Health, Social Care and Sport Committee

Meeting date: Tuesday, March 28, 2023

Official Report 740KB pdf

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Scrutiny of NHS Boards (NHS Golden Jubilee National Hospital, NHS Greater Glasgow and Clyde and NHS Highland)

Item 2 is the second in a series of scrutiny sessions with national health service boards from across Scotland. I welcome Pamela Dudek, the chief executive of NHS Highland; Jane Grant, the chief executive of NHS Greater Glasgow and Clyde; and Gordon James, the chief executive of NHS Golden Jubilee National Hospital.

I will move straight to questions. I have been asking all health boards about their financial situation. Obviously, demand on all health boards across Scotland has increased. There are also the pressures of heating and operating, because rises in fuel costs and inflation are affecting our public bodies just as they affect the whole country. That puts pressure on health boards to manage budgets, while health problems in the population at large may be increasing because people are feeling the pressure.

I want to ask each of you in turn how you are managing that. What impact is it having and can you see how you might reach break-even?

You will see from our submission that our predicted financial situation is a bit scary because of the size of the gap that we are looking at and are trying to resolve over the next three years. That significant amount of money includes the adult social care gap, because NHS Highland is the lead agency and because of the proportion of the gap in NHS Argyll and Bute. It is our prediction of the total size of the gap that we need to close.

We are working on that. Our submission sets out some of the value, sustainability and efficiency actions that the board is taking. Our fundamental focus is on redesigning services and delivering them in a different way, by working with our partners to optimise the wider public pound in pursuit of good outcomes for our population. Significant work on all those aspects is under way through partnership working, by having programme boards looking at the evidence to see what we can do differently and by working closely with our communities.

Inflation is having an impact. We saw a 35 per cent hike in our energy bills last year and predict a 20 per cent rise this year. We are doing as much as possible to move forward with energy efficiency. All our new builds will meet net zero standards and we are carrying out risk assessments on any current plans. Our new community hospital in Aviemore, the hospital at Broadford and the national treatment centre were built to the standards that were in place at the time of design, but are at the top of those specifications. We are engaged with a district heating system in Caithness and hope to be able to do the same in Fort William. A number of other initiatives are under way as part of our sustainability and climate work.

Highland is probably the most fuel-poor area of the whole United Kingdom and this has been a very difficult winter for many people. Are you seeing the impact of that in the level of need that your patients display?

We have had more of an anecdotal response to that through the reports that come in when we see people at the hospital front door and they speak about their difficulties, and we are definitely seeing that through the lens of children and families. It is well evidenced that in-work poverty is quite prevalent across the Highlands and Islands and Argyll and Bute. From a health board and social care perspective, we spend a lot of time looking at access and how we can deliver close to home, albeit that doing so can be extremely challenging in certain circumstances. We look at the matter from that perspective.

We are one of the main employers in the area, and we have welfare and support arrangements for staff in collaboration with the council. It has carried out a few initiatives relating to benefits and additional income maximisation in our board, for example.

Okay. My colleagues will probably follow up on some of that. I ask Jane Grant for her perspective from Glasgow.

Good morning. Similarly, we have financial challenges, but we are predicting a break-even position at the end of March, which is positive. There has been hard work by colleagues in the health board.

We are going into the next year with a recurring deficit that is similar to that which we had previously. We have worked hard to manage our resource within the framework that we have. We have a number of initiatives like those that Pam Dudek has outlined to increase our efficiency and look at our prescribing budgets to ensure that we are using them in the most efficient way.

We are also looking at some service redesign and energy efficiency. We, too, have access to district heating initiatives, and we are working towards our new builds being net zero carbon, although that brings a slightly higher initial capital cost. There are a number of issues there.

On supporting our patients, it is clear that people are presenting at a more fragile stage and are more frail. We are trying to support people to access our services and to support them in their homes to try to keep more patients in their homes when it is suitable to do so. We are also ensuring that there are wraparounds for patients who are discharged to try to ensure that, where required, there are financial services or there is advice on home energy, food packages and that kind of stuff. We have engaged in quite a lot of work to ensure that, as people are discharged from hospital, we work with our social work colleagues on a whole-system basis to support those who are most in need of such services.

Good morning. As Jane Grant’s board is, we are forecasting a break-even position for this year. Our latest submission to the Scottish Government for 2023-24 also shows a break-even position. However, there is challenge in that. We need to find around £6.6 million-worth of savings, which is around 2.8 per cent of our overall budget. We are working in a number of areas that colleagues have mentioned, such as procurement and prescribing, and we are aligning with the national sustainability and value programme.

We are currently working on a business case to link into the Clydebank district heating system. That will be positive not just for the hospital but for the community of Clydebank, as it will allow access to the heating system for social housing around the Golden Jubilee hospital in the future. That will act as an anchor point in the community.

Colleagues might want to pick up on that.

I thank the witnesses for their overviews, which were really interesting. I want to come in on how you deliver capital investment and returns in district heat networks. You have outlined specific projects that you have in mind. Ms Grant, will you go into more detail about potential district heat network investments that NHS Greater Glasgow and Clyde is looking at in particular?

Clydebank health centre has the potential to access the process in Clydebank, and we are looking at that. That is one of the initiatives.

We have also looked at other district heat pumps that are set up in some of our premises and the ability to have those in place in a number of properties, such as the dental hospital at Dykebar and in Leverndale and Stobhill. We are also looking at how we can maximise the waste-water-to-heat process at the Queen Elizabeth university hospital.

I heard colleagues talking about solar panels. We have them in a significant number of our health centres.

Does the board use a metric to assess what return on investment it might get against a capital spend? Are you able to test that as a business plan?

Our estates and facilities guys would do that process.

That is great.

I also ask all of you whether you can provide an update on your repair backlog and capital investment programme to deal with that and cost avoidance efforts. As they say, a stitch in time saves nine. I am interested to know what proactive efforts are under way to address the repair backlog in your estates.

We had a £98 million capital investment budget for last year. That is mainly around things such as the north-east hub approach in Glasgow, which will be a good community facility. We have spent a lot of money on primary care improvement plan premises and so on, and on new radiotherapy equipment and those kinds of things. We are trying to cover the whole range of community and primary care and acute services.

We have also spent a lot of money on a new robot and on a trauma and orthopaedic assessment centre in Paisley. We have quite a lot of premises, so we are trying to do that. We have also spent a lot of money on medical equipment, because we need to have a rolling programme of replacement.

We have significant challenges in relation to the maintenance backlog across Glasgow and Clyde. The backlog is not all in the places that you might expect; there is quite a big backlog in the Queen Elizabeth university hospital, because we have a large retained estate there. The institute of neurological sciences also has a big backlog. We are working on a business case to replace that just now, because it needs significant investment.

We are looking at a lot of energy management schemes to try and save money and ensure that we are recycling the resource that we have and are not simply pouring more money in. We have all talked about net zero carbon. We are trying to do all those things, particularly as we approach new builds, and use the backlog maintenance money that we have to refresh our estate in as sustainable a way as we can.

Are there opportunities in relation to your retained estate to achieve capital returns from disposal of surplus estates or investment in surplus estates for other purposes, such as the former acute hospital site at Stobhill or the east house at Gartnavel?

We have a range of disposals. We have a programme for that. We are also looking at whether we can maximise our use of premises with other colleagues in local authorities and so on. We look at a range of issues in relation to all those premises to maximise the benefit for the whole population.

My question is particularly for Pamela Dudek.

Given the number of older buildings, local hospitals and so on across Sutherland and Caithness, and right across NHS Highland, what programmes are under way to keep those facilities in good condition and open in the first place so that people have those services close to home? What is under way to also ensure that all services are not centralised in Raigmore hospital?

Some of those buildings are very old—some of my family are from Sutherland, so I know how old those buildings are. How is the progress of work to make sure that they can take some of the new equipment that they were never built to take?

I will start with our backlog maintenance, as a starter, and that will answer both questions.

Our backlog maintenance sits at around £80 million. The majority of that backlog maintenance refers to Raigmore. Although it is old, our estate is generally in reasonable condition. Our head of facilities and estates is risk assessing all our buildings. He has been moving through that in the time that he has been in post and, where we have opportunities to improve things, that is happening. That is quite a reasonable programme.

Again, like others, we also have a programme of investment in relation to primary care. We take a risk assessment-based approach to that, and our high-risk backlog maintenance is now under £1 million. Our head of facilities and estates has therefore done a lot to address that.

09:15  

As you say, with the dispersed population that we have, it is critical for us to have fit-for-purpose services locally. However, there is also a big question as to how we use those services and how not just the building but what we do in it is modernised and how it is all made fit for the future.

There is a real loyalty and connection to what has gone before. We need to work hard with communities on that because they often perceive the building as the thing that makes it safe for them whereas, actually, what is important is what goes on within the building. Therefore, that will be a focus as part of our strategy and redesign. The buildings are enablers in our pursuit of what we are trying to do.

We have two great facilities in Aviemore and Broadford. We have a redesign capital project for Caithness. We also have the Belford redesign and new hospital planning under way. Therefore, that estate looks good. We are working closely with people in Argyll and Bute on what else we need to do in that region but, having visited a number of the facilities down there, I can say that some of them are really good. It is not always the case that people there are forgotten in the back of beyond and that we are not doing anything about them. The figures support that.

Good morning to the panel. My questions follow on from what Pam Dudek said about buildings as enablers and the important thing being the quality of care. Although I accept that that is true, I have a direct question for Jane Grant on NHS Greater Glasgow and Clyde.

The repair backlog at the Royal Alexandra hospital is now more than £80 million. The one at Inverclyde royal hospital is now more than £100 million. In a recent report, Healthcare Improvement Scotland pointed to the quality of care in Inverclyde being excellent, but said that there were serious challenges with the fabric of the building. How sustainable is it to run those hospitals with an ever-increasing repair backlog of those scales? Does there need to be more sustained capital investment from Government to do something about that?

We have backlog maintenance requirements and capital requirements on all our sites. There is a large number of sites in NHS Greater Glasgow and Clyde, as you are aware, and Clyde is a key element of our service delivery. However, I would not single out Paisley or Inverclyde as being the key issues. The situation requires us to look across our real estate for the acute sector and primary care to ensure that we maximise it.

As Pam Dudek says, we assess risk to ensure that we use the resource that we have in the best possible way to cover the areas that are of most concern to our patients. We have everything in NHS Greater Glasgow and Clyde from brand-new real estate to—as you rightly point out—facilities that are less new. However, we have spent quite a lot of money trying to refurbish areas within all sites to ensure that they are fit for purpose.

In the Queen Elizabeth university hospital, we have single rooms, but in Glasgow royal infirmary, we still have Nightingale wards, and in Paisley, we have four-bed and six-bed rooms. We have a mixture of facilities and we need to manage our resource on a risk basis to ensure that we use it as best as we can across the estate. Of course, we could use more resource, but we have to prioritise the areas that we feel will have maximum benefit to patients.

We also have to invest in the areas that are less visible, such as lifts and windows. They are not the kind of areas that everybody wants to do shiny new things on, but we have to spend money on the fabric of the building to ensure that it is kept up to pace as best we can.

Given that Healthcare Improvement Scotland has said that there are substantial challenges to the safety and wellbeing of patients and staff in Inverclyde, is it sustainable in the long term to run a repair backlog of more than £100 million?

We clearly could do with more resource and would be happy to use it if we got some, but we have to base our decisions on risk. For my whole career, we have been juggling resource to ensure that we manage the risk as best we can. The backlog maintenance figure is high and we would like to have more resource, but we have to maximise what we have across the board and that is what we are doing.

I think that all boards stratify their backlog maintenance into significant, high, medium and low levels. If you look at the backlog maintenance in totality, you see that the element that is significant is very small. As Jane Grant said, we clearly focus on that element, then on our high level maintenance, based on that stratification. That is part of all boards’ property and that is their management strategy.

Emma Harper wants to come in quickly on that before we move on.

I have a quick question for Gordon James. You talked about prescribing, which I know is not just medication but includes diabetes tech—things such as pumps and Abbott Libre and Dexcom monitors. My question is about weighing the balance between the diabetes technology and making sure that we avoid poor blood glucose control. I know that there is a campaign called “Diabetes tech can’t wait”, and I am interested to know how you weigh up avoidance of complications of type 1 diabetes—I declare an interest as a type 1 diabetic pump user—against prescribing and the costs of all of that.

We do not deal directly with type 1 diabetic patients in the Golden Jubilee hospital. I should also declare an interest: I, too, am a type 1 diabetic and have an insulin pump. I do not know whether that question was planned with that in mind, but I do—it is sheer chance. [Laughter.]

Over the past year, in the Golden Jubilee we have saved more than £100,000 by moving to the best prescribing medicine for our patients. Specifically on the use of technology such as insulin pumps, we look at the whole-life cost: what does it mean for the patient on their journey through healthcare and all the way through their life?

In the Golden Jubilee portfolio, we have the centre for sustainable delivery, and within that we have an area that focuses directly on innovation, called ANIA—accelerated national innovation adoption. It looks at accelerating innovation across healthcare and it works in collaboration with the chief scientist’s office. Just last week, we have seen two of what we call “value cases”. One was for digital dermatology and the other was for closed-loop diabetic insulin pumps, which marry real-time monitoring with insulin pumps. I am pleased to say that the process was approved, and we will roll out insulin pumps and closed-loop systems, which we already have in stock in the NHS, across Scotland and fast-track that with investment.

Paul O’Kane has questions on performance issues.

I will start with a general question. At last week’s evidence session, we heard some discussion about the lack of prioritisation of preventative care because, understandably, there has been a huge focus on acute care and trying to address issues, backlogs and all the rest of it. Does the panel agree with the assessment of last week’s panellists that there has been a large focus on acute care to the detriment of preventative care?

It is not as straightforward as that. We have all been active in the space of prevention for a long time, but perhaps that has not been as deliberate as might be possible or at a consistent scale across our areas. In health and social care partnerships and outwith, in community planning, I do not think that there is a board that is not active on that. I sit on the national group that looks at community planning. It did an assessment of all areas and all NHS boards were very active, with their partners, in that space around prevention and early intervention. There is something to build on there.

I am from a community background, so I am probably more of an activist in pulling back into what happens in the community, but it is inevitable to some degree in acute settings, when they have the pressures that they have and the backlog with scheduled care and everything, that they are diverted to the very urgent, here-and-now situations.

The conversations that chief executives have, both nationally and locally, are very much about how to have a reasonable amount of sustained investment in prevention, because we all know that investing in early years and in primary prevention will help us in the long term. There is a commitment to that, but budget pressures and competing demands in the here and now mean that following that through can be very difficult.

We have to look across the spectrum and balance all the competing demands. NHS Greater Glasgow and Clyde has had a public health strategy since 2018 and aims to turn the tide by using prevention. We have been focusing on that as much as possible and have a range of initiatives. We try to work closely with our colleagues in public health, in health and social care partnerships and in community planning to maximise potential across the health board area. The Glasgow Centre for Population Health is also part of our public health setup, although it also has a wider remit.

The key focus for the future of our country must be on children and young people. That is what we have been trying to focus on. There is more to do on the prevention agenda for conditions such as type 2 diabetes. There is a range of work, from traditional health promotion through to more emphasis on screening. We are thinking about how to assist people to live their best lives if they have type 2 diabetes. Child poverty action plans are a good vehicle for trying to ensure that we invest at the right point in that journey.

As Pam Dudek said, it is challenging to manage backlogs and emergency demand here and now while also keeping a focus on the long term. Greater Glasgow and Clyde has a population health and wellbeing committee to ensure that we are giving enough attention to those things at board level, as well as delivering the strategy.

Given that the Golden Jubilee hospital is a national elective centre providing specialist heart and lung services, we do not have a remit for public health. However, I agree with my colleagues that preventative medicine should be a key focus in public health. It is also important to educate and train our citizens and to engage with them digitally. That will be key.

I want to ask about accident and emergency and particularly about waiting times, which is a question for the territorial boards rather than for the Golden Jubilee hospital. The standard that patients should be dealt with within four hours of arrival has not been met for quite some time and, in 2022, we had the worst figures on record.

Pam Dudek and Jane Grant, can you give us a sense of why that is happening? Is there an issue with staffing and resources in A and E departments, or are there wider issues caused by where people present? Last week, we heard some of your colleagues say that they would rather have people come to A and E than anywhere else, if they choose to present at all. Are inappropriate presentations an issue?

I am happy to answer first.

That is not the starting point. Our A and E consultants tell us that about 40 or 45 per cent of our presentations are for minor injuries, but that those are also relatively quick and simple to deal with. They say that any performance issues tend to come from the flow of patients into the hospital: access to beds and the time spent waiting to move people into the hospital. That is caused a much wider-system issue, which relates to delayed discharges, the care home and social care position, and hospitals’ ability to discharge early in the day. That is the area that colleagues highlight to us.

Our rural general hospitals’ performance against the standard can vary from 100 per cent down to the 80s on any given day. However, I have seen the odd day when performance in NHS Highland has gone below that, when we had a major trauma or something. The biggest issue by far for Raigmore hospital is being able to move people on to their next destination.

In the rural generals, the consultants have told me that performance is usually down because some kind of trauma or major incident has taken place that has meant that they have a bit more to deal with than they normally would. In the wards, issues are about staffing and care home placements—we have lost 104 care home beds in NHS Highland in recent months.

09:30  

Would you say that that delayed discharge plan is a key issue?

Yes.

Will Jane Grant comment on NHS Greater Glasgow and Clyde?

Of course. We have a range of issues in NHS Greater Glasgow and Clyde. We have five main emergency departments and a number of minor injuries units. We actively try to encourage people to use the MIU when appropriate to ensure that the main emergency departments do not become logjammed with people who would be better served elsewhere. We do, and will continue to do, quite a lot of promotion around that.

Our main issues are similar to those that Pam Dudek highlighted. We have elderly, fragile people presenting at emergency departments. You will have heard from colleagues that we spend quite a lot of time with the flow navigation hub to try to reduce the front-door demand and ensure that when, for example, virtual consultations are clinically appropriate—and only when they are appropriate—we expand our portfolio of offerings for patients. That work has been successful but there is more to do.

We have also looked at things such as taking some of those distressed patients who require mental health assessments away from the main emergency departments and into the mental health assessment units. Some additional services have been set up in NHS Greater Glasgow and Clyde, too, and they have proven to be pretty successful.

The principal issue is one of flow, and we, too, have delayed discharge challenges: around 300 delayed discharges on any given day across NHS Greater Glasgow and Clyde, which is a fairly significant number. We are working hard with our health and social care partnerships and local authorities to maximise potential, because sitting in an acute bed is not best for our patients, never mind those patients who are trying to come in.

A range of factors exist. Staffing is sometimes a factor. Although we have been pretty successful in recruiting in recent days, there have been staffing challenges. Flow is one of the biggest issues, but we need to ensure that we maximise our performance in flow 1—the minors flow—which is where the major volume of patients comes through.

There is no one size that fits all; we need to look at a range of things. We are looking at how we can maximise and redesign the flow within hospitals not just around flow 1, but also around the Glasgow continuous flow—GlasFlow—model in relation to moving patients. We are also looking at using our predicted date of discharge more accurately, ensuring that we maximise the number of discharges in the morning as best we can, and using our discharge lounges to ensure that patients who are waiting for discharge are not occupying a bed while others are trying to get in. We are trying to do a big range of things, working closely across the whole acute system and with our HSCPs.

Jane Grant mentioned a number of alternative routes for patients to be seen and the fact that the board is trying to encourage people to go to the MIU. You did not mention the general practitioner out-of-hours service, which is a key part of the issue. Inverclyde has been without out-of-hours GPs since 2020 and no plans from the board appear to be in place to reinstate that service. Instead, the board is directing people 15 miles up the road to the provision at Paisley.

First, do you think that that decision is good value for money with regard to supporting people to be seen in the appropriate place? Secondly, what kind of impact will the fact that people cannot see an out-of-hours GP in their community realistically have on A and E front-door services? Might you be able to give the reasons behind that decision?

Of course. The board has not taken a final decision yet. We are still working on a number of possibilities for GP out of hours. We are still in business continuity across Glasgow and Clyde, for the whole of Glasgow and Clyde, including Inverclyde.

As you know, there have been issues around Glasgow and Clyde’s GP out-of-hours service. We completely transformed the service three or four years ago. People could just walk in, which caused difficulties and was not an appropriate mechanism. It was probably the only board in Scotland at the time that did that. We have completely redesigned the service.

We have a GP out-of-hours service in Inverclyde. There is a home visiting service and a focus for transport to Paisley if the patient needs it. A large number of consultations are now being done by phone throughout Glasgow and Clyde, and not just in Inverclyde. The service model for GP out-of-hours services is changing, along with our consultations for out-patients and so on. That virtual mechanism will become more embedded—it has certainly become more embedded since Covid—across our all-services offering, which includes the GP out-of-hours service.

We have not seen a significant increase in emergency department attendances in Inverclyde on the back of the GP out-of-hours service situation. We have been monitoring that quite carefully. However, the board is still considering the options, because we recognise that there are strong feelings in Inverclyde about the services that we are providing.

We have a GP out-of-hours service in Inverclyde and it has not increased the activity in the emergency department.

Can I add to that? Out of hours has been a challenge for many years. I ran an out-of-hours service in another board for many years, and sustaining and configuring it was a constant struggle. It has been no different since I came to the Highlands. The bit that is tricky for us, on which we really need to work hard with our communities, is the perception of what is and is not happening in the community. It is a bit like what I said before about what people have traditionally experienced: they think that any change means a reduction in service and a lower quality service. We have many conversations like that. In the Highlands, a number of communities do not wish to use 111 and feel quite upset with us when we ask them to do so, when what we are trying to do is to have an arrangement with 111 that can help us to manage the postcode better and respond better with the local teams.

For me, though, there is something about building up confidence in communities and helping them to understand what is a safe service for them. Just because there is a change does not mean that a service is unsafe. We have a lot of conversations like that with communities, and the out-of-hours service is a key issue. If the service is not something that the community recognises, it can often feel quite unsafe. However, it is incumbent on us to change in that arena because, when we were trying to spread a thin workforce across a patch, it was probably less safe than some of the innovative ways that we might try to work as we go forward. Our clinicians want to work differently in that space, so it is about trying to bridge that gap of understanding and address that unsafe feeling, and we have definitely got that as an area of work at the moment.

We move on to questions about Covid recovery, led by Emma Harper.

I am interested to hear about Covid recovery in all three areas. We hear from the health boards that come before us and we know that healthcare is really complex. As a nurse, I worked during the pandemic giving vaccines, and I saw how busy, committed and professional the staff were. I am thinking about acute care, mental health care, emergency care and elective care. Jane Grant said that one size does not fit all, when trying to address Covid recovery. I would be interested to hear about any actions that have been taken to progress recovery from Covid. What is working? What isnae working?

On Covid recovery, as you would imagine, we are working hard on the elective backlog. There is a large backlog of patients who require treatment, and we need to balance that with the high level of demand for emergency care. We are trying to manage both, at the moment, which has been a challenge. We are working hard to reduce the number of long-waiting patients, in particular, and we have had some success on that—more so in the out-patient set-up than with in-patients, which has been a challenge because of emergency demand over the winter.

Lengths of stays in emergency care have for us been quite high, which has not helped us. However, we are trying to use our ambulatory care hospitals. We are fortunate to have two such set-ups in Glasgow, and we are also looking at whether we can ring fence some beds in Gartnavel general hospital and Inverclyde royal hospital, to make Inverclyde a centre of excellence for our orthopaedic elective work. Quite a lot of work is being done on how we can manage the bed base in a different way to protect it from emergency care and make sure that we can keep working on our elective backlog.

In addition—as, I am sure, Gordon James would say—we are making good use of the Golden Jubilee hospital and we work hand in hand with it, as one of our partners, to deliver elective care.

I am not sure whether you want me to go more widely—for example, into cancer—or just to stick to that.

I suppose that the issue is competing priorities, when acute care beds are occupied by people who are not well. When it comes to acuity, patients are getting sicker before they are even in the hospital. When beds are being juggled, it is very clear that there are challenges. For example, use of the Golden Jubilee and the sequestering of beds for elective surgery or the national treatment centre, for instance, should support the management of elective treatment so that we do not have competition between bed priorities. Is that what we need to look at?

You are absolutely right. We try to make use of and maximise all our elective capacity across Scotland.

We are also looking at a number of initiatives to keep people out of hospital beds, if that is appropriate—for example, through increasing our remote monitoring and our out-patient parenteral antimicrobial therapy service—and we have been pretty successful in delivering reductions in the numbers of patients who could have a different service model. That is the way of the future: to maximise potential in order to keep out of hospital people who are not best served by being there.

We recently did a day of care audit, to look at whether we could do anything else for patients in hospital, and not just those whose discharge is delayed. Some things emerged around use of allied health professionals, for example. Perhaps we could move some patients to having their AHP treatment done more in their home or in a community setting, rather than their waiting to have some of it in hospital. We are trying a few things that are emerging from that day of care audit, to minimise bed days and make sure that the beds that we use are for acute patients.

We have talked a little about delayed discharge, but if, for example, we can do more remote monitoring and treat people more in their own home or in a community setting, that is what we should do. We need to do all of that.

During the pandemic, a decision was taken to keep the Golden Jubilee as a green site. We restarted our planned care operation about 10 to 12 weeks after the beginning of the pandemic, which has ensured that we have continued to offer planned care all the way through. Between 2019-20 and the current year, there has been a 20 per cent increase in our surgical throughput in knee, hip and eye surgery, and within our specialist cardiac service.

As Jane Grant has mentioned, we work with boards across Scotland and support patients who have long waiting times. During the pandemic, we opened phase 1, which was our eye centre. Currently, we do about 30 per cent of Scotland’s cataracts. Just over 11,500 will be done this year.

We are on plan to complete the construction of phase 2 at the end of the summer, which will increase the expansion on our site of orthopaedics, general surgery and endoscopy. That is an £80 million investment in addition to the eye centre that opened two years ago.

The original plan for those sites—phase 1 and phase 2—was a regional asset management plan all the way up to 2035. However, we have been working with colleagues in boards and in the Government on how we can bring forward full-volume throughput of the sites much earlier.

09:45  

Speaking from an NHS Highland perspective, I will, like Jane Grant, say that our system has been out of balance. Emergency demand has definitely had quite an impact on our scheduled care programme, with regard to our ability to release or ring fence beds for surgical care.

On the medicine side, we have had whole-system working across the community and the acute hospital, with the aim of achieving in-hospital interventions, or actions on planned date of discharge and early discharge. We have absolutely been assessing the mechanisms that are in place with daily oversight of the system, as we think about moving towards reconfiguration and about optimising what we do in the community so that we are able to move people out of hospital.

As for the elective side of things, it is fair to say that we are, in a number of specialties, out of kilter with our pre-pandemic performance, but the most challenging areas are those that were already challenging in NHS Highland before the pandemic. We have a plan under way with the Scottish Government to set out trajectories, and the matter of where we will get to is being refined at the moment.

Clearly, the national treatment centre, which opens next month, will be a huge asset and a really positive step forward for us. The centre will take on all the eye care that is currently being carried out at Raigmore, as well as dealing with less complex but high-volume orthopaedics cases, which will free up space and opportunities at Raigmore.

With regard to orthopaedics and trauma, we expect that by October—indeed, at three points; in June, July and October—our waits of more than a year will be down below that level and that, by 2023, we will be starting to get back into balance with the treatment time guarantee. Those are our predictions at the moment, but we will obviously keep a very close eye on things and carry out surveillance.

Moreover, once the ophthalmology and eye care service is up and running, we expect those waiting lists to get back into balance fairly early on in the life of the NTC. That will obviously create capacity that the centre can then offer to other boards, but in the first instance, we will be working with NHS Grampian on its orthopaedics waiting times, taking 30-odd per cent from the figure that I have cited.

Good morning, panel. My question, which is for Jane Grant, is about gynaecology waiting times. I think that things are looking much better with a lot of other waiting lists, but why are you still having issues with gynaecology?

There is no doubt that we have had some challenges with gynaecology. Our waiting time, particularly on the out-patient side, has been lengthier than we would have liked. We have put in place some waiting list initiatives in order to reduce that, and the number of long-waiting patients is coming down, but we have had to move some of our staffing resource into obstetrics, which has, over the past few months, caused a slight imbalance where previously things were in balance. However, we have an active programme of insourcing and waiting list initiatives to reduce times as swiftly as we can, and we are seeing some early shoots growing from that work, which is under way as we speak.

Thank you. We move on to an issue that I know we have touched on a lot this morning: progress with the recovery plan. The questions will be led by Stephanie Callaghan.

The Scottish Government annual progress update back in October said that “significant progress” in delivering on the ambitions of the recovery plan had been made. Do you agree or disagree with that? That question is for all three witnesses, starting with Pamela Dudek.

Can you repeat the question, please, so that I can give you the right answer?

The Scottish Government annual progress report back in October said that “significant progress” in delivering on the ambitions of the recovery plan had been made. Do you agree with that, or do you have some challenges in that respect?

I agree with that, but we still face some challenges. We have worked really hard and have used every opportunity of remobilisation and recovery to try to step up and bring our system back into balance. In our conversation today, we have described some of the challenges that we continue to face. Every day, we look at where we are and at the art of the possible, but we generally do that from a challenged position. Of course, that position is quite volatile. My experience is that it can look like we are making good progress and are on our way, but then some variables change and things become difficult again.

I do not think that we are on a smooth path, and it would be fair to say that there has definitely been movement and progress in some areas, but it can at times be challenging to sustain that future pathway and feel confident that we are on an even keel.

Progress has been made. It has been a difficult period for the health service across Scotland and the United Kingdom. We have had to balance the emergency flow with fragility and frailty of patients that are greater than they had been. We have had a significant increase in things such as our referrals for urgent suspicion of cancer, which has led to a backlog that we have to work on. We have to address that, because we are dealing with people who are, rightly, anxious. We have diagnostic challenges in that respect, and we need to ensure that endoscopy and imaging services and so on are appropriately resourced to handle the backlog. Within that, we have to prioritise patients who we think are most in need and at highest risk, and we have to do all that against a significant elective treatment backlog and the emergency challenges that Pamela Dudek has outlined.

As I said, progress has been made, but we have to reflect on and recognise the fact that our staff have had two or three years of significant pressure. That is the position that we are starting from, so we have to reflect on how we can support our staff and make things easier for them, rather than just asking for more and more from them. We have spent quite a lot of time trying to ensure that our staff are supported appropriately, while recognising that we have a public duty to ensure that the services that we provide can be provided swiftly and at appropriate quality. Undoubtedly, we are on a difficult journey.

I agree with my colleagues. The pandemic has been challenging not only for patients, but for all of us in society. Obviously, the winter pressures over the past few months have added to the challenges that we face.

That said, we have made progress. Last year, in the Golden Jubilee hospital we pivoted in order to address long-waiting patients across Scotland, and you will see that the number of patients who are waiting for longer periods has reduced, as a result. I think that we have made progress, but I recognise that there are still challenges in the system.

At the Golden Jubilee hospital, we have the centre for sustainable delivery, which has two pathways on which we work with specialist delivery groups—clinical and managerial groups—across Scotland, looking at patient-initiated reviews and active clinical referral and triage of patients. That is really about putting patients at the centre of the process. Through those two programmes, we have removed the need for about 100,000 patient appointments. I can use my situation as an example. I am a type 1 diabetic and, if my control is good, I do not need to see a doctor, but if my control gets worse, I can initiate a review myself. What happens really depends on the needs of the patient. Using those pathways to transform our services has helped us as we have come out of the pandemic.

You pre-empted my next question; I was going to ask you about what you have been doing at the Golden Jubilee hospital. How significant is that? Should it be scaled up and applied elsewhere?

We are already scaling that action up. Almost all the boards in Scotland are engaged in patient-initiated reviews and active clinical referral and triage.

As I have said, about 90,000 patient appointments this year have not been required. I stress that that is based on clinical intervention. Senior clinical intervention is part of the process, and in patient-initiated reviews it is down to patients to re-engage with the service or to have a realistic medicine conversation with the clinician who is delivering their care.

Is that essential in order to make an impact on achieving the ambitions?

Absolutely—and it is having an impact already.

Do I have time for a second question?

Do you mean a fourth question? Other members want to come in, so please make it quick.

I have a quick question for Jane Grant and Pamela Dudek. In its report, Audit Scotland said that it does not feel as though there has been a full reflection of the scale of the challenges and that that has had an impact. Is that accurate, or do you feel that some of the stuff had to be quite local? There were high-level targets. Was making decisions at local level helpful or unhelpful for what you wanted to do to?

It is really important to have the local aspect. We need both—there is a lot of learning that we can take from national direction, and there is a lot of support from that. However, the local context is important. If you consider that the NHS Highland region includes 42 per cent of the land mass of Scotland, 36 islands and a widely distributed population, you will see that one size does not fit all .The context is different, as are the assets that the board might have at the local level. The local ability to assess what is needed and to pull in partners for some of the work is important. We always try to balance the two.

There were a number of unknowns as we forged our way out of the pandemic into recovery. We are still in that territory, but the insights that we have gained will help us to understand more and more what we might need to think about differently. I think that we will be on that journey for some time. Local context is important in designing and responding to what the population needs.

I agree with that. We require an overarching direction of travel, but we need local autonomy to do that. We have been on a journey for the past two or three years, and we are not at the end of that journey—even today. Yesterday, I had 487 in-patients who had Covid, which is a large number. They were not all there because they had Covid, but it brings added complexity in terms of infection control.

Covid is not over in the sense of it no longer impacting on our services: it still does. That means that we have a number of closed wards, so our bed base is still quite challenged. We need to ensure that our patients and staff are as safe as they can be, especially on the Nightingale wards that, as I have described, we still have in NHS Greater Glasgow and Clyde. One of your colleagues said earlier that it is a complex environment. That is true: it is an incredibly complex environment to manage. We are still managing Covid. We are doing so in a different way, but the numbers are high so we have not finished that work yet.

I have worked in the health service for quite a large number of years, so I know that, during the winter period, between Christmas and new year we usually get a lull and a reduction in emergency demand. However, this year, there was certainly no such reduction, probably for the first time in my whole career. That was because of Covid, flu and so on, as well as emergency demand. This winter has not been what I consider to be a traditional winter, and we are still only in March. In order to balance everything we need both the local and national aspects.

I will bring in colleagues. Evelyn Tweed has a question on this issue.

Stephanie Callaghan asked some great questions, and she asked mine.

Emma Harper wants to come in.

My question comes on the back of Stephanie Callaghan’s question. Does the Scottish Government enable and support you to do bespoke local delivery? We have Pamela Dudek here from NHS Highland, which is rural; we have urban representation from NHS Golden Jubilee National Hospital and NHS Greater Glasgow and Clyde; and, last week, we had a witness from NHS Borders. Does the Government support you to deliver local plans that work for your areas?

10:00  

Broadly, yes. Some policy decisions have been challenging for us. For example, it will be no surprise to the committee if I say that our rural GPs were at odds with the GP contract. We have had a lot of press about the fact that vaccinations are now the responsibility of the boards that deliver them. In a number of areas, they are still raising with us their feeling that that area should be GP led. Such issues come along regularly. However, the reality is that, with the vaccination programme being the size that it is now, many areas are not of a mind to be involved in that way. Also, given the demands on general practice, I am not sure that we would want to add in that other layer again in the way that is being proposed.

In those circumstances we are trying to work within the local context and to understand the rationale there. There is a confidence in what has happened before, which I can understand, because it worked well. However, we have now transitioned to a very different programme, so balancing views can be challenging at times.

On the whole, I do not feel constrained; I feel that we have a lot of levers that enable us to examine locality planning and optimise our resources at that level. It is for us to drive that process in an improved way, as we have done historically. NHS Argyll and Bute, which is integrated and where everything is under an integration authority, has great leverage to support its local context and shape, and we can see the benefits of that approach. In fact, all of its secondary care pathways lead to Jane Grant’s system. Again, there are great examples of cross-boundary and cross-board working there.

I want to ask you a bit more about that. We have had petitions about maternity services—in particular, in the Caithness area—which, over the years, have been picked up as presenting an issue. I know that a review of those services is happening at the moment. Will you give us an update on what is being done to better serve women and their babies in that part of the Highlands?

We are probably still in the middle of trying to understand what the optimum model could be. We are considering what women’s voices bring to the table as regards what they want. The words “safe” and “unsafe” are common terms in relation to services. We are trying to understand what it would take for more women to give birth locally, because the birth rates there are currently low.

The committee will know, from petitions and from the work of the local campaign group, Caithness Health Action Team—CHAT—which is mindful of them, the choices that are currently on offer to the women of Caithness. We are working closely with the CHAT campaign group. At our meetings within the past fortnight, its chair has publicly announced that our working relationship is much improved and that it is keen to continue to work with us to see how we can optimise services. However, we are still in the middle of trying to understand that.

We are conducting a strategic review of maternity services for NHS Highland. Although giving birth in Caithness involves long journeys for women who are in labour or at that stage of pregnancy, so does giving birth in Lochaber, Skye or Campbeltown. We have many remote areas in which there is variation in our birth rates. We are trying to understand our system and to carry out deep dives with clinicians to see how we could perhaps shape ourselves better in the future.

What is the projected timescale for the review’s conclusion?

We are right bang in the middle of it. We are looking to take to our May board meeting a revised business case that will set out the resources that we are looking for.

On the back of that, we have been looking at the key performance indicators and working with the team live to consider the rationale for our caesarean section and induction rates. We are seeking to understand and explain that aspect and to improve on it where it is possible to do so.

Does that review include getting feedback from new mothers who have been taken on a long journey to Raigmore, for example, on what they would have preferred?

Yes. We are working with the Highland maternity voice partnership, and we are looking at how we can expand the knowledge and intelligence that we get from mums who have birthed recently on why they made the choices that they did.

Again, we hear anecdotally from people that distance is very much a choice. Do they want to take the risk and hope that everything is fine and that they manage to birth successfully, or do they want to be in a place where they can get additional care if things go wrong? That would appear to be the challenge in people’s minds, but I want to test that further with women who have had that experience.

Thank you for that update.

We will move on to talk about the escalation framework, with questions from Gillian Mackay.

How do the boards feel about the progress that they have made under the current escalation framework and the issues on which they have been escalated?

NHS Highland experienced escalation in 2018 in relation to finance, culture and leadership. We have also had special measures in place for some of our mental health services, particularly child and adolescent mental health services and psychological therapies.

Last year, we were de-escalated on the culture, leadership and governance aspects, but we remain at level 3 for finance and mental health measures. I will start by discussing where we are still escalated, and I will finish on the positive aspects, where we have been de-escalated.

Finance and resources are an on-going challenge for us and we have worked hard on that area. During my time with the board, I have seen significant progress in our finances, and it is very disappointing that we find ourselves in the current situation as we look to next year. However, we have a capability, and we will apply that and do our best to move forward with a confident plan. As members can imagine, we currently have a huge focus on that.

With regard to psychological therapies, there is a robust plan in place and we have made good progress. Our director of psychology, who came in to take up a new leadership role, has deployed that plan thoroughly and very well, and we are making the right progress and are confident in the plan.

With CAMHS, the process has been slower. Given the CAMHS waiting list, the model on which CAMHS was delivering services, which was not in line with the national specification, and the staffing challenges that it has experienced, we have had quite a legacy. However, again, we have brought in some refreshed leadership and we have had external support, and we are now moving in the right direction, albeit that we still have some way to go.

That goes back to our discussion about prevention and early intervention and our work with the council on education and health visiting. Early intervention needs to be part of that plan, and we are actively involved in developing an integrated children’s services plan.

Those are the areas of escalation. I will now turn to de-escalation. One area of de-escalation relates to governance. We had a full programme around the blueprint for good governance, with an action plan, and we completed all our actions for improvement. We are now a pathfinder for the self-assessment of the new blueprint and, last week, we had a board development session in relation to self-evaluation and further improvement. That was a very positive session. It was testament to the work that we have done and it looked at how we can build on that. The board wants to continue to improve and move forward.

We have invested significantly in leadership across the organisation, and we have in place a development programme that we are reviewing and improving. We have a strong team working in and around that.

Culture is a funny one for me. When people talk about changing culture, I do not find that very helpful, because culture is not something that we just change. There are many cultures in a complex system, and there are many different ways in which people work. We need to create the right environment, where people can thrive and work well together. That is absolutely what we have tried to do. We have been very successful in the post-Sturrock period, closing off all the actions associated with Sturrock, and we have had the NHS Highland healing process. As a board, we have been trying to look forward while making a positive impact.

As for how different things feel for people on the front line, having been out and about lots throughout the whole time I have been in Highland and having worked in many other boards, I have found people to be very passionate about what they do and I have found teams with fantastic profiles of working together, with no grievances or real issues, as well as areas where people have had some really bad experiences—and everything in between.

There are now many ways for people to raise concerns confidentially, including through our independent speak up guardian service, which has been really successful, and through our whistleblowing champion, who goes out all the time, both with the manager and privately, and is therefore accessible to people—and we get his reports back. We have taken every report that has been made by him, by the independent healing process panel or openly through our own reporting of iMatter, through our board. We have made great progress, but this will always be a live issue. In a big, human organisation with many different beliefs and perspectives, we will always have to work on the relational issues and support people. Michael West will be coming up this week, and he has been before. There is a big focus on “Civility saves lives”, and we are pursuing work around team conversations and values.

I am particularly interested in the area of culture. I note the number of sites where NHS Highland operates and the number of workers who are potentially not coming into contact with a lot of colleagues. How do you overcome that challenge of ensuring that everybody’s voice is heard and that you are accurately hearing what is going on at different sites, given the small number of staff in some places and the potential for some relationships to be not very good? People may be much more easily identifiable if they make a complaint there, compared with what happens in NHS Greater Glasgow and Clyde and some of the bigger hospital sites that we have, where raising concerns anonymously is slightly easier, I suppose.

There are a few ways in which we have tried to do that. You are absolutely right: in the more rural areas, we are living and working together, so home life comes into work life sometimes, and that can be tricky. Our guardian service goes out and about, and it is present in a proactive positive way among our services. One of the most recent times I was down in Campbeltown, the guardian service was present in the hospital. It is not just a person who comes along when there is a problem; they are there to give support, to hear from the team and to act as a conduit for bringing support. There are also whistleblowing champions.

We have had a huge emphasis with our leaders on the importance of knowing what is going on in their system, and we have encouraged open debate, encouraging the celebration of difference rather than excluding it. Through our performance management framework, we have spent quite a lot of time on the people measures around sickness, absence, grievance rates and the temperature of the team. We are building on that all the time.

Do you feel that you are receiving adequate support to improve not just the things where you are still on level 3 but those other aspects of culture, so that you can continue to make progress? What other support do you feel needs to be in place to help to de-escalate the level 3 things while you keep improving on the things that are at level 2?

We are getting very good support on the things that we need to deal with, but some of those issues are pretty tricky. On culture, it is really for us to keep doing what we have been doing and to build on that.

10:15  

Culture comes from the people and the leaders, clinical and otherwise, who are in the system and from how we behave—we all need to own it. Clinical leadership is hugely important, because culture is not just about how we behave or how well we get along; it is about the standards that we work to and how we interact with our patients, among other things. We need to own the culture, continue to promote it and move forward with the initiatives around it. Culture remains a top priority for the board to focus on, and you would certainly see that. However, the board is still trying to make sure that people at every level see the difference, because we still have people who say that they do not. We need to understand why that is and what we can do about it. That is an indicator that we know about.

A number of colleagues want to ask about culture.

I was struck by what Pamela Dudek said about culture, because there is a big report that suggests that culture is not what it should be in NHS Highland. Fiona Hogg, the head of people and culture, has left. In January, there was a report in The Spectator titled “The NHS is drowning in paperwork”, which talked specifically about the Highlands, as did a BBC article from 14 February titled “Vulnerable patient died ‘due to lack of nursing staff’”. Those are all examples of where culture is poor, because, clearly, issues were not properly escalated. There are plenty of other examples that I do not have time to go into. From what you have said, it does not seem as though you have got on top of the culture in NHS Highland. What specific steps are you taking to ensure that the culture is where it should be?

Are you referring to the Sturrock report?

Yes, but previous reports have also talked about the culture within NHS Highland.

Recent reports that we have taken to the board formally have come from the independent panel on the healing process, which set out the areas of focus that needed improvement and, as time went on, cited improvements that we had made. On the recent health and safety case—and by no means do I mean that there are not on-going culture-based issues within our health boards; we will always have to work on the culture of our human system—

What steps have you taken?

We have taken and will continue to take steps around early resolution—monitoring and surveying how our teams are through a number of metrics, including sickness and absence, grievances raised, and our iMatter and listening and learning surveys, and through performance. Those interventions are live and on-going.

We have a range of interventions from an organisational development perspective, which involve our OD team working with other teams that are struggling. Our independent guardian service will work either on a one-to-one basis with individuals or with teams, and we have whistleblowing arrangements. Informally, we all try to make ourselves available at all levels to work through some of the issues. Clearly, when we have had a serious incident such as the death of a patient, and recognising the falls aspect of that, we use formal review processes and take the learnings back into the organisation.

Tess White has some questions on culture and governance.

I do. I have two questions: the first is for Pamela Dudek and the second is for Gordon James.

My first question builds on the question that our convener asked about maternity services, and it is about the culture in the NHS Highland. We have had petitions on the subject, which have been referred to. You said that you are consulting women’s groups, but we have heard loud and clear from women’s groups in the Highlands that they feel like second-class citizens in relation to not just maternity services, but general women’s health, including endometriosis.

It would be helpful if you could give your feedback on that consultation so that the groups know that you are listening to them and will follow it up.

Absolutely. Points have been made through that route and also through chat. I see them as they come in and I review them with the team. Our local team in Caithness and the teams in Raigmore that relate to those pathways are working much more closely within the locality to understand those perspectives and look at what else can be done. I am very aware of the issue and we will continue to work with the groups to try to get to the right place.

So it is definitely on your radar and you are working with them. Is it one of your top—

[Inaudible.] I have read that and we will be looking this week at how we respond to that. When I or any of the team are up in Caithness, we certainly try to meet those people whom we can meet face to face.

Thank you. My second question, which is for Gordon James, is about the employee questionnaire. We have a copy of the statistics for the various health boards, and I note that the figures for the Golden Jubilee hospital are declining or below average. When it comes to staff governance and the staff experience, what are you doing to address the poorer performance in relation to how staff feel about their wellbeing?

We are doing a lot of work around staff wellbeing. We were the first board in Scotland to launch a spiritual care strategy. It puts patients and staff at the centre; it is about love and kindness and what they mean to the staff member or patient. We launched that strategy, which is the first of its type, in January.

On physical health, we have our occupational health service, to which staff can self-refer. We have mental health first aiders who help staff through any difficult times. We also run a series of events on wider societal issues such as finance, and we bring on board the Samaritans, mortgage providers et cetera to help staff.

As well as the whistleblowing arrangements that all boards have, we have an employee assistance programme with a confidential line that staff can contact to raise any issues that they have.

We have a spiritual care and chaplaincy team that speaks to staff of all faiths and none, as well as the public, and we are undertaking a number of activities, such as mindfulness and breathing in to the weekend. We have a full programme of staff events that we have been undertaking over the past year.

Staff might say that that is cure rather than prevention. Staffing is a big issue, so having mindfulness is not going to cure issues with staffing.

Do you mean in terms of the number of staff—

I am talking about people and their wellbeing when they come to work, and whether they are stressed because of other issues.

That is why we have mental health first aiders et cetera. In our wider activity, we look at social wellbeing, including what is affecting the person in their daily life and how they feel in the workplace. We do things such as hold Schwartz rounds, which provide an open forum for people to discuss issues that are affecting them. Again, that is led by our chaplaincy team. We also have a volunteer team in the hospital that supports both patients and staff.

Does it concern you that you have declining or below average performance?

During the pandemic, we saw a slight dip. I believe that, as we go forward into future years, given the work that we are doing, we will see an increase in the numbers again. We are absolutely committed to staff wellbeing.

I mention to colleagues that we want to talk about mental health services and staffing issues, and we are still on governance and culture, with a number of members wanting to come in on that. We have only 20 minutes, so please keep your questions succinct.

I will be succinct, convener. My question is for Jane Grant. I am looking at NHS Greater Glasgow and Clyde’s website, and there is loads of information on staff support and wellbeing—there is information on peer support, self-referrals, mental health, stopping smoking and speaking up. The website says that you are listening. Put simply, how is that marketed to staff? How do they know that they can access those services, from an education standpoint?

We have a variety of ways of doing that. We have our core brief, which I send out every week and which outlines some of those resources. We send out regular briefs during the week, in which we highlight things to staff. Staff sometimes raise issues that they want to put in the briefs, so that we can be clear about those. We encourage line managers to have conversations with their local teams to ensure that we get suggestions. We have an active communications and engagement department, which works hard to ensure that we do that when ideas come from staff.

Last year, we launched an internal comms and engagement strategy, and we are working on the actions within that, because communication with our staff is absolutely critical. The internal comms and engagement strategy is the focus of our work to ensure that we permeate the whole organisation. It looks at a range of things, from core values to things such as collaborative conversations and the sort of activities that Emma Harper described around ensuring that we have active staff, as well as things such as mindfulness and smoking cessation services. We recently launched a support mechanism for staff, through which they can access small grants if they are in severe financial difficulty, and which they do not have to pay back in the short term.

We are trying to do a huge range of things. The communications strategy and our comms department are the principal way in which we do that.

Do you use social media, too?

Of course—that is all contained in the internal comms and engagement strategy.

Paul O’Kane has a question on that issue, and then he will move on to staffing.

My question follows on from that point. Jane, you spoke about the work that has been done in the previous 12 months. However, do you accept that, in the past 12 months, the number of whistleblower complaints in NHS Greater Glasgow and Clyde has doubled? That suggests to me that there has been a failure to empower staff to speak out. I have heard directly from staff that there is a culture in NHS Greater Glasgow and Clyde of people feeling that they cannot speak out, particularly where, for example, someone might be the only staff member on a ward in a hospital. Do you accept that?

We have tried hard to ensure that staff have access to whistleblowing processes. The speak up campaign has been successful. To be honest, I am not sure whether you would judge success to be more people or fewer people speaking up. I am keen that our staff speak up. It is incumbent on us to ensure that all line managers, as well as the appropriate mechanisms, are supportive of staff to ensure that they feel that they can raise things locally. However, when people feel uncomfortable about doing that, there has to be another mechanism, and our speak up campaign has been successful in that regard. We have done a whole review—

Do you recognise that whistleblowing is a last resort for staff?

Absolutely. We have a whistleblowing champion, as others have described. He carried out a full review of our whistleblowing processes, and an action plan was developed, which we fully implemented. At our board meetings and so on, the whistleblowing champion is positive about the actions that we are taking on whistleblowing. However, we cannot rest on our laurels on that—we have to be proactive about it all the time, because we want staff to feel that they can raise issues in a constructive way and that they will be supported to raise things when they want to do so.

I want to expand on that issue. We are interested in the retention of staff. We have a real challenge with keeping staff in their roles because of anxiety, stress, burnout and associated issues.

Staff in NHS Greater Glasgow and Clyde have at various points described their experience of some hospitals as “hell on earth”. That is a quote from a member of staff. I go back to the point about the single staffing of wards. That was uncovered at the Queen Elizabeth university hospital and at Inverclyde royal hospital, where it has certainly happened on more than one or two occasions. Much of that information had to be found through freedom information requests. To what extent do you believe that it is a significant problem? How is it being dealt with at board level?

10:30  

We have had an issue with having only one registered nurse on wards. We have spent an enormous amount of time trying to address that, and we have been reasonably successful. It happens much less now, and we have a regular reporting mechanism that highlights areas where we have staffing challenges.

The key thing for us is to try to recruit more staff and to retain our existing staff. There is a lot of work going on in that respect, and we have managed to recruit in excess of 200 international trained nurses to support our staffing. We have challenges around staffing, as all boards in Scotland do, and we are trying hard to recruit and retain more staff.

It is incumbent on us to make sure that our turnover is low, which means supporting our staff when they are in post and making sure that we listen to their issues. Sometimes, issues such as short-term sickness make the challenges very difficult and, as you have heard today, the Covid position leads to higher levels of absence. It has done so for us, which makes it difficult, particularly on smaller sites, where there is less flexibility.

To go back to the point about culture, would you accept that some staff who have found themselves in such situations have either not reported that via Datix or whistleblowing procedures, or have not spoken out because they do not feel confident or supported to do so? Indeed, they have felt that there might be repercussions if they were to speak out and express their concern about being on a single-staffed ward.

We are certainly doing all that we can to encourage people to report, to make sure that we understand exactly what is going on in any ward that has only one nurse and to support colleagues when they have been under stress or duress. It is not a subject on which we can rest on our laurels; we have to be proactive all the time in trying to support people who want to raise issues.

However, as I said, we have been reasonably successful in making sure that the “Speak up” campaign has been successful. We have the whistleblowing champion, who is very active, and we do quite a lot of other things through our area partnership forum, which is most vocal if it has things that it wants to raise. We are endeavouring to respond.

Is the board regularly informed about where that is still happening, if it is still happening, and the plans that are in place to tackle it? Is that information shared publicly through board papers and those sorts of things, or will we require to make an FOI request in the future to understand the picture?

A lot of those things would be dealt with in our board committees. As you can imagine, in a board with a £4 billion budget, there is an enormous amount of activity at board level. The board committees are where we do most of our business of that sort, which is reported, and our non-executive members question and scrutinise the performance of the executive team.

Okay. As far as wider staffing issues are concerned, there is a particular issue around the national waiting times centre and the expansion of staff—there is obviously a need to recruit a large number of staff in order to upscale. Gordon, do you think that the timescales and the plan for that are realistic?

Phase 2 is the new elective centre and, as I mentioned earlier, the original plan was for roll-out to extend all the way to 2035. At the moment, we are looking to accelerate that plan. We have set ourselves a target of recruiting about 250 staff by September and an additional 250 staff by the end of the financial year. To date, we have recruited 120 of those staff across different disciplines.

As my colleagues have said, there is a challenge around nursing and some of the nursing workforce. As Jane Grant mentioned is being done in Glasgow, we are successfully utilising international recruits. We are also working with our sister organisation, which is part of the Golden Jubilee and NHS Education for Scotland. That is the NHS Scotland academy, which is hosted in the Golden Jubilee. We are looking at different roles and pathways, including advanced practice roles, perioperative roles in theatres and so on, and roles prior to being a band 5 nurse. That gives us a good opportunity to look at the skills mix that we have to recruit.

Obviously, the national centres are crucial to our recovery and to avoiding people having to languish in a lot of pain. If we do not meet those staffing targets, will that jeopardise the expansion of those services?

There is always an opportunity for us to look at some of the different roles. I did not mention bank staff; we also have access to them. We have about 850 nursing and healthcare support workers on our bank whom we can use. We will consider all avenues for recruiting staff to meet the targets that I mentioned.

We will now talk about mental health services, the questions on which will be led by Paul Sweeney.

A major outcome of the pandemic has been the increase in mental health conditions and demand for the associated services. We note that the recent budget allocation of £290 million for mental health funding restored the £38 million provision that was cut as part of the emergency budget review. Although that is welcome, it is still, in effect, a freeze on funding for mental health across the national health service in Scotland. That is being compounded by recent announcements such as Glasgow health and social care partnership’s announcement of a £22 million cut in its service provision and the consequent loss of 197 positions. I am sure that that will be carried on across Scotland.

I invite the witnesses to comment on whether that will have practical impacts on their service delivery. Is that a bit of a false economy across the public service provision for mental health in Scotland? My impression is that, in many areas, we are robbing Peter to pay Paul. As chief executives, do you share that impression?

We have been fortunate to have quite a large investment in mental health, although we would always like to have more. One of the challenges has been the availability of trained staff to support that.

Mental health services are a spectrum from self-support, through peer support to traditional CAMHS and psychological therapies. One of our whole-system challenges is to ensure that we do not overmedicalise, so we are working closely with our partnerships. We work closely with psychological therapies teams and CAMHS teams, but we also work with local authorities and the third sector to ensure that we signpost people to the right place, which is often not into the health service itself.

We are not complacent at all—record numbers of people have been referred into our services—but we need to invest in a tiered system and ensure that we do not just leap to the highest tier. Our approach on that is to work closely with the third sector, the health and social care partnerships, local authorities, including Glasgow City Council, and a variety of other stakeholders to ensure that we cover all of that.

Pam Dudek made a point about prevention. We need to invest in getting to people to have the conversation before something becomes a real mental health issue. That is where we believe that our investment should be, through schools and so on, with young people. There is a big spectrum, but where people need the service, we have to consider how we support them and how we use people with lived experience to help, rather than us just doing something to people.

Mental health is a huge spectrum and a hugely important issue. You are right to raise it, because we need to ensure that we give it as much attention as physical health, if not more.

You are right, Mr Sweeney, in that if we do not acknowledge, understand and respond to what is happening, we will end up with a disease burden of mental illness that could have been prevented. We need to recognise that.

I agree with a lot of what Jane Grant said. We need to get to the nub of what is happening in communities and what the mental health or wellbeing, versus mental ill health, of those communities looks like. We then need to consider the strategies that we can implement as an organisation or with our partners to shape services and respond to need.

Things such as suicide, drug-related deaths, the impact of poverty on our communities and the early years are all really important to us in the Highlands, and we are trying to get a collective understanding, through community planning and our services, of what else we can do to shape things differently.

At the mental illness end of things, our assessment team, which was put in place more than a year ago, has been very successful. Our police and ambulance partners have been picking up some of that workload. That is not necessarily the right response, so we have been working closely with them, and they are seeing the benefit of that.

There is an awful lot to do and a lot to keep an eye on. However, for me, things start with being sure that we understand what response is needed and not just jumping to a medical response when there is perhaps a need for a wider or broader response, as Jane Grant said. That is prevalent in the Health Foundation’s recent report about inequalities, “Leave no one behind”. We also need to look at the wider factors that can influence how well someone does.

I am conscious that your board is quite specialised, Mr James. I do not know whether you want to say anything about that.

We do not have any mental health services.

Okay. That is fair.

I want to go back to a point that was made. I accept completely that overmedicalising can often be counterproductive and maybe not appropriate. However, I am looking at the metrics. I will take Glasgow and Clyde. In 2019-20, 111 people had their CAMHS referral rejected and were re-referred by their GP and, in 2021-22, 414 people were referred again after rejection. I take on board the point about appropriate presentation, appropriate referrals and whether they are required, but a second referral could suggest that a clinician—that is, a GP—believes that the patient needs that help and is not getting it on first asking, and has therefore reiterated the referral. Are budgetary pressures increasing the threshold, rather than it being a case of judgments being made about clinical appropriateness?

No. We have refreshed our whole approach to psychological therapies and CAMHS, and our rejection rate is much lower now. We have increasing referrals, so we have more people coming on to the waiting list, but we have invested in a huge redesign process, additional staff and different ways of doing things, and we are now hitting the access targets for CAMHS after a period of instability. We have completely revamped that, and we are moving to a new model across Glasgow and Clyde. One of the issues was that CAMHS were managed within our partnerships and, in small partnerships, if some staff left or a highly specialised interaction was needed, we did not have the ability to easily flex across Glasgow and Clyde. The model is being redesigned as we speak to maximise our potential to ensure that children and young people in particular have access to those services in a different way.

CAMHS have been completely redesigned and, as I have said, we have been reasonably successful in delivering that. However, we are not complacent in the slightest. That is a hugely important issue for the board, and it will continue to be so.

I will comment on adult mental health and the relationship between primary care and secondary care. When I have been out in GP practices recently, I have seen that we have definitely not quite got that right in terms of how that comes back together. There is investment in primary care, with link workers and community mental health staff being more aligned to practices, but there is definitely room for improvement in the relationship between the gatekeeping, which might be too rigid, and the referral process. We should not lose the person in the middle of it and the clinical conversation that might have a different outcome. Our teams are looking at that.

Evelyn Tweed can ask the final question. We must then pause.

Do you have a sense of whether people are put off coming for mental health services because of the long waiting lists?

I could not give you a factual evidence-based response to that question at this point, but I could go off and consider that. I am a mental health nurse by background, and I suspect that there will be an element of that, as there probably always has been. If the system feels too difficult to navigate, people might not be able to see how they can get there.

Looking at inequalities, we see that the people with the greatest need are often in a situation where it is very difficult for them to use services in the way that we might have set up those services to operate. My background is in working with addiction, and I found that to be very much the case in that area.

There is always a challenge around how we get to the people rather than expecting them to get to us when they are in that level of distress and in a difficult set of circumstances. That is an on-going issue that we will continue to work on. It comes down to our capability and expertise in considering and applying access through an inequalities lens.

Our communities are often very tapped into where we need to go and how we work with them. I am not saying that we are not tapped in—we have strong local community planning groups and community councils, certainly across the Highlands, and it is good for us to tap into those to understand the communities. Nevertheless, we still sometimes create services that are probably more service driven, because of the constraints of trying to deliver a service, and which do not always fully take account of how difficult it might be for somebody to come forward.

Sadly, we have run out of time. I thank all three of you for your time and for answering all our questions. I suspend the meeting briefly to allow for a changeover of witnesses.

10:46 Meeting suspended.  

10:55 On resuming—