Public Audit and Post-legislative Scrutiny Committee

Meeting date: Thursday, December 20, 2018

Official Report 771KB pdf

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Section 22 Reports

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“The 2017/18 audit of NHS Highland: Financial sustainability”

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“The 2017/18 audit of NHS Ayrshire and Arran: Financial sustainability”

Item 2 is on the section 22 reports “The 2017/18 audit of NHS Highland: Financial sustainability” and “The 2017/18 audit of NHS Ayrshire and Arran: Financial sustainability”. I welcome our witnesses to the meeting. John Burns is the chief executive of NHS Ayrshire and Arran and Professor Elaine Mead is chief executive of NHS Highland. Both will make opening statements.

Thank you for inviting me here today to give evidence to the committee regarding “The 2017/18 audit of NHS Highland: Financial sustainability”.

As you are aware, NHS Highland is currently not financially stable, and I would like to take a few moments to outline the reasons for that position. There is an increasing challenge in balancing the three areas outlined by the Auditor General, namely finance, waiting times and the quality of care.

In NHS Highland, we have continued to ensure that there is a clear focus on the quality and safety of care—including adult social care—through our Highland quality approach, while maintaining key waiting times for patients, which has been to the detriment of our ability to maintain financial balance in 2017-18.

There are significant challenges that are specific to the delivery of care in remote and rural areas and island populations that, without doubt, are complex and more costly due to the significant distances. Covering 41 per cent of the most remote and rural geography of Scotland, with an ageing population, it has been more challenging every year for NHS Highland to sustain the historical models of care within budget, due in part to our inability to recruit key members of staff.

Our focus has been on ensuring that we can provide an appropriate and timely response to keep people safe, both in and out of hours, but that has come at a significant cost.

As a board, we are committed to the reduction of waste in the system and the transformation of services to ensure that we have sustainable and integrated care, fit for future generations, for the people of the Highlands.

In order to do that, we must change. Such change inevitably takes time, but we have already embarked on that journey, and I thank our outstanding staff for their continued efforts. I will be very happy to do my best to answer questions from the committee. Thank you, convener.

The 2017-18 audit of NHS Ayrshire and Arran set out in its summary that we need to address both efficiency and transformation to tackle the challenges that we face in NHS Ayrshire and Arran. In our submission to the committee for this evidence session, we have set out our approach to looking at that throughout the system in Ayrshire and Arran, across integrated health and care planning.

Our 10-year strategy is called caring for Ayrshire. The plan will be delivered through our transformation programme, which will underpin the reform that we believe is needed to our model of care. We will strive to deliver the right care in the right place, in a system that has the right balance between acute service provision and community provision.

As well as the transformation programme, we recognise—as the audit report set out—that we need to have a strong operational grip on our day-to-day management and, in doing that, we need to ensure that we provide our services at best value and with the right safety and quality.

This is a significant programme of work that we are undertaking. To ensure focus, we have established a robust operational governance and programme management arrangement. We have a delivery plan in development for the next three years that will address our performance, service delivery, service change and service redesign. We will bring together the impacts on workforce and infrastructure and pull all that through into the three-year revenue plan.

I believe that the work that we are doing is building a strong foundation for that three-year plan. I want to reflect the hard work of the teams across Ayrshire and Arran in committing to the work that we require to do. Our partners will play an important part in delivering the reform that we need in Ayrshire and Arran.

I have a question for NHS Ayrshire and Arran. Your submission describes the effective prescribing programme and the improvements that your respiratory prescribing-to-care work has brought about in the short term. What are the clear long-term outcomes against which that initiative will be measured?

The programme looks at the end-to-end pathway for respiratory care. Within that, we have looked at the impact of prescribing.

Ayrshire and Arran was in benchmark 1 for the higher-cost prescribers in respiratory medicines. We have taken the view that the best way to change is to look, with our clinical teams, at how we transform and deliver services differently.

On the respiratory pathway, we focused specifically on how we effect change to prescribing, particularly around inhalers, and on how we can move some money into community-based pulmonary rehab and specialist nursing—moving some reinvestment from prescribing to other services that are evidenced to be highly effective.

You highlighted that the cost seems to be highest in relation to steroid inhalers. How do you reduce the use of those given that, presumably, people are dependent on them?

We have worked with our respiratory team, primary care teams, pharmacists and others to look at the care pathway and at where medicines can effectively and properly be used. Within that, we have recognised that by investing in areas such as pulmonary rehabilitation and specialist nurses, we can provide support for patients that improves and enhances their quality of life while at the same time reducing the level of and spend on prescribing and moving some of that money to investment in areas where there is evidence of a positive impact. The early indications from our work are that patients like it, that it has reduced the number of unscheduled care admissions to hospital and that it has reduced the length of stay for those who need to be admitted. It has had a very positive impact on outcomes for patients.

Has there been any negative impact?

No.

The NHS Highland submission talks about redesigning models of care and so forth. It states:

“These new models will be more sustainable but they have proven to be very difficult to consult and agree. Even where there has been consensus, through public consultation, decisions have come under constant public and political challenges. Not surprisingly the pace of change has been very slow.”

Will you give examples of public and political challenges that you have encountered?

Yes, indeed. We continue to consult on any changes that we would like to make. Clearly, a number of those services are very precious to local people. Skye may be an example of a place in which we looked at how we could reconfigure out-of-hours services to give us the best possible value to meet people’s needs. As I said in my introduction, the important thing for us is to ensure that services are safe for them. As we looked at the services on Skye and redesigned them, we found that local populations had not felt safe. They said that they were concerned about any reduction in the level of care that was being provided.

However, there is a significant cost to how we provide out-of-hours services. For example, in Wester Ross, out-of-hours costs per case could be as high as £1,400, whereas in an Inverness practice they could be just £70. Therefore while the process must be driven by access and safety, there is a cost element. We need to ensure that we can provide the best care for people 24/7.

The opposition that we have had is because people do not always understand about emergency care and feel that the out-of-hours care, which is provided mostly as primary care by general practitioners, is the same as emergency care, which is a 999 response. We need to communicate better and to engage much more with politicians and local people to make absolutely sure that they understand that changing the out-of-hours service does not have an impact on the emergency care services that we provide for them.

In the example that you gave about Skye, has there been a public kickback against the proposals for change?

Indeed, and we have involved local people and politicians and have had Sir Lewis Ritchie join us in that work. We are making progress now, but there is an additional cost to any of the changes that we have wanted to make.

You have mentioned political challenges as well as those from the public. What political challenges have you had?

We have had them at all levels—at local level, for local members providing support to their constituents, but also party members bringing forward the concerns of their local constituents. That is understandable, as people right across our patch are concerned about changes that we are attempting to make.

Most recently, in Caithness, we have had a wide-ranging public consultation over a number of years. Local politicians and the public have asked us why we need to make changes. Our reason is that the existing models of care are simply not sustainable in their current form.

In my experience, if you are suggesting fairly radical changes the first thing to do is to brief local politicians fully, so that they understand the reasons behind them and can get behind the whole process. From what you are saying, that does not seem to have happened here.

We could have done better, but we have made every attempt to meet local politicians regularly and to brief them. We now have the full support of all members of the local authority in Caithness, on which a motion was passed last week. It takes time to have conversations, share the evidence and help people to understand all parts of the jigsaw in a local area that lead us to need to make a change. Time is the issue for us. We need to spend a lot of time explaining the need for change and why the current models of care are no longer sustainable.

Do you think that the current type and level of communication that you have with the public and with politicians are adequate?

We can always do better. We always reflect on how we are engaging. We meet our MSP and MP colleagues regularly, but we also meet our colleagues from both Highland Council and Argyll and Bute Council.

Obviously, your changes have to be open to public scrutiny.

Indeed.

Is it worth revisiting how you are approaching the process? From what you are saying, the whole project and the models are being slowed down. If everything is meeting public and political challenge, clearly you will not achieve your targets within a reasonable time.

No, and that is the difficulty that many boards face, but particularly in our own region, where we need to change the models in remote and rural areas.

We need to make changes across our whole patch, from Campbeltown to Wick, and we need to engage with the communities in all those areas. However, it would take us two and a half hours to drive just to have a conversation with someone in Wick, for example. It might be timely to do that, but it takes a huge amount of the local team’s time to continually engage in that way. However, we understand and accept that we cannot make changes without engagement, and we will continue to do our best to engage with local people.

09:15  

My questions are for John Burns of NHS Ayrshire and Arran. Good morning, John. First, I echo your comments in paying tribute to the great work that the staff throughout NHS Ayrshire and Arran are doing, particularly in Crosshouse, which I know very well.

The Auditor General has written some fairly detailed reports on NHS Ayrshire and Arran over recent years, principally regarding concerns about its overspend and brokerage. She has also highlighted a lack of attention to detailed financial planning and the consequent impact of that on performance. Ultimately, she finds it difficult to see how the board can achieve financial balance in the coming years. How do you respond to those findings?

We started this journey in 2016-17, when we recognised that we needed to do more than just deliver an efficiency programme, as I referred to in my opening statement. We have been developing a new approach to deliver transformational change while delivering the operational grip that is necessary. In the past 18 months, we have made significant changes to our approach. We have a much tighter operational scrutiny programme and very detailed programme management through which every programme and efficiency is tracked and reviewed regularly for progress and delivery. We have introduced clear accountability for each programme and we are now seeing the change deliver. We review matters in-year through a financial control schedule, so that we are clear about how we are delivering what we are delivering and, if something is not delivering, what scrutiny and interventions we need to make. I believe that we have moved on significantly, and we have a strong position on which we continue to build.

Is there anything that is peculiar when it comes to NHS Ayrshire and Arran? It has been widely reported that you have overspent significantly. I, for one, have said in this committee that you are spending money on healthcare needs that people in the population actually have. There is an argument and discussion to be had there. What is your view? Does the funding formula correctly reflect the health needs of the Ayrshire and Arran population, or should thought be applied to adjusting and revisiting that to award fairly what NHS Ayrshire and Arran needs in order to deliver that healthcare?

We recognise that the funding formula is the same for all NHS boards, so we need to work within that formula. However, we have also recognised that we need to change the balance in our health and care system in Ayrshire and Arran. There has been an overreliance on acute hospitals. Together with our health and social care partnerships, we are looking to develop the right balance. For example, we have recently made a significant investment in intermediate care and community rehabilitation across all three partnerships to support patients coming out of hospital and, where patients do not need to be admitted, to provide additional support for them in the community. We believe that there is a strong evidence base for that work, and that it is already bringing change in the use of unscheduled care beds.

We are seeing quite a lot of change and transformation, but we recognise that we have some real challenges in terms of our population’s health across Ayrshire and Arran. Again, we are looking to ensure that we provide our services in a way that supports patients to take ownership of their health and wellbeing, where that is appropriate, and to use technology, including digital technology, to provide some of that. Where it works—it is in its very early stages but it works well—we need to scale that up. We need to continue to look at the reform agenda in NHS Ayrshire and Arran in order to get the right balance.

You mentioned a couple of areas, such as unfunded beds, but what are the key areas that will help you to get control of the finances in the coming years? Is it workforce? Is it prescribing? Is it agency staffing? Is it all those things? How are you making progress in turning it round?

It is all those factors. We are making good progress on prescribing. Our primary care teams are doing excellent work on prescribing, and this year we will exceed our target. We set an ambitious target for hospital prescribing changes and, based on current forecasts, we will slightly exceed it.

There is no doubt that workforce is a challenge, and we are clear that we need to be a board that can attract and retain staff, particularly medical staff, in areas where skills are scarce. We have a record of being able to recruit staff, but there are some hard-to-fill posts, which necessitates spend on locum doctors in order to maintain services. We need to continue to look at how we redesign our services to make them sustainable, because if we cannot get the medical workforce, we need to look at the workforce model that supports that service.

We also need to look regionally at how we work with our colleagues for some of those solutions. As you know, we already have examples of where that works well, where Ayrshire partners with other boards and the pathway back to Ayrshire is effective.

I know that you rely on working with partners in the integration joint boards in North Ayrshire, East Ayrshire and South Ayrshire. Presumably, they all run at different paces. What factors do you rely on that are outwith your control but impact on delivering the successful transformation strategy that we seek?

We can manage much of it in the health and care system, and the strength of our partnership is important there. You are right to say that the three boards are different and work at different paces, but we work well together. As we look forwards, the biggest change, which Elaine Mead referred to in her earlier responses, is about ensuring that we have the right communication about change with our communities. As she highlighted, we are looking to work and engage with communities about the need for change, why it is important and what it will give our communities, not what it will take away, in terms of having sustainable services with expertise when it is needed.

Forgive me, Mr Burns, but communication is in your control. Mr Coffey asked you what factors are not in your control.

There are factors that are not in our control. If we cannot get the workforce, that is not something that we have direct control over. We work with NHS Education for Scotland on training for posts, but we need to work with our communities. I absolutely accept that communication is in our control, but the ability to influence and impact change sometimes requires that control to be shared with our communities, so that it is not just us who are moving forward, but all of us together.

What I meant, convener, is that the pace of change on health and social care is different in the three council areas, so the health board does not really have full control over discharges from Crosshouse hospital. It works well with partners but, as I understand from previous discussions, the pace differs. How can we help move that along a bit faster, so that all three councils operate at the same pace in a system that, we hope, will successfully fulfil the health and social care integration agenda?

All three Ayrshire councils are working on that. We recognise that they are in different places, and some of that is because their reform in social care is at different places. One thing that we should and could encourage is the sharing of best practice across health and social care systems.

You project an additional overspend of £30 million for 2019-20, but we know from the budget that you have been allocated an extra £25 million. Can you assure the committee that you will balance the budget? In prior papers, you have stated that you will, but are you confident that you can achieve that in the immediate coming years?

I am confident that we are doing everything possible to achieve that, and it is absolutely our intent. The cabinet secretary’s position is that we should plan our revenue over a three-year period, hence the three-year plan that we are developing. We are clear that we need to deliver a balanced budget.

None of the issues that we are hearing about is unique or new. Why did the planning for transformation not start earlier? Did the Scottish Government not pick up any of the issues coming down the line through monitoring?

As I said, we recognised in 2016-17 that the level and pace of change in Ayrshire and Arran were not sufficient and that we needed to look more widely at transformation. We were seeing financial pressures at that point. We had been able to balance our books and deliver efficiencies over many years, but 2016-17 was the first year when we saw that difficulty. At that point, we started our work to develop the programme that we have today.

I will come on to the workforce challenges in a second, but I want to pick up from where Colin Beattie left off. Professor Mead, you said that the current model of care is “not sustainable”. We all probably agree with that, but is it because of budgetary pressures and the need to make efficiency savings and cuts, because we have workforce pressures and simply do not have the staff to deliver the service sustainably, or because there have been so many advances in medicine and medical technology that it is simply not right to keep the model as it is? Which one of those three is it?

I believe that it is all three. That is the combination that we are all challenged by and are here to celebrate. There has been such fantastic innovation and progress in medical technologies over the years. We are keeping people alive for longer, and therefore their requirements and needs are more extensive. We have innovation, new technology and new drugs. Just in NHS Highland, we have had a 35 per cent increase in the cost of hospital acute drugs in the past five years. We need to give those drugs to our patients.

Taking the example of Skye, if you had the budget and the GPs, would you still want to reduce out-of-hours services on Skye?

We would always want to look at best value and make absolutely sure that we have the right model. We are not looking to change the models because of money; actually, we are not able to recruit the GPs. Particularly in Highland, which is maybe a barometer of some of the changes in the rest of Scotland, we see most acutely the pressures due to the inability to recruit staff. There is a need to make the public understand that we cannot have everything in the way that we have always had it. We want to be able to reconfigure things that are really not best value and not necessary while maintaining safe services. We will never compromise on safety in our services.

Just to clarify, are you saying that, if there were adequate numbers of GPs and adequate funding, there would not be a reduction in out-of-hours services on Skye?

We would still want to have a conversation about whether that model is the right one for the resources that we have available. We have pressures across the system, as a result of things such as innovations and the cost of drugs. For example, in our radiology services, we have had a 55 per cent increase in the requirement for imaging through computerised tomography and magnetic resonance imaging. All those things add up to additional cost. We need to consider whether we wish to continue to invest in things, whether we are getting best value and the needs of the local community. We need to have that conversation more widely with the public to understand exactly what the needs are.

09:30  

Is there a huge vacancy rate for radiologist and radiographer positions?

Yes, it is huge.

That will be a huge challenge across the country.

It is a major problem. In total, NHS Highland has 36 consultant vacancies; 13 per cent of all consultant positions are vacant. All those positions need to be covered. That will cost us £15 million in locums while we continue to provide the same models of care. For a number of years, we have been looking to change those models—all boards are doing that.

What proportion of your consultant vacancies are you advertising as 8:2 contracts or 9:1 contracts? What impact is that having on recruitment?

We are now very flexible with contracts for colleagues, and we allow conversations. We are not just looking to recruit to individual posts; we want families and partners to join us. We are doing everything that we possibly can. The difficulties in recruitment are not because NHS Highland is not a fantastic place to work and practise. As you have outlined, there are simply not enough consultants in many specialties.

Is the situation the same in NHS Ayrshire and Arran in relation to the 8:2 and 9:1 contracts? The British Medical Association makes it very clear that one of the big frustrations in trying to attract consultants to come to Scotland rather than other parts of the United Kingdom has been the 8:2 and 9:1 contracts. There has also been a range of other issues, but those contracts are a key factor.

We have moved away from offering 9:1 contracts. The issue is about good job planning, whether we use 8:2 contracts, 9:1 contracts or whatever. We need to ensure that there is the right job plan for the service, and for the consultant as part of that team, which reflects all the work that a consultant does and not just the direct clinical care that they offer.

I found it interesting in your answer to Willie Coffey’s question on the things that are not in your control that the issue that you picked was workforce planning. The way in which workforce planning works is being redesigned, and we are waiting for the comprehensive workforce plan that will be published at the start of next year. We are trying to make it a national strategy, so how much connection is there between the health boards in creating that comprehensive workforce strategy? How is the absence of a comprehensive workforce strategy impacting on service delivery in your health boards?

We have our own workforce strategy, and I am sure that all my colleagues in other boards have one, too. We are looking at workforce planning across the west of Scotland—I can speak only about the west—as part of the regional working that is under way. We think that it is important to be able to identify and support new roles beyond a single board, so important regional work in going on. That work will connect to the national picture, because it will connect to training programmes and training need. When I say that workforce planning is outwith our control, I mean that we do not control what we do with the training numbers. However, we can control our workforce plan and how we redesign our workforce so that it is based much more on multidisciplinary teams. That is the way forward.

The workforce challenges connect to the service reform that needs to take place to make the system financially sustainable and sustainable for patients. Would it help local health boards if there was a national strategy and intention from the Government and from all political parties? We could be honest with the public and say that we will not magically find 5,000 people to fill the vacancies for nurses, GPs and consultants, or the money that is needed to do so, and that, if we want to make the service sustainable, we need a programme of reform across Scotland, which will involve all health boards. If there was that national intention and message from the Government and from all political parties, would that help with the local engagement that is needed and with your ability to persuade local people about the service changes that are taking place in individual health boards?

There is no doubt that a common positive message across Scotland on reform and the need for change to deliver safe, sustainable and high-quality care for the future would be an important part of moving forward quite difficult agendas.

Is that common message missing just now?

I think that we could do more.

So you would like some leadership on that from the Parliament.

Yes, it would be very positive if we had a common view on the need for reform and the importance of that reform.

Excellent.

When we speak to national health service staff, it is clear that they are under more pressure than they have ever been and that they feel that there is not enough of them, which adds to the workload and pressure. Because of that, they fear what might happen to their delivery of care for patients. That situation also increases the risk of clinical errors or the perception of clinical error. On top of that, there is a growing feeling right across health boards that there is a culture of bullying and intimidation and a lack of a genuine whistleblowing process. I know that NHS Highland has had some particular issues with that. Can you address directly the point about a culture of intimidation and bullying and what seems to be the lack of a robust whistleblowing process?

From the standpoint of NHS Ayrshire and Arran, we are very open and the whistleblowing process is shared across our organisation, so staff are aware of it. We have also worked very hard on culture and values in the organisation and have worked to engage staff on change. We do not get it right all the time and can always do better, but I think that we have a strong foundation in NHS Ayrshire and Arran.

I agree that honesty and local engagement are critical going forward in NHS Highland. The staff are very tired and are often working in pressured circumstances. However, I am also optimistic, because staff are very keen to change. The support to be able to change and to have a conversation about why we need to change will be helpful for front-line staff.

Professor Mead, you said in your answer to Mr Sarwar that there was a 50 per cent increase in the use of CT and MRI. Why is that?

The technology has improved to allow imaging to show more diagnostic benefit, so we find that clinicians are continually now asking for the newest technologies and tests. The CT and MRI imaging machines are now becoming invaluable in diagnosis.

So your diagnosis rates have gone up.

Absolutely. The use of tools and techniques to make better diagnoses is increasing. Again, that is to be welcomed, but the lack of the radiologists who are needed to read those images puts huge pressure on the departments.

Has the diagnosis rate gone up 50 per cent to match the expenditure on CT and MRI?

I am not able to tie those two things directly together, because it might just be that people are using a different tool or imaging technique to be able to make a similar diagnosis. I do not think that there is a correlation between an increase in the use of CT and MRI and an increase in the number of diagnoses. They will just be using those techniques to diagnose in a different way.

Those are clinical decisions, but CT and MRI are hugely expensive. How much is an MRI scan?

I am afraid that I cannot tell you exactly, but we can find the information for you as a cost per case.

My understanding is that it is quite a lot of money—it runs into thousands.

Indeed, and the cost and time that it takes to report many hundreds of slices of those images is significant.

Are there health economists in the Scottish Government who can marry those figures up? There must be.

There must be, and I would welcome that.

I have a question for you about the cost of locums in NHS Highland. You probably anticipated that we would ask this question. The committee looked at this issue when we took evidence from the Auditor General on her report on your health board. In your written submission, you very helpfully provided a breakdown of costs, so thank you very much for that. If I am reading your table correctly, the total pay costs for two locum doctors in your health board runs to over £900,000. Is that an effective use of taxpayers’ money?

It is stark, which is why we wanted to put that information into the public domain in the way that we have. I would say that it is a good use of taxpayers’ money because we need to provide a sustainable service in the hospital concerned. It is a rural general hospital where we need to have a 24/7 emergency care response and the staff need to be expert in that care and able to address anything that might come into a rural general hospital. Not having an appropriate senior-level response is not an option for us. It is geographically important to the Ambulance Service and the patients to whom we provide care.

The figure on the table of £900,000 for those two individuals is stark. That figure is there because we have managed to secure people who have wanted to come back on a regular basis and, therefore, have been paid and shown as two individual costs. They are two locums who have continually come back. Having the same people coming in on a regular weekend basis helps the team. Having 10 people coming in 10 times would have cost the same but would not have provided the continuity of care.

I understand the reasoning around it and I agree with your decision that the hospitals must be staffed by people who can do the job. That is the right thing to do. However, as the accountable officer for NHS Highland, you must be tearing your hair out when you are approaching the end of the year and you find that you have had to pay nearly £1 million for two doctors. What is the process that leads you to the situation in which you need to pay out nearly £1 million of taxpayers’ money for just two doctors? What would prevent that situation from arising?

We do not address that only at the end of the year; we consider it throughout the year. The medical director is taxed with overseeing the costs of medical locums, and I take his professional advice on a weekly basis about what represents appropriate clinical care and cover for the various hospitals.

What would prevent you from having to make that hugely expensive decision?

Quite simply, recruiting high-calibre medical staff into those roles would prevent that. We are continually trying to do that in all the rural general hospitals.

And what is the obstacle to that? Are we not training enough doctors?

The role of the specialist generalist, if I might describe it as that—the individual in a small rural hospital who has to address anything that comes through the door—is not a role that is commonly trained now, and is not particularly attractive.

Is that the fault of our workforce planning strategy?

I think that it goes back even further to some of the training options. Certainly, NHS Highland is working hard to have junior doctors rotating through our rural general hospitals in order to make them attractive places for them to go in the future. We are talking about extremely challenging roles in those rural general hospitals, without large support teams that you might get bigger hospitals.

Liam Kerr and Anas Sarwar have supplementary questions on this specific point.

On the point about the cost of the locums, those two individuals come through an agency, so there is an agency cost. Why are they not employees? Presumably, you offer to employ them. If that is the case, what salary do you offer them? Is it the same as what is on this table, or are you actually saying to locums such as these ones—I appreciate that we are focusing on these two, but the issue must apply across the system—that they will be paid less if they take an employed position with you than if they stay with the agency, even though it takes a 10 per cent cut or whatever?

That is, indeed, the situation. We would always attempt to secure in-house locums or permanent staff first and foremost, or offer short-term locum posts. Where we have attempted all those things and have still been unable to address the issue, we have to go out to the market, because we have to secure the cover. We have a very tight process that involves going through one particular agency to secure individuals; it is not a completely open market.

Often, as the need for cover gets more pressing, either in a hospital such as the ones that we are talking about or in an out-of-hours service, market forces require us to pay more than we would pay as a salary. There are some individuals who will work as locums rather than choose to take a permanent position.

09:45  

This must be infuriating for you. I completely understand your frustration, because having to pay £900,000 for two doctors, which is almost the equivalent cost of nine consultants, must be hugely frustrating given the other financial challenges that you have. As you said, the cost is dictated by the market. The market dictates what you have to pay those staff, because you have to have those doctors in those settings in order to deliver the care to your patients that you want to deliver. How should the Government intervene to regulate this area? Should the amount that agencies charge be regulated? I am not saying that there should be a cap on what you can spend on locums and agencies—because you need to get in agency staff—but should we be looking at capping what an agency or an individual nurse or doctor can charge for a single shift, so that there is not this complete manipulation and abuse of health service budgets as a result of the challenges that we are facing across the country?

We chief executives have had the conversation many times about how we can manage the situation most effectively. Often, we—even together as boards—have held the line with agencies, but there comes a point, particularly in rural areas where there is a particular need, when we have to say that we need a doctor today. Therefore, it is very difficult to hold a party line, unless we get to the point where we say that we will not be able to admit patients to one of our hospitals.

Rather than being left to the chief executives of the health boards, should that party line not apply nationwide and be put into law by the Parliament?

In that case, to balance out the market, there would be some times when, for sure, we would say that we cannot have a doctor.

When local people in Skye see £900,000 being spent on two doctors and then think about how they cannot have a GP out-of-hours service because it costs £1,400 a patient, do you understand their anger at that situation?

Indeed, and I understand that we have to look at all the issues as a whole health board. The people of Skye would not necessarily be looking at what is happening in other parts of Highland; equally, the people of Skye would also benefit from having those doctors in their local rural general hospital if they needed that emergency access.

You said to Anas Sarwar that there are not enough consultants. In your submission, you say that one of the challenges to do with that is

“Increasing specialisation in medicine”

such that

“consultants are no longer trained in a way that allows them to work in generalist settings, such as Rural General Hospitals”.

That is highly concerning. Have you raised that matter with the Scottish Government and/or the medical training facilities?

Yes, indeed.

What response have you had?

We are recognising that situation now. Certainly, the royal colleges are in conversation with us and the Government about how we might want to reconfigure the training for the future. As I have mentioned, we are benefiting from having trainees moving through rural general hospitals, and that training of generalism is now moving in an almost completely different direction from the superspecialism that we have seen in the past. However, we are not benefiting from having physicians—such as respiratory physicians or cardiologists; there are many things that they can do—that have maintained the skills to take on a role in small rural general hospitals, where many specialties have to be covered.

It surprises me that we are in this situation. Is the situation being addressed so that there will be such generalists in the future?

The colleges are discussing that. I cannot speak for the actions that they are taking, but we are hopeful that people are beginning to recognise the importance of the generalism role as a specialty in its own right. In NHS Highland, we have certainly made many representations to try to rebalance how doctors are trained.

That might be something to put to the Scottish Government officials shortly.

In your submission, you go on to refer to the difficulty of GP vacancies. You suggest that you have

“developed a number of initiatives and ... approaches to address”

that particular challenge. Can you tell us what those approaches are and whether they are working?

Yes. It is more difficult for GPs or independent contractors to identify and give an exact number of vacancies, but we still see vacancies in about 12 per cent of practices.

The initiatives that we have had to take are looking for other members to join the team who are not doctors but could undertake some of the functions that doctors might previously have led on. For example, some of our north coast practices now have pharmacy practitioners working at an advanced level. They work as part of the team and take a huge amount of pressure off the doctors. We originally did that as a trial in the north, and we have found that it is possible for us to recruit pharmacists and give them extended roles, working as part of a team, which takes significant pressure off the doctors on a daily basis. We are looking to spread that initiative across NHS Highland.

If we start from a position of saying that those initiatives are working—

They are.

—to address shortages, how is that knowledge being shared? For example, is Mr Burns on the phone saying, “How are you sorting this out?”

We regularly share knowledge at the chief executives’ meetings and present to each other some of the innovative things that we have been doing. Most of our innovation has come out of immediate need, and some of our needs are more challenging in remote areas than in others. We are always happy to share.

I represent the North East Scotland region and we often have fairly similar challenges. I would be pleased if NHS Grampian, for example, was on the phone to you to ask what you are doing that is working. Is that happening?

We do have those conversations. I do not recall that we have had a conversation about extended-role pharmacists, but I would be very happy to have that.

Mr Bowman, you have been very patient.

Can we go back to the information on the consultants? If I understand it correctly, one of them worked 5,188 hours. If my maths is correct, that is an average of 14 hours every day for 365 days.

They will have been paid for out-of-hours work as well as in-hours work. They will also have been paid for overnight calls. One of the difficulties that we have with locum doctors is that they are paid even if they are not called out. They are available to us and often on site so that we can call them.

That just seems to be a very high number.

We are looking at a snapshot of this year. Will that individual have been working for you in the previous year? Are they continuing to work?

Forgive me, but I cannot tell you about the previous year. We might have had other doctors. I can certainly tell you that there have been vacancies in that particular hospital for a number of years, so undoubtedly there would have been similar costs associated with maintaining 24-hour cover.

You do not know whether that individual has been there in the longer term.

No.

Would you be happy if they had?

I would always ask that we are looking to fill the post substantively. That would be the way to reduce the costs. If we had people in substantive positions in those hospitals, those costs would immediately reduce.

I do not want to get into specifics, but it is almost as if that person has been working there for a long time and is presumably quite comfortable with their role.

I understand the point that you are making, Mr Bowman. As I have said, the medical director is overseeing the cost of locums and the way in which doctors are being used. He will be working with the local practitioners to decide whether to continue in this way.

Professor Mead, I understand that you are looking forward to your retirement. Is that correct?

Thank you. I will be leaving NHS Highland at the end of this year. I am not retiring; I am simply moving on to other things.

I see. I wish you all the best in those posts.

Thank you so much.

What progress is being made with the recruitment of a new chief executive?

A recruitment process is under way to recruit a chief executive. I understand that we have not yet secured a permanent chief executive but progress is being made in securing an interim chief executive for NHS Highland.

There will be an interim chief executive. Has much progress been made with a director of finance?

We are not out to advert for a director of finance; it is under discussion.

Do members have any further questions for our witnesses?

I have a brief question. Professor Mead, at the beginning of the session, you said something about how it can take two and a half hours to get to a meeting within the board area. Do you not use information technology and things like Skype to have chats and meetings? Why do you need to drive for two and a half hours?

We absolutely do that. We are one of the biggest users of Skype and videoconferencing. The NHS near me service will reduce the need for our patients to travel for out-patient appointments.

We were talking earlier about the importance of engagement. You will know that face-to-face engagement is important, so when we have those public meetings, we go in person.

As there are no further questions from members, I thank you both for your evidence this morning. I will suspend the meeting for a couple of minutes to allow the witnesses to take their places.

09:56 Meeting suspended.  

09:59 On resuming—