in the quality of the data and the transparency with which we present it. We are looking to improve. I am not disputing that there are things that can be improved, but what I am saying is that we are improving on the basis of work that we have already done. I am happy if Shirley-Anne wanted to give more detail on that. I think that I would like to refer back to last week some of the evidence that we received from the four NHS boards. They gave a joint submission here and it was pretty negative in terms of how this is going to work. In fact, to quote from it, how this will be done is not yet clear, but it is believed that the new national workforce planning group will provide leadership on how it can be done. They do not seem to have a terribly upbeat idea as to how all this is going to come together. I realise that it is complex, but if the highly paid guys who are running the board do not know how to do it, how is that going to work? I will bring Shirley-Anne in a second. Because we have made a determination to consult on the different chapters or phases of the plan as we have gone along, we are currently consulting on the second part. We are working with Cosla and Solace and others, as I have said. Clearly, if I were to ask any chief executive now, how will part two of this work exactly, the answer inevitably must be that they cannot know in full, because it is not here yet. You cannot know how something is going to work before it is here. My view would be that we do have the necessary governance in place. We do have the necessary consultation in place. If the feedback from chief executives is that they would like more clarity on how it is going to work, we will be very happy to provide that. I have to say that I am slightly concerned if senior chief executives are giving the impression that they do not do workforce planning. They do. I know that those individuals do workforce planning. They did not give the impression that they were not doing workforce planning. They were quite clearly saying that they did not see how it was all going to be brought together across the whole of the NHS. In other words, what I took from it was that there is certainly workforce planning taking place within the different disciplines. How are you going to pull all that together at a national level to have a coherent national plan? Those four boards seem to be saying that they do not know how it is going to be done. They said that boards plan using a bottom-up workforce planning approach, extending that to involve partners across health, social clear etc, will provide a more considerable workforce plan. However, they say that there are all different tiers and everything here, and they said that they do not know how it is going to be done. Is the national workforce planning group, as they think or they believe to stay to their words, going to provide that leadership guidance that is going to take this forward? If so, how? If it is acceptable, I will invite Mr Rogers to give you the details of how that is going to happen. I joined the NHS in Scotland nearly 22 years ago, and we have been workforce planning for at least as long as that, probably longer. Where the workforce planning methodologies have been put in place, what we have been attempting to do over the last few weeks is to give boards and all the other agencies that are required to come together to develop this plan one methodology, a simple methodology. If I cast the clock back to my early days in NHS Scotland, we probably did do that by specialty, and we certainly did that by board. Clearly, members of the committee will understand that as we evolve our workforce planning approach, those things are not going to cut the mustard going forward and have not been for a little while. So, the workforce planning methodology that we have put in place, the six-step methodology, which we have put in place across NHS Scotland, we have now been working with colleagues across wider public services involved in the delivery of healthcare to share that methodology. So, we have the same approach, we know how to count same things. Just to give an indication of the breadth and complexity of that, part one of the workforce planning involved consultation was 79 different stakeholder organisations who have a stake in this. So, sharing that methodology, giving that leadership through the workforce planning group is a terribly important thing that we do, so that we are all doing the same kind of thing, and we can make modelling, scenario, planning and all the rest of it assumptions on the basis of that. The national workforce plan is different for three reasons, only one of which is about it being national. So, the ambition, the scale of the ambition around the workforce plan was to do three things. The first was to bring that into a national picture, which we are, we have done with stage one and we will continue to do with our methodology rolling it. The second was to look at workforce planning from the perspective of being multi-professional. So, if I might, just for the purposes of illustrations say, it's fine and dandy having enough surgeons, but if you've got enough surgeons, but you haven't got enough anesthetists, there's no good. If you haven't got enough theatre staff, you can have as many anesthetists and surgeons as you like, and so on to porters and cleaners and all of the other people that make up the health service. So, this is an attempt to do so in a multi-professional way, which allows us to plan for scenarios around professions that are emerging. So, 22 years ago, the number of paramedics, for example, in Scotland, was quite small in comparison to the number now. We can look at similar growth around things like emergency medicine and intensive care, where we've seen professions emerge and we've seen those require different relationships and different teams to make those services work. So, the second thing, the second ambition of this plan, which I believe it's starting to do, and I can give some evidence if that would be helpful, is to take the health service and look at it from how do teams need to be planned to work together and to deliver services in a multi-professional kind of way. And then the third ambition was that we increasingly recognise that health, the health of the population, is not simply delivered by the NHS, that in order to create and support people to be healthy and support people at home, we need to do that through a range of agencies. So, the third element that is different around the ambitions of this plan is to make sure that we're not just looking at health in the traditional sense, but we're also looking at all of the services that supply, support and help people to live at home to get back into their health, into their homes once they've emerged from hospital and so on and so on. Final things that I think make this a little bit different. For the first time now comprehensively, we're considering the workforce not just in terms of the established workforce, but also spending a good deal more time developing our understanding of the workforce in training. I think that you made the observation about the long-term nature of medical training. It's really important that we understand what our supply pipeline looks like. It's really important that we understand not just the numbers of that, but the reasons why people make decisions. So, what is it that a student entering medical school is going to come out with at the other end, bearing in mind the long-term nature of foundation and specialty training? So, the ambition of this plan, and we've already started to see the evidence around it, will allow us to look at not just the supply that we have now of our existing workforce, but also those people coming forward through training, what their choices are, not just in terms of whether or not they decide to stay and practice medicine in Scotland, but also how they choose their specialties, how we try and create the specialties that we need in a more attractive way to attract the kind of numbers. The final thought, and forgive me, giving it a somewhat false amount, but we can come back to any of it. The other thing that the workforce plan has allowed us to do is to look at the training ratios that we deploy in Scotland. So, if I think back 20 years ago, if we needed a person, we needed a GP, we trained a GP. That's no longer good enough because people make choices about how they want to work in Scotland. So, they won't necessarily want to work full-time, they won't necessarily want to stay in the same specialty for their whole career. So, we're now in a position where we can nuance the training ratios, and indeed, in general practice, we're now training two for every one that we think that we're going to need to try and allow us to be sensitive to those things. So, our ratios are not simply one-for-one across the piece. We have 1.4 ratios, we have 1.6 ratios depending on the specialties, the shortages that we expect to have. It isn't finished yet. I'm not going to sit here and say, we've got everything that we would ever need to have, but we're a lot more mature now than we were, and we've got the foundation blocks in place that allow us to use the same methodology across the piece so that we at least understand the things that we're trying to move forward. What you're saying sounds good, but when I look at the joint submission from the four boards, they make it seem much more a raw work in progress with not a lot yet done to pull things together. I wonder if there seems to be a gulf here between the confidence with which you're putting forward what seems to be logical ideas and what seems to be the consideration on the ground. Just to ask one other question on that particular piece, the joint submission says that work is under way to try and bring key workforce data together into a single platform. What's the cost of that? A single platform, to me, suggests a major IT project and bringing together lots of different systems that are going to feed information into that. Is that the case? Is there a budget for this? Is there a timescale for this? How is it being managed? I'm very happy to take that. I'm not surprised that the chief executive who gave evidence last week could identify a greater degree of maturity in some of the systems than in others. Some of the issues about planning a workforce across social care provision involves a great many of organisations, not all of whom are statutory partners, so getting the methodology in place isn't instant. We're talking about some organisations that are very large, some organisations which are much smaller, some organisations that have specialist workforce planners, some organisations that don't. Sharing that methodology is a journey, and I'm not going to pretend that it isn't. In terms of your specific question around cost of platform, if I might just give a little bit of an explanation, people will understand that there are a number of ways that people enter the health workforce, so they will do so through medical training banks, GMC registers, NMC registers, midwifery training, a whole raft of different things. Some of those have different systems that have been built historically to achieve those things. The cost of the platform that we are expecting is actually that we will generate efficiencies from taking all of that information that is currently held in a plethora of different places and actually bringing that together and probably running the vast majority of that through NES and some of its established platforms. The reason we're able to do that harks back to the point that I was making about starting workforce planning with people entering education into health, so into their medical education, into their nursing education, and building that platform from there. We've made some inroads into that already. We're using the Churras platform that NES have developed to do some of that for us, and we're getting ISD, ASD, and lots of other agencies working together to share data in a way that gives us a central place and to use that central platform to allow us to model. Why hasn't all this been done before? We're changing the way that we're doing workforce planning. NHS England has just announced that they're about to have a national workforce plan, which I'm very pleased to see, because we are moving from a board-based approach to a properly nationally based approach. That's consistent with our approach set out in the delivery plan, which was published in December 2016, where we are being very clear about what's being done nationally, regionally, locally and in communities and at individual level. That is consistent with the direction of travel that we've adopted. What you're saying is very significant. You're moving from a board-based to a national-based workforce planning. Does that mean that workforce planning is going to be centralised and effectively taken away from the boards? No, it doesn't. I mean, Shirley-Anne can see more about that. Some aspects of workforce planning have a national dynamic to them. The number of people entering medical school is something that we will always take a national view on. The number of people entering a particular specialty, we will look at that from a national perspective, sometimes because those specialties have got very large numbers, sometimes because they've got very small numbers and actually it wouldn't do for each board to do an individual thing in that space. I go back to the point that I was making earlier on about the team dynamic. I suspect there is never going to be a likelihood that we will do national workforce planning for admin support in local board offices. For those key critical professional groupings where there is funding arrangements for their long-term education, fitness, midwifery, medicine, various other AHPs and medical scientists, for example. The notion of us doing that always on a local basis is probably not going to be a sustainable one. We need to do some things nationally, so the work that we've been doing around widening access to medical schools, for example, could never have been done on a board-by-board basis. It needed a Scotland-wide approach to be able to do that. I think that it would be wrong for us to conclude that there will be no activity at board level because there are some jobs that need to be workforce planned at local level because of the nature of that job. Also, remember that workforce planning is part of a triangulation between service planning, financial planning and workforce planning. Local decisions around where services happen will also be a big influencer around the workforce plan. Thank you, convener. Good morning. Just to start off, I would like to direct a question to Mr Gray. You have two roles, Mr Gray. You are an NHS chief executive and director general in the Scottish Government. I put the question to the boards last week. What do you see as your role in terms of how you perform those two roles in relation to the board? Are you directive? Do you tell them how you will be working going forward, or is it much more consensual and collaborative? I have two roles. I generally describe my job as having three in fact. If I can do that just to start and then answer your question. I am a member of the Scottish Government's executive team, so I have a corporate responsibility with other director generals and the permanent secretary for the corporate performance of the Scottish Government as a Government department. I am, as the director general for health and social care, the principal policy adviser to whoever is the cabinet secretary for health of whatever administration. As chief executive of the national health service, I am responsible for delegating to the chief executives of the health boards authority and responsibility to perform the functions of these boards. I am the accountable officer for the health budget and I delegate to those who are accountable the authority and responsibility to carry these matters out. I am assuming that you are not asking me about my management style and preference but rather about the governance arrangements that are set. So the governance arrangements at the top level would be that I have to satisfy myself that the accountable officer for a health board has the capability and capacity to carry out these functions in order to make a proper delegation to them and I require therefore certain assurances annually about the delivery of what has been delegated. I have powers of intervention through the ladder of escalation, which we have, which has five steps on it. The fourth step would involve direct intervention by me. The fifth step involves direct intervention by the cabinet secretary or minister, so I have a power of intervention. In terms of how we go about things, it is always better to get people to agree to things than it is to impose them. For example, on an issue such as junior doctors hours, we reached a point at which I wrote to the chief executives of the health boards setting out what I expected. At the start of my tenure, there was considerable use of what was called chief executive letters. Those were letters of instruction. I have reduced that considerably. That was a decision that I took simply on the basis that if one is continuously instructing the health boards to do this, that and the other, then in effect you are removing from them a sense of responsibility for doing it. I use those letters very sparingly. I use them to delegate money and functions and in matters where, as I say, I think you have reached a point where you have to deliver an executive decision. Generally, I would prefer to engage with the chief executives of the health boards and the medical directors and the nurse directors and others on the basis that we would reach agreement about the best way to do things, but ultimately I can and do decide. Just to focus on the plan that Colin Beattie was exploring, last week it was made very clear that I asked the question, are you telling me that there is no plan? The answer was, there is no plan, which I found terribly concerning. I then put the question to one of the chief executives, who is responsible? Who has failed here? The answer that I got was, all of us from health board to government have failed to pull together the link between short-term operational delivery and long-term workforce planning. Is that your view? Who has failed here, Mr Gray? No, it is not my view. I am perfectly clear that in all things I could always do better. I never take the view that I have reached some state of perfection where I could not improve, but as to saying that we have failed, I think that Mr Kerr is out of respect for those who gave evidence. Let me not seek to interpret what they said, what they said is what they said. Let me tell you what I believe to be the case. We have already published part 1 of a workforce plan. We are developing part 2 of it and part 3 of it. That does not seem to me like failure. It would be perfectly legitimate for this committee and other commentators to say what they thought of the plan. I would not object to that. It would be entirely proper. However, to say that we have failed to produce one is simply not accurate. There is one. Let me stop you there, if I may, Mr Gray, because that is very much now. I will explore that in a second, going forward. However, what I am interested in—Shirley Rogers talks about the workforce planning that has been going on for 22 years, I think that he said—we are sitting here with a significant hole in the workforce, which has not been planned for. It would appear. Who has failed to plan? Nobody has failed to plan. It is easy for me to sit here and say that nobody has failed. I do not regard your question as unfair. We are where we are because, as I said in response to the convener, changes in context, in demand and in the way that we do things. We have reached the conclusion—I think rightly—that a national workforce plan was now necessary. That is what we are producing. If every time we produce something new, we describe the past as a failure, it is going to make it very hard to produce anything new. There is not going to be much motivation to do it. Would you describe the past as a failure given where we sit now? No, I would not. The patient satisfaction with the NHS is at 90 per cent. That is not, to me. That is evidence of success. That is not evidence of failure. I am just slightly struggling with that given that, as I think you know, I sit in the north-east where we have significant workforce challenges. I accept what you say about the delivery, and I accept that the people who are there are working very hard to ensure the level of delivery. However, I cannot help but conclude that we are sitting with a depleted workforce because no one apparently has planned for it in the past. Am I unfair in concluding that? Mr Kerr, it has never been my habit to describe committees as unfair. I will not do it now. What I will do is say this, and I want to bring Shirley-Anne if I may in a second. I was at a conference last week for general practitioners, which was run by Pulse magazine. It happens every year in Scotland, and I was interviewed at it. I spoke to an audience of about 270 general practitioners and their support staff and some patients. I heard from a general practitioner that one of his colleagues, who is also a GP, had hurt her back. Because of concerns about workload and about her own income, she was continuing to work even though she was writing sick notes, as he put it, for people who were no more unwell than she was. In other words, she was working in a condition where she was signing other people off. I am not complacent about this. That is not how things should be. In some areas in general practice, it is very difficult to recruit close to impossible. I accept that as a fact. I am not pretending that it does not exist. I know that in the Highlands, and the chief medical officer has been there recently, and he can say more as required. He is struggling to recruit into radiology. I accept that. However, if we describe that all as a failure of planning, that means that the whole world has failed to plan. There are recruitment pressures, as I say, in every health system in the developed world, and they are probably worse in the third world. We are sending people to help people in other countries where they have no supply at all. I am not sitting here saying that there is some state of perfection in Scotland. There is not, but that is why we are doing what we are doing. I hesitate really over conceptualising it as failure. The example that I would give is this. In 2014— Mr Gray, what I will do, if you do not mind, because I think it is perhaps more important that we do project forward now. If I use words that I think have been used earlier, we are where we are, you are now trying to get a handle on it. Looking forward, and I posed the question last week, what if we are still sitting here in three years? Let me pose you the question, if I may. Who owns this process? Who has got the ball? Who will be sitting here in three years if it does not work? I am the accountable officer. I have got the ball. I am happy to sit here. I hope that I will be sitting here in three years because I believe that I will have something good to give account of. I am supported by the director for workforce and strategy, the chief medical officer and many others in delivering this. Ultimately, I have got the ball and I have never failed to accept that. I appreciate the clear answer. I have two brief questions, if I may, on a slightly different tack, but the same sort of thing. We are obviously all very concerned about the future, and it is good to hear that you are intending to get it sorted. What are the practical consequences, in your view, for both the staff and the patients? The Attorney General refers to urgent workforce challenges. If that is not addressed, what do you see as the consequences, if that does not work? I think that the consequences would be bad, but may I make use of my colleagues and bring them in? I would really like to draw on the senior expertise that I have here. Perhaps Shirley could say something about what we are doing, and then Catherine. In particular, I think that we should focus on Mr Kerr's question about what we are doing and what consequences we are therefore seeking to avoid. I would be the first to recognise that there are some challenging recruitment circumstances across various parts of Scotland, and you are right to identify some of the issues around rurality, for example, and GP populations and so on. Just to put some sense of our continued effort into that space, because what I would not want to do—I have been very proud to work for the NHS for 22—is that something that is very important to me. I am not going to sit on our laurels and say, have we not done well when we know that there are big challenges ahead? Let us face those challenges. We are currently sitting with 96 per cent full rate on our specialty training posts for medicine in Scotland, and that is extraordinary. Within that 96 per cent are some great successes, but there are also some real challenging areas, and we know that. Our efforts around widening access into medical schools are efforts into increasing the numbers going into nurse training and various other things that will try and improve on that. There are some successes to point to. If I point to the track record of emergency medicine, which I mentioned earlier on, where we are seeing a 192 per cent increase in the establishment from 2006 to 2017, we know that we can do this stuff—paramedsin—a similar size growth in respect of the paramedic communities. We are looking at different models of how we provide care. That means that people, wherever they live in Scotland, whatever their healthcare needs, get what is appropriate to them. We are working really hard on how people feel working for the NHS. As the director of workforce, I do not spend my time just doing workforce planning. We also spend a lot of time looking at employee engagement, how people are feeling, how we support people in the workplace, when times can be quite difficult. I recognise that. There is a lot of activity going on right now to make sure that the supply of our workforce is improved, that we look for different models—things such as physicians' associates, for example, which are being used to great effect in Grampian, to address some of the issues there and to see whether there is greater scope to roll out those kinds of initiatives. Continuing to focus on rurality, you may have seen that there was an award made to Aberdeen University yesterday for the exposure that it is giving to its medical students to rurality. We have been working very hard in the area of rural practice to try to make sure that people who work in rural Scotland feel supported and have good, appropriate educational links. The ability to recruit into rural Scotland is enhanced when people feel that there is an opportunity to continue to develop their clinical practice through academic links. To explore just on the recruitment—forgive me, because I am just aware that my colleagues wish to come in—I have one question on recruitment specifically. The Auditor General notes a 6.3% increase in overall NHS staff levels since 2012, and about the same time an 11% real-terms increase in staff costs. The report then goes on to suggest that there is not always a clear link between staff shortages and the outputs to service delivery. Has there been a formal assessment of the relationship between increase in staff levels, increase in staff costs and the actual outcomes delivered by the NHS? It is a very fair question. It is fair to say that one of the things that we are working on now is that notion of productivity and outcome. You will have seen some of the reports that were published yesterday where BBC was making commentary around that dimension in England, and there is work starting there now to look at that very same issue. It put bluntly does the growth and does the growth in cost generate a commensurate improvement in health? For certain things we have the foothills of some evidence that would suggest that there is a relationship. For other things there is still a sense that greater efficiencies and the way that people work together in providing appropriate community solutions, for example, might be an investment in community staff that overall would have an improvement on our financial position because people are not being admitted to hospital. The short answer to your question is that I do not have it yet. The longer answer to your question is that we are on it and we will have it over the next few weeks. I am grateful, thank you. To start off, I hope that that is a positive note. We know that there are more staff in the NHS, there are more doctors, there are more nurses, there are more consultants. In fact, there are nearly 3,000 more GPs in the service than there were, say, 10 years ago. The public satisfaction that you have mentioned, Mr Gray, is very high. NHS in Scotland is highly regarded and it seems to be performing the best of all the UK NHS services. I would like to put that on the record. It is a very strong positive. However, there are many issues that do face the services. As we all know, I am interested to get your views on the whole bigger picture about service redesign and what that might look like over the next few years. We know that there are precious and GP practices. We know that that is influenced by the pensions issue early retials and so on. We know that the A and E services are under pressure, despite it is performing very well, but it is under pressure. We know that they are spiralling costs and the agency and local costs and so on. What are we doing in these three key areas that I think the public would expect to see some progress on in the next few years to try to manage and improve those aspects of the service? You are asking me about service redesign, about pressure on staffing—you have mentioned A and E in general—practice, and you have asked me about agency and local costs. Those are the three things to cover. What I might do is ask the chief medical officer to say something about clinical staffing and what we are doing about that. I will say a little about service redesign and I will ask Shirley to pick that up further in the context of transformation. Shirley chairs the Transformation Delivery Board and local costs. Shirley will give further detail. On service redesign, we are already implementing the legislation that paved the way for the integration of health and social care, so we are already doing that. I think that it would be fair to say that it is more advanced in some places than others. I would be the first to say that, but there are some successes to draw on. The reason I spoke earlier about looking at what we do nationally, regionally, locally and in communities and individually is because our service redesign has to be coherent around that. Moving the focus from hospitals and estates, if your view of the health service is largely informed by hospitals, practices and offices, I want that view to turn right round so that it starts with the individual. Our design of our services is focused on more people living longer, healthier lives at home or in a homely setting because that remains our strategy. Why this local, regional, national piece matters so much is that if we are patching the way that we do that, if we are unclear or incoherent, we end up doing things either twice or not at all. If I give one regional example, in the south west of Scotland, one of the things, as in all other areas, that we have to be ready to deal with over weekends when there are fewer staff on duty is gastrointestinal bleeds. If that happens over a weekend and you are in Lanarkshire, Ayrshire and Arran or Dumfries and Galloway, there is pressure on the number of doctors available to deal with that. That original solution is what makes sense there, otherwise you end up with recruiting enough doctors for most of them to stand idle most of the time rather than dealing with the emergency or being short because one board has enough and the other two don't. The three chief executives there have been working on designing a system that means that that service is provided regionally because that is not just the most efficient and cost-effective way of doing it but because it is the way that actually delivers the best service to patients. I am going to stick at that one example, there could be many. In terms of service redesign, it needs to be focused on the patient, not on the provider and say integration of health and social care is proceeding. The other and last point I will make before handing over to the chief medical officer is that engaging the public in service redesign is utterly fundamental. It can be the best service redesign in the world but if the first time the public hear about it is when you close one thing and open another thing you know very well what is going to happen as a result of that. We will do things that people won't like. I rather hesitate to say that but not because they are bad or ill-conceived or misjudged but if people are used to a service being delivered in a particular way, the prospect of change is hard. We have a responsibility to make sure that those changes are properly understood and a proper clinical buy-in. We owe that to the public. Thank you. I think that one of the issues about pressures, particularly if we start with A and E, is very well illustrated and it brings us back to Mr Beattie's questioning and Mr Care's questioning about the past and then looking for the future. Mr Neil will remember the time that the Royal College of Emergency Medicine came forward with a really difficult, challenging workforce crisis but when we look at that time what was happening there and this is where the complexity and also the dynamic change of how our services run plays through. The demand in A and E was increasing. People were doing traditional on-call rotas. There were consultants available only for the most severe cases and we were also having A and E used in a very different way than it is now. People were not signposted to other areas but what we then did was add a four-hour waiting time target to a pressurised system, which then led to the senior decision making part of the team. The consultant is really saying that there aren't enough of us and, as Sirlie has said, that consultant workforce has almost doubled in that seven, eight, nine-year period and so that's a system that is changing according to the demands and the pressures on it but that system needs to continue to change and there are examples across Scotland of where the signposting in A and E is better than others so there's much less demand, there's more direct access via general practitioners so that the emergency medicine doctors are used only for emergency cases and there are also different ways of working where the senior decision maker is triaging at the front door and preventing admissions. There are also areas of Scotland where there's a team at the front door who are able to discharge directly back to home for a frail elderly person who's perhaps fallen, they will take a physiotherapist with them, there will be an occupational therapist there to assess them and traditionally those people would have come in being admitted and of course that's not the right thing for that person but it's also increasing pressure on the system so part of our plan is looking at these different ways of working but also taking into account what we now know to be better for people and the way that we're treating them is actually better overall for outcomes and I won't assume but some of you may have read my or heard of my realistic medicine chief medical officers report and what that has talked about is that some of what we do is overmedicalising and over treating people and in fact what we've had the reaction not only from doctors but from all of the healthcare professionals and the public is that people are saying actually we realise that we don't always have to see a doctor, we don't always have to come to be admitted, there are alternatives and in fact much of the evidence is particularly if I take the biggest group of conditions that GPs see, musculoskeletal conditions, about 40 per cent of GP workload, they have in fact often a better outcome from seeing a physiotherapist, the GP is not necessarily the expert, orthopedic surgeons tell me that in fact with physiotherapy and rest many of these conditions don't need any medical intervention so to our GP workforce pressures while I would absolutely agree that that they are there and recruitment and retention is very difficult what we're doing is responding to changing needs to also looking at evidence for what is going to provide the best outcomes for people and that traditional model of doctor doing something is no longer the right thing to do, so GP practice is not just about recruiting more GPs, it's about looking at that staff mix, it's about looking at what in fact the right type of practice of professional is for that problem and doing that in a much more systematic way. The GPs are welcoming this, I've been to speak to groups of GPs recently, they're obviously under pressure and what they do tell me all the time is that they don't have enough time, so what I would like to see is that that general practitioner who is a generalist and expert generalist with a medical degree is only seeing the people they are going to make a difference to, only seeing the people that they are the right practitioner for with their medical background. What the GPs tell me though is that that means they're going to get the difficult and complex patients and sometimes in a busy clinic it's quite nice to have something that takes two minutes or five minutes and lets them catch up, so there are unintended consequences of that but of course what we must do is the right thing to do for the people of Scotland. I think that that re-examination of our traditional way of treating people is fundamental to all of this and so far with the reaction to realistic medicine the public agree. The transformation aspects and then move into your question about banking agency. If I can pick up the transformation stuff, the DG has already talked about national regional local activity and I wanted to pick up a few things that I think are really important in the work that we're taking forward around that. The whole thrust of our transformational strategy is to try and support local people and communities, individuals and communities to get what they need, where they need it and where it makes most sense for them. Some of the activities around regional activity, it's interesting that the chief executives that you saw last week were all of the regional leads for this work is about doing the things sensibly at a regional level that should be done at a regional level to allow those local things to get on with what they're doing and provide services. Some of that gives us an opportunity to try and reduce some of the harmful variation that we see. Some of that gives us an opportunity to roll out quickly and with some consistency, some good practice where we find it into a larger platform. Some of the things that we're thoughtful of, we heard evidence yesterday, I was hearing some evidence yesterday about the fact that one in four now of the cases treated by the Scottish Ambulance Service has a mental health dimension. That's something that was not even, I'm not even sure if it was recorded 20 years ago, so we're looking again at how we train people to deal with the reality of the cases and the complexity of the patients that they are now seeing and that's requiring us to go beyond those traditional boundaries and look again at things like mental health first aid. In fact, we were hearing yesterday, I think of approximately 16,000 if I remember rightly, Scottish Police Service individuals who have been given mental health awareness training, so a different landscape, a different training. We need to embrace technology, so some of the service transformation that is taking place will actually be invisible to anybody, things like where we read a radiology film. The technology exists to now allow us to do that wherever, a new capacity, so you'll see increasingly in the east of Scotland a relationship developing between Fife, Lothian and the Borders using capacity there to be able to read technology films because it doesn't actually matter where you are, it's a film that you're seeing, so that enhanced use of technology. Finally, some thoughts around innovation because I think if we are genuinely to make our best efforts to make the NHS sustainable going forward then there is a great deal of innovation that we are seeing and we need to promulgate. An example I'll give of that is of a consultant working in a district general hospital, she was a gynaecologist who discovered that women who came to her, unless they were diagnosed with something very, very serious, seldom came back for their second appointment and she did the brave and unusual thing of ringing up her patients and saying why not, why aren't you coming? And they said because it takes ages to get there, it costs a lot of money, we haven't got very good childcare and it's all very difficult and if it's not terribly serious we'll kind of live with it. So she did two fantastic things, the first thing that she did was to front load that first appointment with everything that she thought was likely to be needed so that people didn't need to come back and then even better she went out to primary care and worked with GPs and nurses to make sure that the basic procedures that could be done and previously done in the district general were done in the GP clinic in their own home, close to their own home. So our transformation agenda is not simply about saying, you know, the public has got to, it's not about saying the public has got to change its ways specifically around some of the things that Catherine picked up, it's not in realistic medicine, it's not just about that, it's about saying that the NHS going forward will use greater technology, will use more innovation to support people to deal with the issues as they see them. You asked specifically about bank and agency and I'm going to start by saying to the committee which something which I know that you will already know is that bank and agency spend is high, it exists because the primary objective of the NHS is to ensure patient safety. So board chief executives do not necessarily rush to spend on bank and agency staff but they would rather do that than try and run a service that is not safe for the patient. I just want to say that none of that means that we are content with the amount of money being spent on bank and agency so I wanted to just share with you some things that have been done very recently in the last year to try and make sure that that position is improved and I can say that in the first six months of this year that position is improved over the first six months of last year that the data depending on where you select it from is slightly variable depending on whether or not you include all sorts of on-costs and that and various other bits and pieces but I think we would all acknowledge that it's too high. So the first thing that's been done is a refresh of the NHS Scotland national framework contract, the contract was renewed this year for medical staff with a number of supplies rising from 10 to 35 meaning that 80 per cent of medical work should now come through that contract. That means that there's a standard rate that means there's a greater degree of consistency and hopefully some efficiencies in respect of that. You will have seen in that in England the consideration was given to a capped rate in terms of trying to address how much money is paid to agency workers. We haven't gone for capped rates yet because of the patient safety issues that I talked about earlier on but we are trying to ensure that there is a standard rate for the NHS in Scotland. In respect to the staff bank, which of course is a little bit different, we now have over 35,000 nurses in Scotland registered on the staff bank and some 2,800 doctors registered on the staff bank. So we all recognise that agency spend is higher than we would wish it to be using the MasNet network, which I think the chief execs gave some evidence about last week, which is the managed agency service network. We are now seeing accurate reporting on the spend and we're trying to reduce that spend quite significantly. As I said earlier on, the first six months that I've seen for this year are an improved position on the first six months of last year. Those were very long answers but very welcome. Thank you a little bit. I could just ask you about a particular issue in GP practices. Last week I had the opportunity to say to the committee and there are people giving evidence that one of the surgeries in my constituent says that I've got 13,000 patients, 2,000 of whom come there every week. So on average they're coming back again every six or seven weeks, every single one of them. Paul, in terms of reaching out to the public and taking them with us in this service redesign journey, how successful they feel that it's being, given that we're seeing something like that, that's causing huge pressure in the surgery. Many of whom, as you said, Dr Calderwood, probably don't need to be seen by their GP. How do we manage the expectation that the public have, that they are entitled to see their GP when they come into the surgery and demand that they do so? There are a huge number of other qualified staff available to see them, but the evidence on the ground is that big numbers of patients are still coming in every six or so weeks to see their GP. I'll ask Dr Calderwood to pick that up. There's one thing that I just want to say, Mr Coffey. We talk sometimes about inappropriate attendance. It's not a phrase I particularly like. I don't want people to think that it's inappropriate to access the national health service. If they have a need and it's one that we can meet, we ought to be willing to meet it. I'll hand over to Dr Calderwood, but I really would like to place on record the importance that I attach to not doing anything that would discourage people from seeking treatment or care or advice when they need it. Getting them the right treatment, isn't it? The appropriate treatment. One of the deep end practices in Drumchappel came to see me for a meeting. It was a part of their away day for the year, which I thought was quite an interesting way to spend an afternoon. They had played tennis the previous year, but they were telling me about their people exactly as you're describing, who were coming very frequently. They examined very closely why those people were attending. As with many things like this, there's often a pattern so that, as Paul has said, it wasn't that the people were perhaps attending inappropriately, but it wasn't perhaps the GP they needed to see. They put in some dedicated healthcare assistant time. She goes to visit these people at home, in fact, as frequently as needed. That's sometimes once a week it may be less than that. They did a whole series of interventions into medication, being ability to get out and about. In fact, they have really cut down on people coming to attend when they are seen, if they do need to be seen by the GP. The healthcare assistant flags that up, so that's obviously somebody who has, she spoke very emotionally about how she has then got to know these people really well. She can often deal with something over the phone. They were in part needing help of some sort. To an extent, what we do is the only person who can book an appointment to see is the GP. We provide something without really asking that person what they actually need. Innovative ideas like that, which aren't difficult, are in fact much less costly than paying more GP time. Those are the sort of things that we need to be considering having on offer in GP practices. Is that issue in the plan? Do you expect to see an improvement in that? There are kind of stats that are coming out over the next few years so that we won't see things like 2,000 or so people feeling that they have to see the GP every week. We have different examples last week in evidence that different approaches and triage and different surgeries approaches seem to manage the problem reasonably well. Will we expect to see that right across Scotland in a different approach to try and help this problem? We're talking about this much more generally. We're building in these other types of people being part of the GP team. I don't think that this isn't immediate because some of this is needing to spread both across the general practitioners but, as you've alluded to, the people who are coming to be seen. We would see a difference in maybe a few years. We're already seeing some of the realistic medicine making a difference with people asking for interventions or, rather, not wanting as many interventions. I wonder whether I could just... I don't want us to run out of time so if we could all be crisper, that would be really helpful. Let me just quote to you from paragraph 5 of the Auditor General's report, where it says that the recently published National Health and Social Care Workforce Plan Part 1 is a broad framework to consider future workforce planning challenges and not a detailed plan to address immediate and future issues. As I'm listening to you and I'm hearing about these worldwide shortages, I'm looking at that and saying what you've published so far doesn't do the business. Is that fair? I think that, first of all, to say that if you don't have a strategic framework, then your prospects of achieving anything are greatly reduced. I'll ask Shirley to say a bit more. Convenience, I don't want to divert at all, but could you give me some guidance on time? When would you like to be finished just so that we're aiming for that? Don't worry, I'll worry about that. That's my job. You worry about the NHS, I'll worry about the signature. All right, thank you. We're just trying to moderate our responses appropriately. I'll do that for you. Thank you. I do think that we need a framework, but as I was seeking to make it clear earlier, that doesn't mean that we've stopped doing all the other planning that we're doing. We haven't suspended everything else, and now we're going to do this. So there is already planning in place, which is producing health professionals. Let me not give you a list, but Shirley, do you want to say more about the detail? Absolutely. The planning process is to give us a sustainable supply of people to work in the NHS. It's never a stop thing. You do it, you review it, you see what you get, you do more, and you do some things less and some things more. So if I take some of the areas where there is an acknowledged shortage, so general practice is a good example of that. Some of the work around trying to find a more sustainable supply of general practitioners involves, for example, the opening this coming year of the first postgraduate medical course in Scotland. We've never had a postgraduate medical degree course in Scotland before. We're doing that partly because we want to give people the opportunity to practice medicine, but partly because we believe that doing medicine as a postgraduate basis is more likely to give us people who want to practice medicine in Scotland, because they will be more mature in their life choices at that point, but also because we've seen evidence in other places that postgraduate medical courses appropriately designed, which this one will be, help to direct and encourage people towards general practice, for example. So there's a good evidence if we take a comparison with Keel University, which is the university medical school in England, which produces one of the higher proportions of general practitioners, and it does that by giving exposure. So does it give us everything that we need? No, does it start to give us the people that we need to see coming through the supply pipeline? Yes, it does. The point you make about a framework is a very valid point, but remember as well that every year I get from the board's 22 plans workforce plans. It clearly haven't worked, which is why having a single plan is something you accept is important. The first part of it was about the NHS workforce, so I would have expected to see detail there, and according to what it's Scotland, it's not there, so we naturally have concerns about the efficacy of this moving forward. Anyway, I've taken up enough time. Bill Bowman. Thank you, my convener. Good morning. We've perhaps touched on this so far a little bit, but in terms of NHS Scotland, what is the chain of command? So, I'm accountable to the Parliament, and the Cabinet Secretary of the Day is the responsible minister. I'm also accountable to the permanent secretary. She's my line manager. As I've explained, the chief executives are delegated authority by me. The chairs of the NHS boards are appointed by the cabinet secretary, as are the members. I appraise the chairs of the larger boards. Directors who report to me appraise the other chairs. Each chair is appraised on their performance, consistent with the standards set by the commissioner for ethical standards in public life. The responsibility for the total budget rests with me as an official and with the cabinet secretary as the minister. So, how does it work in day-to-day executive terms? So, in day-to-day executive terms, when I have delegated to the NHS chief executives and hence put that delegation within the scope of their board, the expectation is that the executive decisions at board level will be made at board level. Otherwise, there is no system of delegation. I also have directors who report to me. Shirley Rogers and Catherine Calderwood are two of those. I'm their line manager. I'm the line manager for the members of the health and social care management board. How do you, for this way, work that in the sense of we had chief executives here last week who were saying—that has been repeated—that there is no plan? You say something else. I mean, something doesn't seem to work in the way you delegate. So, I'm trying to find a way to answer this, which is useful to the committee. I think that it is reasonable that the people who are closest to the preparation of the plan will know most about it. I think that I have said—and it remains my view—to say that there is no plan is not accurate. I think that one of those who said something along those lines was Mr Davidson, who then went on to say that what he meant was that there was no single plan for everything. Well, that is true. That's not what we're here to discuss today, as I understand it. We're here to discuss the fact that there is a workforce plan. The first part of it has been published the second and third parts are in development. I'm not sure how one could conclude from what was said that the delegation hasn't worked. Well, how does the delegation work? I read the documentation that you provided, and it seems to be passive. We give guidance, we suggest how they do things. It's not as if you, as a chief executive—maybe I'm thinking of other organisations with a chief executive—make sure what he wants to happen happens. So each board has a local delivery plan. They're held to account for that. I have a whole team that does that. As I've explained to Mr Kerr, if a point is reached at which I feel I need to make a decision and give a direction, I can do that. If I need to intervene, I can do that. Sorry, I'll stop there, because I want to understand your question. I just get the feeling that the delegation happens, done. Well, no, definitely not. I meet the chief executives in Plenary once a month. I meet them individually, more regularly than that. I don't meet every chief executive individually every month. I don't want to try to convey that impression. The Health and Social Care Management Board receives reports monthly on financial performance, on workforce, on delivery—in other words, access targets. No, we do not hand over a delegation and then sit and wait to see what happens. It is subject to regular monitoring, which is reported on. There is a health and social care audit group that meets quarterly. I'm happy to say all that now and go into much more detail now, if you wish, or to provide you with that detail in writing. I think that we'd be happy to have that detail in writing. I wonder whether I might intervene at this point, because I'm hearing a lot from you about different planning groups and all the rest of it, but the Auditor General was absolutely clear. Current lines of responsibility and decision-making are unclear. Regional workforce planning is not working as originally expected. There have been misunderstandings around workforce planning. Let me quote from Tim Davidson when asked who is responsible. He said that all of us, from health board to government, have failed to pull together the link between short-term operational delivery and longer-term workforce planning. Isn't that actually the case? No, I don't agree. I don't disagree, as I said earlier, convener, that there are things that we could have done better, but that's why we're doing now what we are doing. I am happy that each chief executive accepts responsibility, in line with what Mr Bowman has been asking, but I don't agree that there has been some collective failure to plan for anything. As I pointed out, we have 156,000 staff in the health service. We have them organised to deliver, and we didn't get that from nowhere. Is the Auditor General wrong in her comments in her report? The Auditor General is commenting, I think, and she is proper to do so on the sufficiency of what we have. We are still working on it. Nobody is denying that, but I am not agreeing that there has been some kind of general failure to plan for a workforce. We have a workforce, it's here, it exists. That there's not enough of them, and they're not in the right place, or the right skills mix. There are enough of them in some places, there are not enough in others, and I've been open about that. Sorry, Bill Bowman, did you have any further questions? Thank you, convener. Well, if we just set that aside, I could ask one other question, just follow up on something else that you said. You have been listening to some general practitioners, I think, you said recently, but by chance I was also at an event last week where a senior GP and maybe Dr Caldwood could comment, if she's perhaps closer to them, who, in a number of ways, pointed to the good things, but a comment that I remember there was a lack of joined-up thinking in the NHS. Does that strike a chord? I think that we would say now that that primary and secondary joining up, in fact, interestingly probably many decades ago, when there were individuals who knew each other, both in primary care and into secondary care, and as the numbers have expanded, I'll take it when you're talking about doctors at the moment, ironically, those good relationships have probably been less good. We have other initiatives, and a very good one, I will be brief, in Highland has been a very difficult number of people coming through for the urology department to cope with. They, again, took this attitude that, let's have a senior person look at this. Again, that's not traditional. Usually the senior person only looks in at the end or at the most difficult stage, and in fact he, as the senior urologist, was able to say, well, lots of these people don't actually need to see a urologist. But what he recognised was that they needed some help. The GP wasn't just sending them for the sake of it. So, actually, what they've done in Highland is they've gone out to the GPs, they've gone out with teaching and discussion to say, if this is what this person has wrong with them, why don't you try this, this and this first? That's what I would have told you if you'd waited for 12 weeks and come up to the hospital, to my clinic. So that relationship needs to be built again. In the past, perhaps the GP would have lifted the phone, and now that isn't the way, that there isn't access like that. So we're looking, actually, in the new collaborative, which is looking at different ways of working without patients, at reintroducing that sort of service where there are people in secondary care with expertise, where the GP is able to phone for advice, and I think that will rejoin some of that disjointed service that you're talking about. Thank you. Hard to beat the personal touch. And the telephone. Can I just begin with a factual question, and that is, what is the current status of Harry Bunz's report on waiting times, which obviously impacts on what we're talking about? I understand and expect to have that published shortly next week. Yes, but I'm soon. Before Christmas anyway. Yes. Right. Okay. That'll be interesting, because that, I think, has potential impact, obviously, on what force. Can I begin by focusing in on the primary care, particularly GP, practices? First of all, again, a short factual question. What is the current status of the negotiations on the new GP contract in Scotland, and when do you expect the new contract to be in place? I expect the contract to be published next week for consultation, all clearly, when it's in place, depends on the consultation. Obviously, the shortage of GPs is an immediate issue, and requires, obviously, imaginative approaches. I appreciate the initiatives that have already been taken. However, I think that we all know of GP surgeries. My own GP is one down at the moment, and it will be the next summer before they get a replacement. If anybody lives, they hear stories about the pressures that GP surgeries are under. My first question—I've got three questions in relation to this—I'll start with the first one, which is always a good place to start. Last week, we saw figures comparing net GP income, the share of the contract income that actually goes to the GP personally, and comparing what happens south of the border with north of the border. The figures that appeared were that, for the latest year available, the net GP's income in her pocket was around £109,000 south of the border, but it was £89,000 in Scotland. How big a factor is that in retaining GPs and recruiting GPs—that differential? There was, of course, a difference in the number of patients as well, so there was a ratio. I genuinely don't want to pre-empt the publication of the contract for negotiation, Mr Neil, because we want to be respectful of the BMA's position in that. The straightforward I should say is that, in the negotiations, we've sought to address some of those concerns, but the precise detail will await the publication of the contract. Is there evidence that that's one of the factors why we have a challenge on retention on recruitment? There is some evidence of that. However, I think that what I hear, and Dr Caldor might wish to comment, is more a concern about straightforward pressure on workload and being able to take time off and being able to give patients who have complex needs the time that they require. Dr Caldor might wish to add to that. It's anecdotal, but I have never had a GP say to me if only I could be paid more. I have. I suppose that they are talking to me about different... It's usually because they're talking about their patients. Okay. The second question is, we heard last week from Tim Davidson of an example, and there are other examples. There was one in five a number of years ago, and we called it for shorthand, the introduction of the Alaska model, and it worked in the GP practice in five. Unfortunately, when the doctor in the practice who was doing it left or retired, the other doctors wouldn't carry on with it, even though the patients and everyone thought the evaluation was very positive. Tim Davidson gave us a similar example of a GP surgery in Edinburgh, which had been under enormous pressure in a deprived area. It didn't name the surgery in the evidence last week. People were waiting two or three weeks for an appointment and it was under so much pressure. They introduced triaging by a doctor. If somebody had a foot problem, they would get referred to a podiatrist along the lines outlined by the chief medical officer. This has been a tremendous success, according to doctors and patients. The pressure is much, much reduced, with the day that he visited, he said that actual appointment slots were not filled and were available for people who needed to see a doctor that particular day. However, he also said that the other doctors in Edinburgh practice said that they weren't prepared to introduce a similar system. Two questions. As a matter of urgency, should we not be trying to get GPs to change their work? Part of the solution to this challenge is for GPs to change their work practices. We know that the BMA has always supported restrictive practices in the past, but they are doing most of the bleeding. Is it not time that we, maybe this is part of the contract that we published next week, but there is a responsibility surely on GP practices? Where there is very clear evidence that a kind of change in practice referred to in Fife, Alaska and similarly in this surgery in Edinburgh, it is time for GPs pretty quickly to be more flexible and be prepared to change their work practices. Indeed, it is in their interest to do so, assuming that the new contract would not penalise any GP for a reduction in the number of patients that they personally saw. There was a long question for you yesterday, which I'll ask the chief medical officer to answer. I made reference earlier on to the relationship between the very important relationship between performance and workforce planning. Coming back to Mr Bowman's question, I can assure you that if we see those relationships not performing in the right kind of way, we will be interventionist in that space. I think that you were asking a question about what do you do when it isn't working. If I give some examples around seeing boards that don't put forward a suggestion around how they want to recruit as part of our international campaign, for example, I will speak to them directly. In fact, in respect of NHS Lothian, there have been a number of instances where I've intervened to say that they need to do something and we've funded particular activities or we've required them to do certain things. Coming back to Mr Neill's point, I'm trying to pick up both of them, the points that have been made in what was a very big question. Let me try to unpick various bits of it. The question was fairly short. Indeed. There is a very broad differential in salaries for GPs in Scotland. The breadth of that difference to establish that average is quite considerable. There are some very high-earning general practitioners and some are not. Of course, there is a mixture of those people who are still operating as independent contractors in their GP model, but there is also a number of salary GPs and different models emerging. Those things are important reflections about how people want to practice and have that relationship between their employer in the wider sense of the word or the people that they provide services to. Where we find evidence that we have got a system that provides a better service for patients, then really our job, I think, is to present that evidence as objectively as we can and seek to remove any barriers that prevent that evidence being adopted. That's increasingly why some of the regional activity that's taking place—I'll take your point about regional workforce planning. Of course, we didn't have a regional configuration to the NHS in Scotland until this year, so I recognise that it's in its embryo. That act of working with the boards, supporting them around transformational change, this year we've allocated funding to all of the regions, relatively modest funding at the stage, but we've allocated funding to them to support that transformational endeavour. I mean that they've got local leadership on the ground, which is really, to some extent, what that's about in going and presenting that evidence to say patients get a better outcome through this model. Let's work with you to remove whatever barriers there might be to the implementation of this model. In this case, NHS Lothian should be going to all the other practices and saying, look, have I ever ensier that this system works much more effectively for both the respect of a patient and doctors? Ergo, we would expect you to implement something similar. We've got examples of that, so there's examples of that happening in Aberdeen at the moment and various other places. Is that not the problem? We do have examples of excellent practice throughout the health service. I always remember the Western Isles computer penned and it was introduced very quickly once developed in the Western Isles and produced fantastic effects, but it's taken five years and it's still not spread across the national health service in Scotland. There is a real problem in getting good practice and particularly where it's new spread across the system. While there's a lot of good examples of very innovative behaviour, it tends to be in pockets and it tends to be difficult to get it spread and get the pace of changes. It's not happening anywhere in the health service in Scotland. It's the fact that the pace and scale and spread of the change is too often too confined to small pockets. In this case, given the challenges facing the health service in Lothian, the priority should be for NHS Lothian to work with all the other practices to try to get him to do something that is blatantly very successful. Does a new contract, without giving anything away, give you the teeth that are required to make those kind of changes? Obviously, it's a dynamic situation, there will be other changes during the period of the contract. We don't know what they are yet, but surely we need to be able to ensure that those changes, improvements, because we're all about improvement. A lot of things are working very well, but we need to improve all the time in the health service. Obviously, the contract has to facilitate improvement and itself not be a barrier to improvement, which it might. The current one probably is. I think that Mr Neil is trying to answer the question himself, but do you have a go? I think that the contract, I hope, if accepted, will remove certain of the barriers. Some of these might just be down to basic workload. In other words, if you don't have time to do anything other than see patients, you don't have time to change anything. I think that I wouldn't want to go further than that, convener, without intruding into what the contract might or might not say. I think that the only other point I would make is ultimately, yes—and I've responded on a couple of occasions this—we can impose things. However, the likelihood of getting a good outcome if you impose something is much less than it is if you get it in by agreement. That's what the chief medical officer and others are doing through realistic medicine, is promoting, if you like, the principles of realistic medicine so that, when the practice of realistic medicine comes to fruition, it will be different. I would agree with that. I will move on to another issue, which is again related to the availability of GPs. There is clearly an element of particularly younger GPs going abroad, particularly to Australia. I was talking to somebody yesterday who had been talking to a recruitment agency who had interviewed 200 GPs in Scotland and 80 of them intend to emigrate to Australia. I think that this is a major leakage of skills from GPs in Scotland. Work has been done to obviously work-life balance and a whole range of things come into this, but clearly we should be doing something to try and keep those GPs in Scotland. We won't be able to keep them all. Maybe we should be going to Australia and trying to get some of the ones that have already gone coming back. It strikes me that that is the specific type of issue that we need to understand so that we know if there is anything that we can do about it. There might not be—I don't know if Shirley-Anne wants to answer that. I think that maybe more sunshine to Scotland is the first intervention. Come to Ayrshire, Catherine. Maybe I'll have to make a slight observation before we get into the meat of that response. I was in conversation with a young junior doc a couple of weeks ago who showed me a photograph of an unnamed Scottish hospital in the rain and the rather attractive sunshine of the Melbourne A&E department. His response to me was, whilst I'm young, I want to go and do some surfing as well. Can you fix the weather? We need to recognise that we operate in an international marketplace. Our responsibility is to make the roles that we have on offer in NHS Scotland as attractive as we can. You touched earlier on about the importance of salary in that space. For the vast majority of the clinicians that I talked to, that's a part of something. It's not the whole part of something. They want to have good shift patterns, and the DG talked earlier on about the work that we've been doing around improving the working lives of junior doctors and various others. They want to have high quality work. We have sitting in the audience at the moment of Scottish clinical leadership fellow giving people the opportunity to develop their leadership skills has been something that has been phenomenally successful for us. We need to improve the attractiveness of everybody's working life in the NHS in Scotland, but not least our doctors simply because of their geographic mobility. There are two things that I would say that many of them come back. Many of them take the opportunity to go on travel and then come back to practice in Scotland for the rest of their career. You're absolutely right that we need to do something whilst we're there, so you will have seen for example NHS Grampian currently recruiting in Australia and working with people whose time there, a couple of years there or whatever it has been, has come to an end and they're thinking about coming home and we're actively recruiting overseas to do that. We're also not just doing that by saying come back and do what you were doing here before. We've got an international training arrangement that is successful in attracting people from all over the world who can come and train here and spend their time here and we've got evidence that suggests border agency rules permitting that if they are able to continue to stay and practice where they've trained, a large number of people seek to do that, so you're absolutely right. And my final question just came back to the plan. The shape and size of any workforce is obviously dependent on the shape and level of demand for the service and if workforce planning is not a perfect science, you'll never get it 100 per cent right, just a fact of life because all the changes that were already mentioned, but you'll get it more right if you've got a good understanding of the level and shape of demand of services in the future and there was a report published, I think, by your cells or commissioned by your cells during the summer, for example, that showed that 25 conditions make up for 70 per cent of NHS activity in Scotland, so if you get that 70 per cent right, there's a good chance, you know, you're going to hit the mark better, so there are ways, methodologies that can be employed to improve the accuracy of a forecast. Have you brought together to inform the workforce plan a research and evidential in one document or number of documents forecast of the level and shape of demand for NHS services in Scotland over the next few years? The short answer is, I mentioned earlier on that we were working with, I think, 79 stakeholders and organisations who provide us with some of that evidence. We've worked closely with COSLA, with SOLIS, with agencies such as the Scottish Care Association and so on to look at the impact that we expect to get from an ageing population, for example, so we're looking particularly at how we support that through additional schools around care for older people and so on in various places. It's not complete, it's never, as you say, it's an art, not a science, but the short answer is yes, and we're doing more and we need to do more of that. So if you've got a forecast of the level and shape of demand, is it possible for us to get a copy of it? I don't have a place, that's what I'm saying, we're working with a number of stakeholders, but I've got some stuff that I can certainly share with you about some of the indications that we're working on at the minute, yes. That would be helpful. Monica Lennon. Thank you, convener. Good morning, still morning. The financial outlook for the next three or four years is really bleak. Not my words, but Tim Davison, NHS Lothian, who was one of our witnesses last week, said that that was the one thing, a takeaway message that we should take from him. He's saying that short-termism in workforce planning hasn't helped, and I think that we've realised that today. He said something that other people hadn't said, and that was that we need to raise our gaze and plan beyond austerity. Whether that's at a UK level here in the Scottish Parliament or wherever, a growing population with growing health needs to cost more money and that needs to be addressed fundamentally. His point about austerity, could you, Mr Gray, you're the chief adviser to the Scottish Government on the NHS alongside other witnesses. What conversations are you having with the Scottish Government about this and do you address or do you recognise the premise of Tim Davison's comments? I mean, I'm assuming that you're not asking me to tell you what advice I give to ministers, because that wouldn't be what I would do in this setting. But let me address your point briefly. I recognise that the pressure on public services, not just on the health services, the financial pressure is high. There is no doubt about that. That is the case in Scotland, in the rest of the UK and internationally. The pressure is growing because of an ageing population, as we've all agreed, but let me tell you about some of the components of what we're doing about that. Realistic medicine is one response to that. The proposals to establish a new public health body are another component of what we're doing about that. The workforce planning that we're doing is another component of that. The transformation planning that we're doing is another. Can you give me a sense of what it is that you're reaching for here? As I say, I'm not about to discuss the advice that I give to ministers. I wouldn't expect you to do that. To go back to the original comment, which was about the financial outlook for the next few years, is really bleak. The witnesses were telling us that we shouldn't expect a big increase in numbers in terms of workforce. There's a whole range of things that need to happen in terms of redesigning services, training, people working differently, multidisciplinary working and so on, but recognising that that financial outlook is very difficult and it's very difficult to do affordable workforce planning, Tim Davison, whose NHS Lothian chief executive is saying, we need to raise our gaze and plan beyond austerity. He's talking about whether it's a UK level or a Scottish Parliament level. We all have to get a grip on that. Do you think that his comments are helpful? Is that something that people need to look at? Is the most senior person that we can speak to about this today? How would you develop that? He's obviously a senior person in the NHS in Scotland. Is he talking sense? I probably have a more positive outlook on life, generally. That's not evidence to the committee. As accountable officer, I work within the financial settlement that I get. I plan within the financial settlement that I get. I respect the fact that Parliament decides on a budget and therefore I work within that. That's my job as a public servant. I am convinced that we can continue to deliver excellent services within the NHS in Scotland and across the breadth of health and social care. I am equally convinced that transformation is essential to allow us to do that. We cannot simply carry on with a plan or produce a plan that says more better, faster. That will not work. We need to transform, and that's why Shirley and Catherine and others are leading work on different aspects of that. I accept that there is financial pressure. I am not sitting here pretending that there is not, but I think that if we take the view that with £13 billion we ought to be able to do something very good indeed for Scotland and for its people, that positive outlook allows us to plan beyond austerity. If we are constantly thinking about the difficulties, we will become absorbed with them. That does not mean that we can ignore them. We cannot. The pressures that we have spoken about are real, and they press on individuals, staff and patients. I would like to ask Catherine and Shirley just to say a little about what we are doing to plan ahead beyond this year, or next, and beyond through Catherine and Shirley. I think that some of the discussions that we are having here are becoming much more common in the clinical workforce, so that that recognition of the austerity and that being something that we have to get through the day job, but we are looking at changing the way that people are working, as we have talked about in many examples. We also know that we need to talk about what the public and what the people of Scotland need from their healthcare services. Many of the ambitions of the new public health body will be that some of that is prevention, so we know that we can prevent many of the ill health that we have ended up treating and will continue to treat. We are also having much more evidence brought forward about the children and young people right back to babies before they are born about how we can actually influence their health outcomes. I think that we have more evidence about what we can do now to salvage, if you like, better health for the future. We have definitely introduced that into how we are training our staff and also into how we are talking about public health and preventative spend to some extent, because some of that will need investment now to prevent problems in the future. If I can turn that specifically back to a workforce planning question, it takes 15-20 years to take somebody from joining medical school to becoming a consultant. I don't have the luxury nor would I seek it to be able to try and predict what the financial outcome for this year, next year, 10 years time is going to be, so I try very hard to workforce plan on what I believe the population need will be. I would contend that we are already training numbers in anticipation of life beyond austerity, because if we weren't, we would be stopping now and saying, oh, we can't afford it, when in fact we're investing more now than we have with more numbers of places in medical school, more number of places in nurse education than we have previously had. I think actually that it's very difficult, coming back to Mr Neil's point about arts and sciences to say in 10 years time we'll have a boom as a result of x, therefore we'll need lots and lots. What we need to do is to try and anticipate the needs of our population, to try and take a view on what we believe are going to be some of the technological, innovative or team-working solutions that might be able to provide healthcare in those circumstances, and give our best shot at getting ourselves a ready-supplied pipeline. My activity at the moment is all about increasing that supply pipeline. I believe that when we're in a position that we have that supply pipeline in every place that we want, whilst that might cost us more in terms of our establishment, it will save us money in terms of some of the discussions that we've already had about use of bank agency and various other things. I think that Mr Davidson's contention about planning taking the longer view, whether that's about riding the peak of austerity or anything else, is exactly where we need to be and why workforce planning in the NHS is more complicated than it is in some other parts of the world, simply or some other parts of industry, simply because our supply pipeline is so long. When I asked Tim Davidson just how complex it is to achieve these affordable workforce plans on a scale of 1 to 10, 10 being the most challenging, he said 10. The reasons and the joint submission that we got from the witnesses included that there's limited information on the future funding that you receive alongside the Scottish Government requiring you to provide workforce projections for three years. Should it be that difficult? 10 out of 10 is not great. I don't know how Tim calibrates, but I would take the point that it's a difficult challenge and any long-term planning you have to take into account a number of scenarios and we try and do that. However, I would also take the point that I made myself earlier on that is that there are certain things that are best done nationally that can take a view that is not just the view of representative chief executives. If I was reflecting the daily or annual budgetary cycle in the way that chief executives are sometimes required to do, I may not make the long-term investments that we are currently doing. There's a reason why we do medical school intake at a national level and we take a view about the long-term sustainable future of the NHS. Mr Greta, I know that you are a positive person and I hate to be gloomy, but I can't help sitting here thinking about some of the real heart-breaking stories that we hear. All of us in this room fully admire and appreciate the work that NHS Scotland staff do for all of us every day, but, as members of the Scottish Parliament, we have surgeries and busy inboxes. We hear about the times when it's not working well. To be frank, that is because of workforce planning issues, because there are not enough people or people who are tired and stressed and appointments get cancelled. We have constituents who are waiting more than 12 months for operations that shouldn't take that long. I spoke to the witnesses last weekend and I asked whether that is inevitable. Do we have to say to our constituents that that is inevitable? None of us really enjoy having to bring those cases to First Minister questions or portfolio questions. I know that Mr Greta, because I was there at the Scottish Health Awards last week, where we were celebrating best practice, an exceptional practice in NHS Scotland. However, you did have a message to Opposition politicians in the room that the next time we have an Opposition debate on health, we should be singing from the rooftops that we have the best NHS in Scotland.  However, when we are speaking to those constituents of ours and their families, we should reassure them that there is a coherent plan. It is going to be properly resourced. We are not just going to accept that there is going to be a small percentage of cases where it just does not go well. What would you say to those people? What I would say is that we take very seriously the matter of workforce planning, that we will take seriously any views or recommendations that the committee makes, and that there are cases that I know and accept where we do not treat people as quickly or as well as we should. No, we should not accept that that is merely inevitable. If we are successful—and I intend that we should be—in what we are doing, so through realistic mention, ensuring that people are not actually over-treated or put on lists for treatment that is not likely to benefit for them, that will then free up space for people who need to be treated more quickly. If we are successful—as, again, I intend that we should be—in transforming in the ways that we need to transform, and if we are successful in having that conversation with the public through the work that we are doing on a new public health body, on population health, about what individuals themselves can do to contribute to their own wellbeing, then we will see changes. The current situation is difficult, and I am not denying that. I am not enjoying—I trust that it is clear. I am not enjoying on opposition politicians to suddenly say, everything is fine, and we should simply ignore any issues that exist. Politicians from all parties, those at the party of government and opposition, bring to me and to Shirley and to Catherine issues that are of concern to them. That is legitimate, and they should continue to do so. Under no circumstances would I try to persuade them not to. I am grateful to you for the way in which the contribution of NHS staff is recognised, but I am not here to say to you that everything is fine and that we have to accept that there are certain areas in which our performance is not what it should be. I am conscious that there might be some members of the public who are watching, who you never know. I am glad that you clarified at a point that was made by another member on inappropriate visits to general practitioners. None of us wants to put people off and get into the door of their GP practice or elsewhere. Last week, I raised a point about the people who do not make those visits who are harder to reach. I hope that you will not disagree, but the Auditor General has pointed out that Scotland's health is not improving and that significant inequality remains. I know that you have mentioned Dr Calderwood's deep end practices. Those are the things that we need to look at in terms of innovative practice, just to be clear, NHS Scotland's message is not to come to your GP. Where we do not have the innovative practice in Lanarkshire, there was a project where nurses and health officers were going out to visit people who were not attending the doctor to proactively make sure that they were okay. That project stopped, I am not sure why, but where we have good practice, as you have mentioned, how can we roll that out? Yes, there are savings that could be made, but it is also going to help people to get better and try to close this gap in terms of health inequalities. I will ask Dr Calderwood to say something about that. As I have sought to prevent as far as possible the use of the phrase inappropriate attendance, I am also on something of a campaign to stop us from thinking in terms of hard to reach, because that almost makes it the fault of the person who we are not reaching. As far as I am concerned, the responsibility is with us to reach them, not for them to find some way of getting to us if we make it difficult. One of the things that we are doing is engaging with local communities to understand what it is that would motivate people to come into contact with a health professional, which does not need to be a GP. Sometimes it is not even a health professional, it may be someone to provide advocacy services for them and support, but Dr Calderwood can say more about that. One of the successes of the deep end practices is that those are embedded in communities and understand them. The links worker programme, I do not know if you are familiar with it, has made a big difference in a short period of time. That is where people are employed to make the links between benefits and all sorts of different services that may be the GP, but also others, and where people are coming with a problem that is not solvable by health. I think that we also are understanding further our health literacy in Scotland. The statistics are not easy to list to, so 23 per cent of working-age adults would not be able to calculate the dose of paracetamol for a child from the instructions on the bottle, and 38 per cent of working-age adults do not fully understand the bowel screening leaflet that advises them to come forward on their 50th birthday. 4 per cent, one in 25, have no health literacy at all. That means that they do not understand what their kidneys are, what they do and why that would be important if there was a problem. NHS Tayside, for example, has really embraced some of those figures and is working with community groups. That is not necessarily about literacy and numeracy, in fact. It is much more about the understanding of why it is important to come forward. I think that some of our health inequalities are based on some of those levels and some of our messaging. I have spoken publicly about that because we are claiming that people are hard to reach and that it is our messages that are not being understood or, in fact, even getting there. Our medical schools have really taken that on board. Again, that is a work in progress. Up until this point, I do not think that people really understood that we are working away trying to get people to come to us when they do not realise that there is something wrong. I talk about the worried well, but more important, the un-worried un-well. There are schemes, workshops and pieces of work. Some of it is through education, much of it is beyond health. I think that understanding our deprived communities in Scotland better is where we need to start. One final question before I let you all escape. The national workforce plan that you published in 2017 does not include details on expected workforce costs associated with NHS reform. What progress have you made in establishing those costs? Can you share that with us today? Can you be a bit more specific about that? To take one example of this, we have spent a bit of time talking about stories about changes that people have made, additional training so that you have a multi-skilled workforce. All of that costs money. I want to know if you have thought about how much that costs and whether you have actually built it into the plan because the plan did not mention it. As you will be aware, the commitment to a national workforce plan is part of our transformational change delivery programme. We had the opportunity to work to create some regional leads for that. I think that those are the chief executives largely that you saw last week. Those regional leads have been working to produce plans that will have that transformational component within it. We have seen the start of some initial drafts of those plans now with the commitment that those plans should be available for publication by the end of this financial year and we can do the consultation there at that. Those transformational plans will have a service change element where that is appropriate, but it will also have regional workforce plans associated with them that will start to help us identify costs and so on. Where we are looking specifically at clinical therapies, some of the stuff that Catherine has been leading on around realistic medicine and various other changes to practice. We are starting to get responses back from CMO and CNO about some of the training costs that might be associated with those. The commitment that we have made is to revisit the national workforce plan next spring and that should be part of that plan. Will there be a budget bid in this budget that you will be making through health for additional money for this or do we see the figure in spring and we wait another year before anything happens? No, I mentioned earlier on that we were allocated some transformational funding for this year. Most of that has been deployed in building some capacity for doing some of that work at regional level. I'm expecting us to have some budget allocation for that next year too. You'll understand that at the moment budgets are not yet set so we're in the process of discussing that. What you've described is money to buy capacity to actually formulate what the costs are. What I'm looking for is what's the money that's going to make a difference on the ground? If I have described it as simply as buying capacity, then that's not precisely what I wanted to talk about. Some of that has built capacity, some of it is funding initiatives, some of it is funding, we were asked a question earlier on about digital, some of it is working in that. You will get a budgeted assessment of transformational costs as part of the work that we would expect to be able to publish next spring. I think what would be helpful is just rather than if you can't provide me with the cost just the process so that we as a committee are clear about when we'll see a figure and how that's built into the budget. On the basis that there are no other questions from committee members, can I thank you very much for your attendance this morning at the committee and can I now move the committee into private session? Thank you.