Contents
- Attendance
- Decision on Taking Business in Private
- Section 22 Report: “The 2022/23 audit of NHS Forth Valley”
- “Decarbonising heat in homes”
Section 22 Report: “The 2022/23 audit of NHS Forth Valley”
We will have two evidence sessions this morning. First, we will consider the Auditor General for Scotland’s section 22 report entitled “The 2022/23 audit of NHS Forth Valley”.
I welcome our witnesses from NHS Forth Valley, who have joined us in the committee room. Amanda Croft is the interim chief executive. Alongside her is Janie McCusker, who is here on her last day as chair of the board. You are very welcome—thanks for joining us. Andrew Murray is the medical director on the board; Kevin Reith is the director of human resources; and Professor Frances Dodd is the executive nurse director.
The committee has quite a number of questions to put to you. Before we get to them, I ask Amanda Croft to make a short opening statement.
I thank the committee for affording us the time today to speak to it about NHS Forth Valley.
In November 2022, NHS Forth Valley was escalated to stage 4 of the NHS Scotland performance escalation framework—which is now the support and intervention framework—as a result of concerns relating to governance, leadership and culture. Concerns were also raised in relation to the completion of the integration of health and social care in addition to a range of performance-related issues, notably in general practitioner out-of-hour services, unscheduled care and mental health—specifically, child and adolescent mental health services and psychological therapies. Further concerns were raised by Healthcare Improvement Scotland about patient safety at Forth Valley royal hospital and by NHS Education for Scotland about the clinical supervision of doctors in training.
In October 2023, NHS Forth Valley received a report on an external review of corporate governance, which detailed 51 recommendations. Prior to the publication of that report, work had already begun on a number of the recommendations. The report’s recommendations were mapped against outcomes of the board’s self-assessment survey, which was undertaken in September 2023 against “The Blueprint for Good Governance in NHS Scotland” to ensure that any outstanding actions were captured in the assurance and improvement plan.
NHS Forth Valley formally reviews the progress against the actions in that plan at executive level weekly and at board level monthly, and we have a specific escalation performance and resource committee to do that. The Scottish Government reviews progress monthly at the assurance board meetings.
Significant progress has been made and continues to be made in several areas regarding culture, leadership, governance, integration, Healthcare Improvement Scotland actions and performance. Those are laid out in the paper that we shared with the committee prior to today.
Many of our actions in the plan are completed, and work across all the priority areas is embedded in existing and future plans, normal business arrangements and our governance process, in order to support continuous learning and improvement.
Thank you. That is a useful introduction for us. Willie Coffey will ask the first question.
Good morning to everyone. One of the issues that were raised in the Auditor General’s report was the very high prison population in Forth Valley. You did not mention that, Amanda, but I want to give you the opportunity to share with the committee your views on the impact of having to deal with that disproportionately high prison population in the health board. What impact does that have on the health board’s finances and performance delivery? I wanted to give you an opportunity to set the record straight for us.
I will say a few words and then ask Frances Dodd to come in on the specifics of the healthcare service for the prison population.
We have just asked the health and social care partnership to take on the responsibility for the operational management of prison healthcare. That is in line with the integration scheme. Over the next year, we will look at moving that into the integration joint board. That does not mean that the health board will not have a big input into that.
We are funded for the prison population that we currently have. One of our challenges is that we will start to receive more prisoners over the next few months. We are in conversations with the Scottish Government and the justice teams as well as the health and social care directorate about how we can continue to fund that. However, as far as the health service is concerned, we are currently managing the funding and financial issues in the prisons quite well.
I ask Frances Dodd to talk a bit more about the prison population and the healthcare service.
We have a mixed population across the three prisons that we provide for in NHS Forth Valley. There are young people, women and men in our prison population, and we cover a range of health services. We cover primary care services in the prisons as well as mental health services, speech and language therapy and dietetic support. A range of health services is provided to prisoners in the prison environment.
We are working hard to recruit and retain staff in the prison environment, and we have provided that workforce in innovative ways. We have open days in the prisons, which are supported by the governor from the Scottish Prison Service, and we have a try-before-you-buy scheme, in which we encourage people to join our staff bank to try prison shifts. We do that to ensure that we have the right environment and the right staff with the right skills and abilities to support prison healthcare. We also provide regular support for patients in relation to escalation to any hospital services. We work with our SPS colleagues to be able to do that. There is a full range of services.
There are challenges due to the ageing population in our prisons. We have responsibilities for long-term conditions management for the ageing population in prisons. However, we have access to the full range of healthcare provision for that.
We continually pay attention to the number and mix of prisoners in the population. We try to ensure that we have the right health workforce to support the needs of the healthcare population in the prisons, and we continue to refine that in the work that we do. We are doing a huge amount of improvement work in the prisons, and there is a focus on patient safety and the quality of care that we provide to our prison healthcare population.
That is all that I have to say. I am happy to take questions.
Amanda Croft said that you are funded for the prison population. However, you have nearly a quarter of Scotland’s entire prison population in your health board area. Does that mean that you need additional, different and more demanding skills that other health boards might not need in order to deliver care for the ageing population that Frances Dodd described?
We have a mix of prisoners across Forth Valley. We have young people, a female population, a male population, people who have long-term conditions and an ageing population.
It is an evolving picture, and we have good representation with Scottish Government colleagues that allows us to connect into networks across Scotland and to identify what the issues are in our prison healthcare environment. The connections are good, we are well wired into the networks across Scotland, and we have a solid connection with Scottish Government colleagues. We also have a very good relationship with our SPS colleagues. We work together collectively to provide the best support that we can for the prison population.
There are always opportunities to have conversations to ensure that we have the right resources to support individuals, with the size of the population increasing.
Amanda Croft suggested that we have moved responsibility over to the health and social care partnership. However, from a clinical and managerial perspective, and for the professional development of staff, we work hand in glove with the partnership to ensure that we provide the best healthcare that we can for the prison population. That is not without its challenges.
Because there are different types of prisoner in each prison, our healthcare delivery and the skill mix are slightly different in each prison. When prisoner numbers increase, as is happening at the moment, we have to review whether the healthcare service delivery is applicable to the prisoner type. We constantly do that in each prison. Young men and women will have needs that are different from those of prisoners with long-term conditions.
Does the additional burden that is caused by prisoner numbers have a direct impact on your financial performance?
Not that we are noticing at the moment. There will definitely be an impact as prisoner numbers increase. We have done some work on what that will mean, and we are in conversations with the Scottish Government about that.
Thank you very much. I hope to come back in later on as colleagues develop their questions.
I want to take us to a couple of broader areas. The first is governance. In exhibit 1 in the section 22 report, the Auditor General notes that concerns about governance arrangements in the health board have been flagged since May 2022, when there was a Scottish Government national planning and performance oversight group report. The terms of the independent corporate governance review were not agreed for another eight months, in January 2023, and the outcomes of that were not considered by the board until November 2023. That seems to be an inordinate delay in addressing something that is pretty fundamental to the functioning of the board. Maybe Janie McCusker will want come in on that and explain why that timeline looks as it does.
If I may, convener, I will take us back to early 2020, when, as you are aware, the board was on an emergency footing. We were advised by the Scottish Government to have more of an agile footing in relation to our governance arrangements, which the board did.
On 31 March 2020, we took to the board how we would operate during that timeline. We put in place revised governance arrangements for the board to meet monthly. We more or less stood down the committees, but we had the committee chairs convene to discuss matters that related to that timeline.
We reviewed that arrangement in June 2020 and reinstated the governance assurance committees. All the committees had met in full session by the end of 2020, and we had resumed by April 2021.
If I understand your question correctly, you asked about the governance review that was conducted in that timeline. That review was commissioned, and it was anticipated that it would conclude within three to four months. That did not occur. I do not know why it did not occur, because we were not carrying it out. I think that there were delays and that additional interviews were being conducted. Once the corporate governance review was undertaken, it came to the board as soon as we received it.
I do not know whether I quite understood your question.
My question is: why did it take so long? Concerns about governance were flagged up in May 2022. Why did it take until January the following year for a review of governance arrangements to be established? Why did it take another eight months before the conclusions were considered by the board?
On governance arrangements that were flagged up, we as a board considered all those issues. Our committees addressed everything that was put in front of them. We were waiting for Professor Brown to finalise the review. We got the final report in—I am confirming the date—October 2023. As soon as we got that report, it went immediately to the board.
It still seems to me that there were quite big delays between those different staging posts.
I will turn to another area that has been identified in a number of external examinations of the board, which is the culture of relations with staff. The particular recurring theme is that the views and voices of staff were not being listened to. Do you accept that finding?
I will come in first on that and then ask Kevin Reith and Frances Dodd to talk about the work that we have done.
We do accept that, and it is important to accept it. If staff are saying that, then that is how they are feeling. We have taken the matter very seriously.
Kevin can come in now, and I will then ask Frances to speak about the latest HIS report and inspection, in which HIS gave us some very good feedback about what staff were saying.
09:15
You will see from our submission that we have done significant work on culture. We have been progressing a huge culture change and a compassionate leadership programme, recognising that we want to make improvements in that area. We have done a huge amount of work engaging with staff across the organisation over 12 months now. We have done a great amount of diagnostic work in a discovery phase, which involved listening to our staff and their views and concerns. We have taken those into key themes for the organisation. At the tail-end of last year we were looking at bringing that together to develop feedback to staff and take that work forward with them.
It is very much about co-creation for us. Having heard our staff’s views, we want to hear about how we can work with them to develop and deliver changes in the organisation and in our culture. Between now and April, we are working with our staff, taking that back to them to hear what they want us to do and to ascertain what we want to change.
We have referenced the whistleblowing and the speak-up work that we do. I have been on a number of boards, and I have seen great attention being given to whistleblowing in the organisation. We are very much about learning: it is a matter of continuing to learn how whistleblowing works. The standards have been new for all boards, and we have been considering the ability of our staff to raise concerns through the appropriate channels, and how they recognise that. As you will see in our submission, we have done some work to improve that. Frances Dodd may wish to comment on how we have developed the speak-up work and whistleblowing.
You refer to the note that you sent us in advance of your appearance here today. There was a lot of managerial jargon in it, and it was quite long. When it came to staff relations, it mainly just discussed whistleblowing. We all accept that whistleblowing is part of a suite of ways for the staff’s voices to be heard, but I would have thought that whistleblowing public interest disclosures were in extremis. As I read it, the point that is being made in the external reviews, including the HIS review, is that there are not good, normalised, routine communications with the staff—including through the staff trade unions, I presume. I do not know whether Mr Reith, as the human resources director, wishes to comment on that.
I am happy to comment on that. When I came on board, there were already arrangements with a regular, monthly area partnership forum meeting—APF—with our staff-side representatives. I meet our senior staff-side colleagues and the employee director every fortnight. We have an open communication, and we explore early intervention—trying to get into issues before they become bigger. The APF has been a really helpful sharing platform, and I continue to attend it with staff. I meet colleagues every fortnight, and there is an open door for the employee director and staff-side colleagues to do that with me and other members of the executive.
We have embraced that approach in the way that we do our work. Like all boards, we have significant challenges to face in managing the financial pressures that are coming over the next year. We have been working with our staff-side colleagues every fortnight, on board with the executive, to consider how we bring their views into frame and how they give us feedback on how we communicate with staff. We are doing that work with colleagues in collaboration, and that has very much been part of our setting out our stall to do things differently.
I am an old-fashioned trade union person. When you say that you engage with your staff colleagues, do you mean that you sit down with the national health service trade unions?
We do, yes.
Partnership working is meant to be a hallmark of good working in the NHS in Scotland, and we are trying to understand the extent to which that has or has not been working.
At the most recent area partnership forum, the feedback that came back from our staff-side, trade union colleagues was that they felt that the visibility of the executive team was greater. They felt that we were working better, and they appreciated early engagement with them, which we have had on a number of things, particularly regarding the money. That is recorded in our partnership forum minutes, so that was not an informal statement. We are getting such feedback frequently now. In fact, one of the bits of feedback has been that people were finding themselves too busy, because we are engaging with staff very early.
That feedback is really important to us. I am asking colleagues for that to be a two-way thing. We will engage with them, but we need them to tell us what staff are saying, as they are closer to staff. We are trying to create such a culture with our trade union colleagues, who are close to our staff—far closer than we are. We have noticed an improvement in that culture over the past few months, and they tell us that it has definitely improved. When Frances Dodd comes in, the committee will also hear more about the HIS inspection that happened a couple of weeks ago.
Perhaps Professor Dodd could come in briefly on the point about staff relations under the HIS report. Other questions about the report are still to come.
Yes—no problem. When the HIS team members came in between 22 and 24 January for a follow-up visit on the inspections that they had undertaken in 2022, they noticed that the process for escalating staff concerns had significantly improved. Staff had commented that there was a much more open culture, they felt listened to, actions were taken and risks were mitigated. Staff on the ground gave that feedback to the HIS inspectors.
The HIS team felt that the safety huddles that we undertake through our normal business processes were much more open. They also felt that there was a psychologically safe environment in which our staff could voice their concerns, and that they were listened to. Staff were escalating the right issues through that route and they were then responded to through the same route. That was an affirmation of the work that we had been doing.
We have also been working across the nursing, midwifery and allied health professional communities to consider what psychological safety means to staff nurses, clinical support workers and physiotherapists, for example. We are trying to understand the conditions that we must create for people to be sufficiently comfortable to raise concerns, which perhaps they have not always been. Our leadership is working to ensure that those conditions are different so that people will feel comfortable to say when things are not okay. Our response to such matters, and how we work on them with staff, through our leaders’ behaviours and role modelling, will reinforce people’s understanding that it is safe to say that things are not okay in Forth Valley. That is what came through in the HIS inspection report.
Thanks for that answer. Graham Simpson wants to come in on that line of questioning.
Mr Reith, I will put this question to you. What would you say that you were getting wrong before?
In respect of our engagement with staff?
Yes. On the whole aspect of culture.
We recognise that we needed to give our staff better opportunities to understand how they could raise concerns.
I will go back to what Frances Dodd said. This is difficult for me. I am hesitating slightly because, since I joined the organisation in late summer last year, I have seen quite an open approach. That has been very much about the way in which we set out our stall and how we approach such issues. Amanda Croft’s leadership style has been all about doing that—she has an engaging, open approach. When I joined, I was struck by how open our staff-side colleagues were in sharing their concerns with me. We then had the opportunity to ask, “What can we do to sort things? How can we fix this? How can we ensure that staff voices are heard?“
Partnership arrangements had certainly been missing in some of our areas. We have re-established those on the acute side, which perhaps had not been working as regularly and as consistently as we wanted it to.
I have seen a really open approach to the way in which we deal with concerns. Our staff-side colleagues appreciate the opportunity to have early intervention conversations, which are not just with me; they are with all our executive colleagues. We have the opportunity to ask, “What can we do before this becomes more problematic or creates more conflict?” That has been an element of our culture. I do not recognise some of what happened beforehand, because I was not there.
From what you have just said, when you came in, you could see problems that needed to be fixed.
Andrew, do you want to come in? You were here.
Good morning. I am Andrew Murray, medical director. I am probably the longest-serving board member, so perhaps I can give a bit more historical context.
I will start by saying that the difference between our previous relationships with staff and where we are now is like night and day. The work done through escalation, and on the outcomes of the various reports, has enabled us to gain momentum in engaging with them.
We were asked, looking back, from a cultural perspective, what we were getting wrong and what we were not acting on. There is probably a missing piece of the jigsaw between what Janie McCusker described, which was the governance-light peripandemic time, and the report that was commissioned. I agree that it took a long time for that to be brought into the organisation and there was some frustration around that but, ultimately, it was an excellent piece of work that allowed us to make a meaningful impact with a lot of the recommendations.
However, a missing piece of the jigsaw was that, in 2021, there was an external review, known locally as the ED review, of the emergency department at Forth Valley royal hospital. The review was carried out by an external group of four former NHS executives. They widened the terms of reference to look at all aspects of governance. There was a reasonable amount of media coverage at the time and Scottish Government colleagues were also aware.
To be fair to us on the board, that review gave us a long list of recommendations, which turned into action plans. We worked through those diligently. A sub-committee was set up, which Janie McCusker chaired. We were attempting to correct many of the issues that had been raised in the findings. There is a read-across, which Professor Brown mentions in his report—he acknowledges the ED report.
Therefore, looking back, there is a longer history. Escalation does not come out of the blue. Escalation is the culmination of processes. We have talked about the HIS information and we have heard about the deanery information, but those alone were not why we were escalated. We were escalated for leadership, culture and governance and, as I said, there is a context to that.
Therefore, we had been working hard as a board to go through those action plans, but we had not managed to create the impact of the delivery. It really took Professor Brown’s report and the escalation process for us to be able to start to transform. I go back to what I said at the start: where we are now compared to how it was is like night and day.
I was going to ask a question about improving training for board members. Having read the Auditor General’s report and the corporate governance review, frankly, I think that the level of incompetence in the board is breathtaking. There is no challenge and very little scrutiny and there seems to be no understanding of proper governance. To me, an induction for board members is an induction, rather than training. Board members should be chosen for the skills that they have and the expertise that they can bring to the board, and not because they come in needing training.
Is there a problem with our recruitment process for non-executive directors? This is not the first time that the committee has looked at problems that have arisen in the public sector and found at least some issues with the way in which non-execs have approached a situation. I am not blaming the board solely—there are other issues—but I am focusing on the board. Is there a problem with our recruitment process?
As you are aware, the Scottish Government leads on the recruitment process for non-exec directors for health boards. The board is required to have some specific skill sets, such as in finance. We also now have a clinical governance non-executive director on the board. That requirement came in after my arrival. That was a key area and I wanted the board to have that skill set within the non-executive directors. Prior to that, we did not have that skill set on the board.
Therefore, the Scottish Government leads on the non-exec director recruitment, which is based on the skills that we might be looking for at a particular time, when we have the opportunities for recruitment.
With regard to Forth Valley, our non-exec representation could be expanded. When a non-executive director arrives, we have an induction package that we give to them. In 2021, we had an active governance training programme, which was run by NES. Previous governance programmes were run with the board prior to my arrival. We also have board seminars, which go into specific areas of the business in detail, building up the knowledge of the board’s non-execs—whose primary role, as you are aware, is to provide scrutiny of the executive directors’ delivery.
09:30To return to your question, I am not sure that I am conversant enough to say that there is a problem. I have been involved in two recruitment processes led by the Scottish Government. I provided the criteria that we would have welcomed on to the board at that time. We were statutorily required to have those criteria, and I was able to recruit that skill set on to the board through that process.
I hear what you are saying—that training has been provided to the board over a period of years, that there is induction, and all the rest of it. However, that did not work so well. What is the point of training people and giving them all that guidance, when it appears on every side that that did not work and they did not take any notice of it? Where is the scrutiny? Where is the challenge?
Since I came on to the board, we have had some very strong non-exec directors who have provided scrutiny and challenge. When HIS came in, we challenged on that and we got assurances at that time. However, HIS came back and deliberated otherwise—it said that we had not fully implemented its recommendations. Certainly, I provide a lot of scrutiny at the board, as do our other non-execs.
The governance review and the overall picture here at my desk do not look too good.
I am happy to come in. I joined the board in September 2023. I do not recognise that suggestion of a lack of scrutiny. I presume that that is because a lot of work has been done while we have been in escalation, but I do not recognise the view that there is such a lack of scrutiny at the board or in the committees.
I am pleased if the situation has improved but, as we are an audit committee, we look backwards. We look at what was, not so much at what is, and we try to get to the bottom of it—to drill down as to why something happened and how it can be prevented in the future. That is our role.
It appears that there have been significant gaps in governance. We want to get to the bottom of that and find out how we can ensure that it does not happen again, because there is a pattern—this has happened elsewhere, albeit not necessarily to the same extent. We want to know, therefore, whether there is an endemic problem. For example, is there a problem in the recruitment processes? We look at everything.
I will speak about Forth Valley. In mid-November, we brought in a board secretary, which Forth Valley had not previously had in a true form. The role of a board secretary is exactly to make sure that non-executives are inducted properly and have the right skills, and to support them with any development. I suspect that bringing that role into Forth Valley has supported our development around that. Obviously, I cannot speak for other boards, but those things have definitely improved in Forth Valley, because I do not recognise that suggestion of a lack of scrutiny since I came into post in September.
That is a relatively short time.
It is.
Again, when it comes to the board, I would like some reassurance that proper scrutiny and challenge are in place, because—hopefully—we have learned through all the deficiencies that have been thrown up both in the audit and in the corporate governance review. What sort of reassurance can we have that those deficiencies have been rectified?
Certainly, we are looking at strengthening and further conducting the active governance programme training for the board. The board has undertaken self-assessment. Two sessions have been facilitated by an external facilitator, to identify areas in which we have been strong and areas in which we have been weak. Through the assurance improvement plan, we have put in place how we will strengthen that governance. That is absolutely there.
The 51 recommendations from Professor Brown’s report will be incorporated in that plan. A lot of mapping of that piece of work has been done and we have a separate escalation assurance board to look at all that work. We are identifying the skill set that we have, where we need to strengthen that and where we need to strengthen any further induction, either by using existing mechanisms or anything else that we can bring on board. I absolutely assure you that that has all been taken into consideration as we work to strengthen that in future.
I will return to a point that I made before. Training is fine and necessary for a board when that is to keep members up to speed about new requirements or about how a process develops, but, when a board member is appointed, I would expect that person to have the skills, experience and ability to be a board member without needing a huge amount of training. If not, what is the point of appointing that person?
The majority of non-executive directors do not come from a health background. I certainly do not come from a health background. The system could be strengthened by having an induction programme—perhaps run by the Scottish Government—on key aspects of the business. That might be helpful.
We have access to online training systems, but it can take time to get into the business of an organisation. That is why we have succession planning, so that we do not have everyone leaving and arriving at the same time and so that there can be networking between existing and new board members to help them understand. It is a bit like having a mentoring system within the board. It is an informal system, not a formal one.
My understanding, based on evidence that we have taken in other meetings, is that each NHS board has unique characteristics because of the way in which it has developed, and that there is a need for each board to provide some familiarisation for directors coming in. That is normal: it is not unique to the NHS. Non-executive directors are appointed to the boards of many different types of private and public organisation.
Let me move on.
We are against the clock. I will bring you back in, but first I will bring Graham Simpson in.
I have a few questions and will start with the current financial position.
You very helpfully shared a paper with local MSPs. It was a finance report dated 30 January and said that the current forecast deficit was then estimated at £10.3 million. The paper also said:
“It is highly unlikely that breakeven can be achieved without additional funding from the Scottish Government and/or a significant improvement in the Acute Services Division financial performance between now and the end of the year.”
Has there been any improvement since that paper was produced?
Our latest position is that we are now quite close to breaking even. That is mainly due to additional national resources coming from the Scottish Government. We do not yet know the exact figure, which would have to go through our board at the end of March before we can make anything public, but that is our current position.
The Government has basically offered to give you more money.
All boards have had some additional resources from the Scottish Government.
You think that that will help you.
We are quite confident that we will come very close to a break-even position.
I presume that you are still having to make savings.
Absolutely. The situation is very challenging for all boards going into next year. We are working on our financial plan for next year and, like all boards, we are looking at making a significant saving. We are in a very different position next year, and we are working on that. We are discussing that with the trade unions and we are working very closely with them, as there will potentially need to be changes in how we work and deliver services. The financial plan will be finalised at the board meeting at the end of March.
As we have heard previously, and as you mention in your paper, a large number of the savings are non-recurring.
Yes.
If that is the case, it is not very sustainable, is it?
No. I will be very honest with you: it is my experience in the health service—with quite a few years at director level and a few years as a chief executive—that that is how we tend to manage, although it is not the best way to do it. NHS Forth Valley is not escalated for money: in recent years, we have never asked for brokerage, and we have always broken even. We are at the lowest rung of the ladder in terms of the escalation programme, which is because the internal and external auditors are reassured and have confidence in our processes. That does not mean to say that we do not have challenges ahead, and non-recurring savings are not the way that anybody would want to go, but that is the reality, I am afraid.
That essentially means that you will be facing this position every year, unless we can sort it out.
Yes.
So, every single year, you will be having to make—
Yes—and I am just glad I am not a director of finance.
You will have to make big savings.
Yes, absolutely. I am not being flippant when I say yes. Unfortunately, that is how we have to work. We have a savings plan in place for next year, and you will know about the agency spend. I am sure that you will want to know more about that at some point. We want to bring that down, which would potentially bring recurring savings, depending on the workforce. It is a really complex area, as I am sure you would agree, and it is not a great position to be in year on year. Unfortunately, that is how we have worked for many years.
What is the implication of that for patients? They are the people who matter. Your staff matter, too, of course, but you are delivering for the public.
Absolutely. There continues to be a challenge, and that is why we have robust systems in place around patient safety and governance. Any change in a funding source is relevant. Our biggest challenge lies in getting the right workforce—which is not agency. All boards in Scotland are facing similar problems. I will not sit here and say that the situation will not impact on patient safety, but we have robust systems in place to try and ensure that patient safety and quality continue as we would want them to.
What is the proportion of agency staff that you employ?
I turn to Professor Dodd, please, and Mr Reith may wish to add something.
We are trying to reduce our agency staff numbers significantly. In the past few months, we have removed off-framework agency staff from a nursing and midwifery perspective—so we do not use any agency staff off framework.
What do you mean by “off framework”?
The agencies can come to us in a number of ways. There is a framework arrangement within Scotland, whereby we can go to certain agencies that broker into a certain framework payment. Other agencies that provided a workforce to us were off framework, and they did not stick within the rules of the framework. We have completely removed our off-framework staffing use in the past few months. We did that very quickly, with good governance control. I and my deputy sign off on any such shifts—that is the level of intensity at which we scrutinise that, ensuring that the quality and safety of care are not impacted and considering all the supplementary staffing solutions that we have in order to provide the necessary level of care for our patients and support for our staff so that they can do the right job at a time when we are under significant demand with the patients coming through the system.
That is one thing that we have done. We are now looking to see what we can do to maximise our recruitment, making sure that we use all the options that are available to us and that we are recruiting locally as well as internationally, in order to meet the challenges around the vacancies that we have.
09:45We are looking to reduce the number of healthcare support workers whom we source from agencies. In the past month, we have reduced that number by 68 per cent. We are doing a lot of work in that regard. I sign off on the use of those workers in the in-hours period, and my executive director colleagues authorise their use in the out-of-hours period.
We are exercising good governance and control around all that, ensuring that we focus on the requirement for patients to be looked after well—staff wellbeing is a factor in that, too. We are aligning that with the number of staff that, from a professional perspective, we would expect to require in order to meet patient needs.
My question was about the percentage of staff members who are agency staff. Do you have that figure?
I do not think that I have that exact figure.
We would have to provide that offline. We are certainly looking at reducing the percentage. As Professor Dodd said, we recognise that the figure has been higher than we ideally want it to be. There is a stepped process to move away from that.
It would be interesting to see actual numbers.
It is a tiny proportion of our substantive staff numbers. I do not have the exact number, but I can get it to you.
The long submission that you sent contains a lot of jargon, one piece of which I want you to explain. Page 4 says:
“Through November and into December 2023, Forth Valley has undertaken a ‘firebreak’ or system reset aiming to decompress the Forth Valley Royal Hospital site”.
I do not know what that means. Can you explain it?
When I hear the sentence read out, I can see exactly why it might be a little mystifying.
The challenges with our unscheduled care performance are at the heart of many of the issues that our regulators and inspectors have picked up on. The HIS inspection focused on patients’ experiences of unscheduled care, and, in the Deanery visit that was mentioned earlier, NES picked up issues that had arisen as a consequence of those challenges.
In the past few years, Forth Valley’s system—by that, I mean the whole unscheduled care process, from people becoming unwell in the community all the way through to discharge from hospital—has struggled to deliver what it needs to for the patients. There are various ways that we can try to improve and data is a big part of that. We work closely with Scottish Government colleagues to understand our data and determine where they see potential for improvements. We recently worked with the NHS’s national Centre for Sustainable Delivery, where Government responsibility for unscheduled care is now based, and it has helped us understand the opportunities for improvement within our system.
I have just realised that what I am saying is quite jargony—I apologise.
Just speak in English, Mr Murray.
I will do my best—you can keep me on track.
The firebreak is another way of trying to reform and reset our system. In practical terms, it meant that senior managers, middle managers and everyone who could unblock decision making in unscheduled care downed tools in their day jobs and focused purely on what they could do to improve unscheduled care. That took us into a short-term, rapid improvement process.
We were trying to use the data to see what we could influence over that time. Fundamentally, we learned a lot, but we did not transform the system, which was frustrating. We invested a lot of time in the exercise and we used the data as well as we could, but we struggled to unlock what we were trying to achieve, which was shorter stays for patients, better performance at the front door and so on. That was frustrating for us, as we had seen other systems—sorry; I am using that jargon again. It was frustrating because we had seen other health boards make progress by doing similar things: NHS Lanarkshire made some gains through the same process, and NHS Borders made some gains through doing something similar—a sort of kaizen thing. However, every system finds it difficult to sustain those gains.
We learned a lot, and the exercise helped to refine the next iteration of our unscheduled care improvement work, which involves the output from the firebreak, the CFSD data and our local improvement plans. That constitutes our improvement process for unscheduled care and our plans for how we can solve some of the long-standing issues within the system.
I am not sure that I am any clearer.
I can try and refine it, if you have a follow-up question.
I am happy to leave it there.
Mr Murray, did you say that you are the longest-serving member of the board or just the longest-serving member who is here this morning?
I would need to double check, but I am pretty sure that that is the case. Yes, Janie McCusker is confirming that.
Please do not take this question personally but, as the longest-serving board member here, you saw your health board escalated to level 4. That is one off from level 5, which is the most serious level and effectively means that the Government has no confidence in the board at all to deliver effective and safe care to patients. Level 4 is almost there. How could the board—collectively and individually—over a number of years have let things get to the stage at which the Government has had to intervene in such a fashion? Surely, the board, on an on-going basis, would be monitoring and auditing processes, outcomes and practices. If it was a private business, it is difficult to see how you would be sitting here this morning.
I have done a lot of reflection on how I could have worked differently and what I could have contributed that might have helped us to move forward more effectively and sooner.
As I alluded to, we could go back and consider a period of years. The issues are clearly set out in Professor Brown’s report. He identified a lot of the key issues about how the executive leadership team struggled to build trust and to function. That is documented in the summaries and the recommendations that he provided. We went through several attempts—formal development processes—to see whether we could improve that performance. Then we had the external report in 2021, which I mentioned, and which was referred to by Professor Brown. Again, that identified leadership, culture and governance issues. In retrospect, you can say that there were some red flags. Looking back, the frequency with which the team had to go through formal organisational development to try and build relationships was telling the wider board a story.
Speaking from the perspective of the executive team, I know that there was a desire to try to work as professionally as we could through those challenges to allow us to be able to reach collaborative decisions that were in the best interest of patients. That was a feature of that period of time. We were trying to be as professional as we could through that, because our role is to work through the challenges, but the issues became increasingly apparent. As I said, looking back, those dots can be joined fairly clearly.
The agencies that have been mentioned and that had a view of NHS Forth Valley also provided us with reports and feedback. There is a national process called shared intelligence, in which agencies come together, review all the data and provide a view of the organisation. The process applies only to health boards, which are not part of the review. Nothing really came from that process, which involved HIS and Audit Scotland—there is a group of agencies that come together to assess an organisation. I do not think that the regulator is involved. I looked back at some of those reports and nothing was ever really identified as being an issue in NHS Forth Valley. However, those of us who were in the system were certainly experiencing some of the difficulties and challenges.
We are very short on time, and I want to move on. Surely the proof would have been in the pudding, and as Mr Simpson said, outcomes for patients are what matter. Could you see a pattern of deterioration in outcomes? For example, your four-hour emergency access compliance is down at 50 per cent, which is way below the Scottish average and that dropped considerably over a period of time. Surely, all those performance issues in relation to the CAMHS statistics, the out-of-hours GP access and the 18-week waiting times for referral for psychological assessment would have been massive red flags to the board that it was in danger of escalation.
I think that they were, and I think that Janie McCusker is concurring.
The escalation process seems to have worked. I noted previously that the systems of regulation and checks and balances seem to have worked. I will go back to what I said earlier. The culture, certainly within the senior leadership team, is significantly different, and we are now making decisions that will benefit patients.
Looking back, there were real difficulties. The four-hour emergency access standard is measured at the acute site. There were real difficulties with the leadership within that particular site; for a long period, it was very inconsistent. We were really struggling, and that goes back to the comments earlier about the culture and the staff. That site had not had the support that it needed in order to deliver, and that was known to all of us within the board. I was watching our four-hour emergency access standard deteriorate and I was briefing the board on that. It was also about the patient harm that occurs as a result of people waiting more than 12 hours in the emergency department. There is a recognised association with mortality—people die as a result of waiting. Those are weighty subjects. I was also taking professional advice from senior medics within Government and telling them that I was seeing that situation happening, seeing the deteriorating picture and seeing a team that was not able to take the corrective action to improve that. It was probably that softer intelligence that resulted in the escalation process being triggered. It is absolutely regrettable that we had to be escalated in order for us to be able to make an impact and bring some of the benefits for patients that we were describing.
Can I move on to the present day? We could spend a lot of time on retrospect, but I am sure that lessons will be learned and that there is a lot of personal regret in the executive leadership team.
Ms Croft, where are you currently with some of the service improvements? It is still looking quite grim for patients in Forth Valley with regard to waiting times across a number of key metrics. At the risk of my questions needing a lengthy answer that we do not have time for, what are some of the steps that you are taking right now to improve, for example, performance with regard to the four-hour A and E turnaround and 18-week referrals for mental health assessments? What are the limiting factors? We have talked about workforce and finances, but what key barriers exist right now to making immediate improvements so that you can de-escalate out of level 4?
I will be really brief and high level, but I am happy to share detail in writing, if that is helpful.
What are the key take aways, so that a member of the public who is watching this meeting can have confidence in what is happening?
The key take aways are that our CAMHS performance, as of January, is the best in Scotland. Our psychological therapies performance has improved and is in the pack, as we call it. I am sorry—that is another bit of jargon.
It is at 64 per cent, against a target of 80 per cent, so it is still—
I have probably got more up-to-date information. Performance for psychological therapies is definitely workforce related and it will fluctuate as the workforce fluctuates. It is a very specialised area but it is about where the team was and where it is now.
I will not talk about the four-hour A and E target, but Andrew Murray might wish to come in on that.
Our out-of-hours GP services have improved greatly. The fill rate has improved up into the 90s. I think that that is correct, Andrew. There is a session next week with Sir Lewis Ritchie—who supported that work—to close the work off, because the performance is very good.
In many of the areas of planned care, you will note that Forth Valley is probably one of the best performing boards. I will not go into detail, but I am happy to supply you with that information.
I will tell you what the key issues are and what we need to do. We need good, strong leadership across the system, which means good general management leadership and good clinical leadership at nurse director and medical director level. We need the system to work as a whole; we need to work not only with the acute sector on the four-hour target but with our primary care colleagues, our integration joint boards and our health and social care partnerships. We will not do this alone as a health board. That is the work that we continue to do. Since I have been in post, I have seen a huge improvement. I am happy to supply more detailed data on the performance on access and waiting times that you require.
10:00
It would be great to have any additional updates that you can provide.
It is interesting that much has been mentioned about workforce issues, and we have talked in great detail about the importance of executive leadership. The other key finding from the external review of corporate governance is about the
“root cause of many of the significant challenges”
that you face as a health board. The review states that one root cause is
“the failure to agree an appropriate business model for the delivery of integrated health and social care services”.
We have not spent a lot of time on that aspect this morning. Have things improved?
Absolutely. When integration was first introduced, one of the key things that boards were asked to do was to transfer services. I mentioned our prison healthcare services, which we have just transferred over to the integration joint board. It is a very complex system—I will try to avoid using jargon—and our mental health, primary care and GP out-of-hours services, which were sitting with the health board, have moved over to the health and social care partnerships.
The two chief officers that lead the integration joint boards are very much part of our executive team; they are involved in every decision. We do not make decisions that will impact on primary care or health and social care partnerships and vice versa. They will be included in our conversations on financial savings plans.
We also work closely with our local authorities. Forth Valley as a region has decided to have one anchor board institution, which is about community wealth growing. We could have four such institutions in Forth Valley, because we have three councils and one health board, but we have agreed to have one. That is a real signal that we are talking to each other and working well together. We are talking about the resources that we have collectively and how we can work with them differently.
I could go on and on, but I am conscious of time.
That is fine. My parting question is for Ms McCusker. It is your last day in the job as chair. What would your advice be to the incoming chair?
My advice to them is that they should ensure that they are made aware of all the issues that perhaps led to where we are today, and that they understand and are briefed in more detail on what has gone on and how that is being addressed. It is important that an incoming chair is made aware of the historical issues that needed to be addressed and that they focus on continuing the trajectory of progress that the board has made.
Amanda Croft, I listened to your comment about the progress that has been made on the 51 recommendations. When colleagues were asking questions, I was able to take a look at your escalation update report, which was given to the board only a month ago. It says that five of the recommendations have been completed, but you said that many of them have been completed. It also says that 14 recommendations have been moved into an assurance and improvement plan but that 32 are still outstanding. Would you mind clarifying what the actual position is for the committee?
Certainly. Again, we will definitely have more up-to-date information, and I am very happy to supply that. We are just about to take another assurance board paper to the Scottish Government assurance board meeting. I get confused with all the meetings.
The current position is that we have completed 89 per cent of the actions, which means that we still have open five high-level actions. One thing that we have learned and had feedback on from the escalation committee is that we were concentrating very much on enabling actions. Sorry—I am using jargon again. Those are actions that allow us to close off a broader action. We have carried out a huge amount of work over the past three weeks on that. We have closed off a lot of actions, which does not mean that we are stopping the work; the work will continue as part of our normal business.
It is fair to say that many of the actions from the external review and other reviews—I think that you commented on the number of reviews that NHS Forth Valley has had in the committee’s last meeting on the issue—I have forgotten what I was going to say. Sorry, but I have lost my train of thought.
Five actions are still open. Those involve some of the culture work and some of the governance work. The main bit of work on governance is embedding an assurance framework. That is more jargon, but all boards have an assurance framework, which means that all their processes align to one framework, and it tells you how one committee relates to another committee and how those relate to the board.
All the leadership actions are closed, but five high-level actions are still open on culture and governance.
Your board paper said that you had completed only five actions. That is a huge jump in one month.
The latest paper explains that.
Okay. Who reviews that performance in order to be assured that the picture is genuine? Who does that verification?
The board has an escalation, performance and resource committee meeting every month—we had one of those one or two weeks ago. The Scottish Government has an assurance board meeting every month as well.
The executives look at everything every week. We supply the information, which we go through and scrutinise whether we have closed off an issue. The board has its monthly escalation, performance and resources committee, but we also discuss some of the actions in other relevant committees of the board—for example, the staff governance committee. The culture work is discussed in the clinical governance committee, as are patient safety and HIS work. A number of committees accumulate in the escalation committee, which accumulates in the assurance board at the Scottish Government.
Are you confident that 89 per cent of the recommendations are completed?
Yes.
Thanks. I leave it at that.
Before we finish up, I will take us back to the report that was produced 22 months ago by Healthcare Improvement Scotland following its unannounced inspection. For example, it reported that it had found a
“lack of documented risks assessments”;
and that
“the addition of a fifth bed within a four bedded bay”
created what it felt to be a breach of standard operating procedures; and so on. There were quite serious allegations about patient care.
HIS also spoke about the vacancy rate as being very high within certain staff groups, such as the registered nursing staff group, in which the vacancy rate was more than 10 per cent, and the medical staff group, in which the vacancy rate was 13.76 per cent.
Will you address those issues in turn and tell us what progress you have made in 22 months?
Yes, definitely. I go to Frances Dodd first, after which, I am sure, Kevin Reith and Andrew Murray will want to come in.
As I suggested earlier, we had a return visit from Healthcare Improvement Scotland at the end of January. I worked with the inspection team. We have not had the team’s final report. We are working with it to give additional information, in accordance with its methodology. However, in its initial feedback, the team has suggested that it did not escalate any concerns around the care and safety that are provided to patients during that time.
Are there still five beds in four-bedded bays?
Yes, there are.
There are. Okay.
Have you carried out all the risk assessments that were required?
Patients who are in a fifth bed in a four-bedded room are risk assessed every day, throughout the day. If the condition of those patients changes, that is escalated through the staff safety huddle—we talked earlier about the staff being comfortable to raise those concerns. If we are unable to mitigate the risks, we try to move the patients out of those areas as quickly as possible.
However, in order to deal with demand, we continue to rely on contingency beds to support the flow of patients through the Forth Valley royal hospital site. That is similar to the position in a number of hospitals across Scotland. We have risk assessments; patients are assessed every day; there is senior professional support to reassess them if any concerns are raised by staff; we have a flow system in the hospital to move patients out of those situations wherever possible; and the infrastructure to support patients in those fifth beds in four-bedded rooms has been significantly improved through the equipment and support that we provide.
No concerns were raised at all about the care that was provided during the inspection visit. I came on to the board in October 2022, and the previous inspection visit had been in September 2022. The same inspectors revisited us in January this year, and they saw a significant improvement in the safety of care—there were no concerns around patient safety during that visit. They saw a very calm environment in the emergency department and in the acute assessment unit. During the three days that the inspectors were there, the environment was very busy, but they said that it was calm and well led. The staff commented that there was great leadership visibility, and they said that they were able to raise their concerns.
The inspectors spoke to a number of patients throughout their visit. The patients recognised that they were in a busy environment, but they had no concerns about their safety or the care that was being provided to them, and they gave very favourable feedback on that care, even in the context of an incredibly busy emergency department and acute assessment unit.
Where are we with staff vacancy rates and so on?
The vacancy rates are certainly now below the level that they were at that time.
We have been doing a number of things. We have been doing on-going tracking and speeding up the process to get recruitment in place. We will be below 10 per cent for those main groups. We track and monitor against other boards in relation to staffing levels for nursing, midwifery and allied health professionals on the medical side of things. I am confident that we would be in the mix—I do not want to use the phrase “in the pack”—with the same sorts of averages that other boards have. Vacancies are a challenge, as we recognise, but we have been doing some work recently on our funded establishment and tying that in with our financial work to ensure that we understand where all our vacancies lie.
The other part of that involves getting the process right. We have been doing some man-marking, as we call it, to ensure that all the vacancies in the system are being progressed rapidly. We have definitely made improvements. That work is on-going.
As has been suggested by other members of the committee, it might be useful if you could follow that up in writing with some more up-to-date information, so that we have that data on the record.
My final reflection follows on from the deputy convener’s previous salient question. Three of you are very new to what are very senior positions in the health board. Did the people who left go through any kind of exit interview?
Yes, we have had exit conversations with everybody. Those will have been different in every case. We are looking at lessons learned from all that, and we will be reflecting that back in.
We have been trying to consolidate; we do not want interim arrangements. The work that we are doing now involves consolidating the team in the best possible way. We have filled spaces where we have needed to get traction, and that has helped us to move the agenda forward. There are on-going conversations, reflecting on those who have left us or moved on and on changes that have been made at the executive level.
Okay, but my question is this: is there a formal process whereby somebody who leaves the health board—who has been the chief executive or who has been in a senor HR role for a number of years, down to those nursing staff who have left, who have now created vacancies in the system—
There are two parts—
Let me finish, please.
Sorry.
My question is: do you have systems in place to understand why nurses have left the health board’s employ, why the chief executive left the board’s employ—I know that it was retirement in that case—and why other people in senior posts have left? You are the new team. Were interviews carried out to capture and record the reasons why people left?
There are two parts to the answer. First, we have in place an exit interview arrangement, and everybody has the opportunity to have an exit interview. We have had conversations with our colleagues in the trade unions, recognising that improvements could be made in that space. Not all of them are happening, but we want there to be more consistency.
Secondly, for the senior levels, we would probably do things slightly differently, with a more detailed, one-to-one interaction, reflecting on what we can learn from that experience.
The last word goes to you, Janie McCusker.
I am aware that that is offered to anyone who wishes to depart the health board, but I am also informed that that is a confidential process, so the lessons learned have to be kept in a confidential space. We could perhaps consider how we can transfer some of that to ensure that we get the overarching thematic areas of understanding improvement—as opposed to specific areas.
10:15
Do not misunderstand me: I am not asking you to send us copies, with people’s reasons for leaving, as a matter of public record; I am just asking whether, as a matter of good practice, you are monitoring those reasons so that you can establish if there are trends or other things.
Yes.
We have been speaking about whistleblowing, for example. I am just asking whether, if there are cultural issues that mean that you are not able to retain staff at any level, you are able to monitor that.
Yes.
We are now bang out of time, and I am sorry that I was not able to bring you back in. If there is something pertinent that you want to draw to the attention of the committee, please feel free to capture it and put it in a written submission after today’s session. We would appreciate that.
I thank Amanda Croft and Janie McCusker. I wish you a happy post-Forth Valley NHS Board life. I also thank Andrew Murray, Kevin Reith and Professor Frances Dodd for contributing to this morning’s evidence session, which has been greatly appreciated.
I suspend the meeting to allow for a changeover of witnesses.
10:16 Meeting suspended.10:18 On resuming—