Health and Community Care Committee, 24 Nov 1999

Meeting date: Wednesday, November 24, 1999

Official Report 224KB pdf

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Stracathro Hospital

Good morning. This morning we will consider a submission that we received through the Public Petitions Committee about Stracathro hospital in Angus. The hospital is a district general hospital serving Angus and part of the Mearns. It has a staff of nearly 700.

This is the first time that the committee has actively considered something that has come to us via the Public Petitions Committee. The petition had more than 25,000 signatures, so the issue is obviously of great interest to the people of Angus and the Mearns.

The committee has already received written evidence; this morning we will take oral evidence. I suggest that we wait until our meeting on 1 December to come back with our response, because we have other business to get through this morning.

I happened to be in the locality of Stracathro hospital during the recess, and I visited it unannounced. It was a useful visit, allowing me to acquaint myself with the hospital.

Members will want to raise a number of issues today. Some of the local MSPs are with us and I will let them ask questions as well if they catch my eye.

We welcome our first group of witnesses, who represent the Stracathro hospital staff action committee. The staff action committee came to the Parliament several weeks ago and put their points to some of us after a meeting of this committee. This will be an opportunity for MSPs to ask the witnesses questions. Margaret Jamieson has a question on staff relations.

What consultation has there been with the staff organisations?

There has been very little contact with staff members. The first that we heard of any changes or ward closures was through The Courier & Advertiser on 23 August. The Tayside University Hospitals NHS Trust held a meeting the day after to inform staff officially of the closures and changes that were about to take place. At that time, there was little or no union representation or involvement; that has improved slightly, but not as much as we would like.

As a member of an organisation on the staff side, you will be aware of the partnership ethos that is supposed to exist in the national health service following the publication last year of the human resources strategy document "Towards a New Way of Working". Do you believe that that document has been central to the consultation process?

We feel that, from the start, there has been a lack of timely and honest consultation. As I said, that has improved only slightly. The document that you mentioned has not been adhered to.

Has anyone suggested that there should be a partnership forum in which to discuss issues emanating from the health improvement plan or the trust improvement plan?

A staff development group was arranged in the hospital. The trust also holds consultations with the unions. However, the trust has no involvement with junior members of staff. It consults senior members of staff, but that is a recent thing. We feel that there has not been the proper consultation that is needed.

In this case, were staff organisations consulted before any announcement was made?

No.

Not at all?

Not at all.

If a decision is presented to a staff organisation as a fait accompli, how can you take that forward? How can that be consultation?

Well, that would not be consultation.

A consequence of the changes that have been made at Stracathro appears to be a problem in retaining staff. Another problem—which has been highlighted by, among others, the acute trust—concerns the training of staff, especially, given the absence of consultants, junior doctors. What are your views on that?

Many of the nursing staff at Stracathro are trained in extended roles, which has been a great strength. However, because staff are now very uncertain about their future, they are having to consider leaving and finding jobs elsewhere. All that unrest among staff is a great disincentive. We are now concerned that we will not have sufficient staff to maintain a safe service at Stracathro.

Do you feel that that is a danger, given the way that things are going?

That is the way that things are going. It will be a fait accompli and Stracathro will not be able to be maintained. We have come here to ask you to intervene to ensure that that does not happen.

Do you want services at Stracathro to be restored to the level of five—if not more than five—years ago?

We are very keen for Stracathro to be a pilot that could show a way ahead for health provision in the future. Research shows that having huge hospitals—almost factory farms—supplying health provision is not a good way of doing things. Large hospitals can have safety problems if patients have to be evacuated, and there can be terrible problems such as cross-infection and the build-up of germs. Modern research indicates that hospitals should have flat, one-storey layouts, with segregated units. Stracathro is ideally suited for that. It would be an economically viable proposition to make it such a pilot. Moreover, our situation would be improved if the big five teaching hospitals were considered separately from the smaller ones.

I do not understand. I know what you are saying about the suitability of the building and the layout. However, at least one of the submissions that we have received has specified the services that have been lost. Indeed, several of the documents refer to a decline in services at Stracathro over five years. Are you asking for all the services that have been lost over the past five years to be restored and for services at the hospital to be returned to the level at which they were several years ago?

Not necessarily. We are asking for adequate services to serve our community. We are well aware of, and grateful for, Ninewells and high-tech medicine. However, we would like the everyday bread-and-butter things to be brought to Stracathro and kept there.

One of our main concerns is that services have been so eroded that the hospital will not be viable. Maintaining services is our main priority, although we would like to return to the position that we were in five years ago. The emergency surgical services were removed from the hospital only a year and a half ago; that had a devastating effect. A brand new general surgical unit had been built for those purposes. We ask that the services that exist be retained, as we are about to lose our stroke service.

Do you hold out hope of returning to the hospital's previous level of service?

Yes.

What would the cost of that be?

Before the surgical services were lost, it was more financially viable to treat patients for those operations at Stracathro than at Dundee. There is now the added financial burden on the ambulance service of transferring people from the area of Angus and lower Mearns to Ninewells. I think that the cost was £756 less per case to treat a patient at Stracathro than at Ninewells for a similar surgical procedure.

The budget will require a certain amount to return the service to the level that you aspire to, which is the level that was achieved five years ago. Has anyone costed how much would be required for that?

We have not carried out costings on that. However, there is a £10 million flyover coming into the site. A lot of bad publicity about Stracathro is being circulated, which says that the buildings are in a terrible state. That is not the case. There are a lot of very good buildings and high-quality care is available there. The financial input should not be anything like as enormous as the cost of taking everybody through to Ninewells, of having to extend the service there and of putting bread-and-butter people into high-tech beds.

You are talking about the decline that has taken place in the past five years. Your submission almost narrows it down to the past two years. Will you comment on what effect the suspension of the two surgeons had on what appears to have been a rapid decline? Your submission says that

"it is now very clear that the current financial crisis"—

a £12 million crisis, I believe—

"will determine all policy decisions".

Will you elaborate on that?

Until the changeover of trust, Stracathro seemed to be paying its way fairly well. It did not have a large deficit, but a deficit was inherited from the other two trusts. There can be absolutely no doubt that the sudden suspension of the two surgeons decimated the surgical service. There was absolutely no attempt to replace those services or to provide proper locum cover. The services had to move to Dundee.

Moreover, we discovered only recently that the trust's policy has been not to award any more long-term contracts to consultants. Obviously, if a consultant does not have a long-term contract, he or she is not going to continue to work at a hospital. That is why the services have been decimated in the medical service as well as in the surgical service. We feel that the trust has not enunciated what is in fact its clear policy; it is hiding behind the acute services review even though it decided, two years ago, to decimate the services.

There seems to be some conflict. Your submission says:

"The Chairman and Chief Executive of Tayside Health Board has repeatedly stated that no decisions will be taken . . . until the acute services review is published."

It also says:

"The Medical Director of Tayside University Hospital Trust has said that Stracathro will close within eighteen months."

That is true: there is a conflict. The board is saying clearly and repeatedly that no decisions will be made until the acute services review is published. However, the medical director of the trust has said on several occasions that he hopes that Stracathro will close within the next 18 months. The fact that long-term contracts have not been awarded—which means that valuable consultants have been lost—bears that out. There is a hidden agenda.

Some of the other submissions that we have received suggest that there is a difficulty in recruiting throughout Stracathro—for nursing staff, ancillary staff, you name it—or, as the management puts it, in finding suitably qualified candidates. Will you elaborate on that?

Yes. That has happened only within the past two years. Stracathro was well known for the fact that people were queueing up to work there. For example, two years ago, the radiology service had 80 applicants for every post. This year, when a post was advertised, there were no applicants. That is indicative of the fact that people do not see a future in Stracathro. You cannot blame people for not wanting to work there.

In effect, you are saying that it is a case of death by a thousand cuts?

Exactly.

I would like to say something about the recruitment of nursing staff. There was, and still is, a job freeze—there are 32 posts available within Stracathro hospital. The job freeze was introduced in May or June. Jobs were advertised in the stroke unit, in the coronary care unit and in ward 15. For a short time, the job freeze was lifted, during which time the positions that were available in those areas were advertised and suitable candidates were to be interviewed. However, those interviews were cancelled at a day's or a week's notice. The G grade within the coronary care unit was informed the same week that her interview had been cancelled.

The stroke unit has experienced similar problems. There were 25 applicants for an A grade post that was advertised in that unit, so we must question whether there is a problem with recruitment.

You are saying that there are 32 vacant nursing posts at Stracathro?

Yes.

What effect is that having on patient care?

It is very stressful for the staff. The staff are dedicated to providing the best care. The posts that are vacant have been so for several months. The patient care in my ward has not altered, as we try our best to provide the nursing care that is appropriate to each patient. The stress is more on the staff than on the patients—their care is not affected by the current level of staffing, as we are putting in extra effort.

I open up the questioning. Margaret, do you have a supplementary?

Yes. You stated that the medical director had said that the hospital would close but that the trust board had said that that was not the case. Is the medical director a member of the trust board?

Yes, he is. He is the medical director of the trust.

He sits on the trust board?

The board and the trust are two separate bodies.

I am asking a specific question. Does the medical director of Stracathro sit on the trust board?

Yes.

So, he is a full member of the trust board?

Yes.

In another submission, it was mentioned that senior medical staff in Stracathro had made it clear, at the beginning of this year, that they had concerns about the sustainability and safety of medical facilities at Stracathro. Did any of the senior medical staff approach you with those concerns this year or last year?

No.

In view of the nursing shortages and the lack of consultants, do you doubt the safety of clinical services now and in the near future?

Yes.

I want to go back briefly to the issue of consultation—we are concentrating on the procedures that were adopted. Are you saying that consultation did not take place or that the consultation that took place was bad, with confusing information and so on?

At the start, on 23 August, there was absolutely no consultation with unions or with members or senior members of the nursing, technical and ancillary staff.

Consultation took place the day after information about ward closures was released in the press. Since then, there has been minimal consultation and the level of communication has been very poor. Technical and ancillary staff members still do not know what is happening.

Ward changes and closures were supposed to take place by 1 December—that was said at the most recent meeting that the trust held with staff. It is now the end of November, but nursing and domestic staff still do not know when those changes will take place. For example, ward 8 will close, but no date has been given for that. The trust has said that it hopes to have posts for people within the next two weeks and that people will be redeployed within that period. That does not give staff much time to make arrangements.

So, in some cases, staff have not even been given minimal information. What did the minimal consultation amount to?

The minimal consultation that has taken place has consisted of meetings of perhaps an hour here and there with nursing staff. There was consultation only after the trust was pushed into a situation in which it had to consult.

I am confused. The submission from Tayside University Hospitals NHS Trust says quite the opposite of what you are saying—perhaps that is not a surprise to you. It says that

"since April 1999 . . . senior management have made major efforts to talk to and to support staff."

A specific point is that

"all staff affected by change have had individual meetings to discuss alternative employment."

More recent steps include the

"development of a partnership working agreement and change management protocol with Trade Unions".

The submission also says that efforts have stepped up a gear since 24 August 1999. The clear picture from the trust is of step-by-step consultation.

That is simply not true. There was a leak—I do not know where it came from—to the press on 23 August about ward closures. At 4.30 pm on that day, the trust decided to hold a meeting at 11 o'clock the next morning. If there had been proper consultation and warning, the trust would not have called a meeting at such short notice to inform staff. We were given an hour in which to ask questions. Once the meeting was over, we had to wait to find out when the ward closures would take place and what would happen to staff.

What about the detailed written information that the trust says was provided to staff?

Personal interviews have taken place within the past three weeks. Staff have been told that they could be redeployed within two days.

Across Tayside?

Yes. That means that they could be redeployed as far away as Perth.

That takes no account of the personal lives and commitment of staff.

Before the current trust came into being on 1 April, was there adequate consultation within the Stracathro trust? I take it that it was an independent trust.

Tayside University Hospitals NHS Trust was shadowing Angus NHS Trust for a year, during which time there was no talk of alterations to services.

During that year, Angus NHS Trust still had legal responsibility for maintaining the human resource strategy of the Scottish health service. Was there consultation between staff and that trust? As Kay Ullrich said, the process appears to be death by a thousand cuts. It seems that the process has been going on for a considerable time and was accelerated by the suspension of the surgeons in August 1998. Were you adequately consulted about the consequence of the suspension, especially on surgical services?

Not at all.

Was there discussion of where the patients that had been admitted would go?

No. One ward—ward 13, a receiving orthopaedic ward—was closed under Angus NHS Trust. Staff were moved down to the general surgical unit to allow the ward to be refurbished, but two weeks after they had been told that they would be moved back to the ward, they were informed that it was no longer viable to keep the ward open. There was no consultation in that period.

Was it your perception that a move that had been a reasonable temporary arrangement to allow refurbishment turned out to be permanent? Did you feel that that was representative of the consultation process and that, rather than being involved, you learned about things as they unfolded?

Yes.

On occasion, the trust got wrong-footed and had to make policy on the hoof. That worked against the provision of services at Stracathro. The staff had to pick up the pieces as they went along.

Clearly, the actions of the board must have been forced by the suspension of the two surgeons, as suspended surgeons cannot be replaced—certainly not by surgeons on permanent contracts.

Surely if one values a service, one goes out of one's way to ensure that it is maintained. That has simply not been the case.

So the trust did not attempt to find locum surgeons?

It did after there was a bit of a furore.

Locum surgeons came for just three months, and then went to Dundee.

I am trying to establish whether there is a pattern of non-consultation by the previous trust, the shadow trust and now the present trust over the episode in August.

Yes. We have a lack of confidence in what the trust tells us because of what has happened in the past.

That is very clear.

I have a brief question on consultation, and then one on finances.

Tayside Health Board tells us that its review process is fully inclusive of all stakeholders, including

"clinicians, general practitioners, both local trusts, three local authorities, Tayside Health Council, Universities and Tayside Health Board."

It is highly commendable that your petition has more than 25,000 signatures. Did you feel that the voice of patients and staff was not being heard through any of those groups?

We felt that we were being ignored. We feel that the cross-party support for Stracathro—every political party in Angus and the Mearns has spoken with one voice on this issue—was totally ignored and overruled. We are here today—very frightened and nervous—to ask you to listen to the voice of everybody in our area. This cannot go on. Somebody has to listen.

It is rather frightening when one sees something on paper that seems impressive but is not so impressive when one hears what other people say.

Your submission says that Stracathro's contribution to Tayside Health Board's deficit of £12 million is £750,000. Can you clarify that? You mentioned a telephone system and so on. Do you feel that you are being unfairly targeted?

Before you answer that question, could we try to keep the answers brief, so that we can take the extra question from Keith Raffan before the end of the session?

Stracathro was supposed to be over its budget allocation by £750,000. That is a minimal amount compared with what is happening elsewhere. We feel strongly that Stracathro is being made to bear an unfair burden in reducing costs through a thousand cuts.

So in effect, if Stracathro were closed, it would have little effect on the overall deficit.

We believe so, and we believe that there is a strong argument for increasing services there. There is a strong argument for using that area for research into the development of services.

Your written submission includes some figures on the costs of surgical treatment at Stracathro compared with Ninewells.

I will continue with the consultation questions. With other local members, I had a meeting recently with Tayside Health Board. I think that the review is published on 15 or 16 December. What indication have you been given regarding consultation after the publication of the review?

Your guess is as good as ours.

So no information at all has been given to you about consultation?

There will be public meetings.

There will be public meetings, but not necessarily meetings with the staff?

We understand that there will be public meetings.

I have one final point. The review has been widely leaked, or at least its broad parameters have been. It seems certain that there will be a hospital in Angus, but the question is where it will be located. During the review, have you been consulted on that issue?

No.

Certain nurses in Stracathro have been involved in the past couple of months with the acute services review, but nothing has been said about that issue.

When you bear in mind the fact that 20 to 30 per cent of the cost of a new hospital is in buying the site, it seems strange to consider buying a site when you have one already, and when a flyover from a main dual carriageway is already in place, with easy access to the north and south.

The location of the hospital is not the concern; it is the services that it provides and the maintenance of those services. That is what is being eroded. The talk of new hospitals being here, there and everywhere in Angus is separating people. At the end of the day, the services provided by the new hospital and those that are provided now would not be the same, so there would be a loss. That is our concern.

The quality of nursing at Stracathro and the care of the consultants and of the teams is such that they put patient care before themselves.

We will leave it there. I am aware that we could ask you lots more questions, but we have run out of time. We have several people to see this morning.

On behalf of the committee, I thank you for coming in. You have survived us: there was no need to be worried. We appreciate your written submission and the oral evidence that you gave.

As I said at the beginning of the meeting, we will examine the matter again at our meeting on 1 December and then decide on our recommendations. We have to find out the parameters of what we can suggest and who we should make suggestions to. You are welcome to stay and listen to the other submissions, or you may escape.

Thank you for hearing us.

Could I leave this picture of Stracathro hospital? Those who do not know the hospital could have a look at it.

Could the picture be passed round?

Yes.

While we are waiting for the next witnesses to come in, it would be useful if I told committee members that when I visited the hospital, there was a mix of accommodation and buildings, some of which looked as if they were new and had not been used much before they were closed down. On the other hand, areas such as the stroke unit looked as if they could do with some investment. Obviously, that is a lay person's point of view.

Members might have the impression that the hospital is falling down. In no way is it dilapidated. It suffers from some of the problems that all older hospitals suffer from. It is well spread out. We should ask the health board and the trust for their views on the points that were raised by the staff about the possibility of using the site for changing health care needs. There is a dubiety between the staff's submission that the site could be used with minimum investment and the trust's view that massive investment of about £10 million is needed.

Our next set of witnesses is here. They are from Brechin and District Patients Association and Angus and Mearns Action to Save Stracathro. Welcome to all of you.

We will kick off with questions. So far, we have focused on matters such as consultation—or the lack of it. You are coming at this subject from a patient-centred viewpoint. In Scotland, we hope to have a patient-centred health service, so you will probably be asked some questions relating to services. Your submission was good in pinpointing some of the practical day-to-day results, or possible results, of some of the changes.

In your submission, you indicated the level of service that there was, is and should be. With regard to consultation with the health board on shaping the services, and with the trust on how it would meet the objectives of the health board, were you, as patient organisations, consulted, or was there consultation with other groups?

My understanding is that there might have been some consultation with the local health council. However, despite repeated announcements that our patients association exists—we were established in 1991 or 1992—the health board and the authorities repeatedly ignore us. In fact, it was the secretary of a community council who informed us of the first of the few public meetings that were held on the acute services review. Consultation and communication do not seem to be words that are in the authorities' vocabulary.

You mentioned the local health council. Was there formal consultation with that council, which is supposed to represent the public in such matters?

I cannot answer for the council. I am not sure whether it was consulted, but I hope that it was, because its role is to be a public watchdog.

Given that the council is a small, select group of individuals, how did it consult the wider population of the area?

To my knowledge, it did not contact any public group to ask for further information. That is one of our concerns. The council has a committee of 15 people across the whole of the former Tayside region: five members per former district. They have an enormous amount of ground to cover. In the area that we cover, we see ourselves as being potentially their eyes and ears, but we are never used in that way.

I would like to make a—

Are those the only representatives of the health council on the two groups considering the acute services review in Tayside?

That is right.

I apologise for interrupting.

I would like to make a point about representation. The only consultation has been the review meetings. We wrote to the trust and to the health board to request a meeting in Montrose, or more particularly, in the Mearns—Stracathro covers quite a large proportion of the Mearns. We were refused by both of them, so Angus and Mearns Action to Save Stracathro was formed to represent all the various bodies throughout Angus and the Mearns. No reason was given for the refusal other than that the trust and the health board felt that the area was covered.

Did you receive the refusal verbally or in writing?

In writing.

And no reason was given?

No. All they said was that they felt that all areas were covered.

Who sent the letter? Was it the board?

If my memory serves me correctly, the letter came from Paul White, but do not hold me to that. It was sent on behalf of the trust.

I have two lines of questioning. The first follows on from the staff committee's submission. Is it your view that what is happening at Stracathro is merely a symptom of a much deeper malaise in the health board and in the trust that has lasted for a number of years? There is some suggestion of bad management and bad policy making. What is your view?

In my view, the situation is a complete travesty. The patients and the people concerned, who account for a quarter of the population, 70 per cent of whom are aged over 65—I am the local chairman of Age Concern—feel that the board has been accountable to no one. The Minister for Health and Community Care states continually in the press that she wants more openness. That is on record in the Scottish Parliament, but it is sadly lacking in Angus.

We have been accused of scaremongering and all sorts of nasty things. All we are concerned about is keeping our hospital, which was healthy, served the community well and is on a beautiful site. Everything I read by architects says that their preference is for a flat-level, one-building site, which is what we have. The flyover has also been built.

We see no reason why acute services should not continue at Stracathro. We feel that there is a hidden agenda; the health board and the trust have not been frank with us. They have not invited us to take part in any dialogue about what they are doing. The staff were given the choice of moving 20 or 30 miles away or losing their jobs in a short time. It is disgraceful.

The thrust of Hugh Henry's question is right. There has been general malaise, which has accelerated. It started many years ago, but started to accelerate about five years ago and got into high gear two years ago. Since then, the process has accelerated. Several highly placed people within the health authorities—excuse me for using that term, but it is useful to mean the board and the trust—are on record as saying that they do not believe that there is a place for Stracathro, that they foresee the hospital closing in the long term and that the hospital does not figure in their plans.

The committee may well come back to Frank Wood's comment about the accountability of health boards, as a trend is starting to appear.

My second line of questioning follows on from an issue raised by Keith Raffan—the suggestion that there might be a new hospital in the Angus area. I have no details about that, but if it were the case, would you support the provision of a new hospital, even if it meant centralising services from existing facilities?

A new hospital would be welcome, but we would have to look very closely at any such offer. Ronald Macdonald has detailed knowledge of the proposals made in the health board's committee papers.

The term "new hospital" is lovely. The man in the street thinks, "A new hospital? That will be like Stracathro or Ninewells." The reality is that what is planned is an ambulatory and diagnostic centre, perhaps with a community resource centre attached.

According to the board's papers from Wednesday, medicine would be reduced to low-dependency admissions, run by general practitioners. Some day cases would be taken. There would also be some "step down" surgery—people coming from Ninewells—and rehabilitation. Surgery would deal with some day cases, some "step down" surgery and some rehabilitation. The papers stated that provision for care of the elderly would have to be assessed and might include a stroke rehabilitation unit. There would be palliative care for medical and surgical cases.

The accident and emergency unit at Stracathro would become a minor injuries unit staffed by nurses. The outpatients department would become a one-stop clinic. Diagnostics would offer plain X-ray film, ultrasound and barium meals, but provision of a computed tomography scanner and a magnetic resonance imaging scanner would have to be assessed.

Analysis of what that means shows, however, that cardiac medicine, including the coronary care unit, dermatology, endocrinology, metabolics, gastroenterology and renal and respiratory medicine would be taken away from Angus. It is death by a thousand cuts; it is like going through the jungle with a machete. General surgery, including emergency and elective surgery, breast, colo-rectal, dental, endocrine, ear, nose and throat/ oral, gynaecological and vascular surgery, would all be taken away. Elective and trauma orthopaedic surgery would go. In oncology, chemotherapy would go. As I said, the provision of care of the elderly, including a stroke rehabilitation unit, would depend on the outcome of the assessment. I have already mentioned what would happen to the accident and emergency department. The laboratory service would be reduced to a hot lab and actual diagnostic services would be subject to discussion.

That is only a glimpse of what the health board might provide in a "new hospital". It would be an acute ambulatory care centre, not a hospital in the way that that is understood by the public. People think that the board is not so bad, but the new hospital would be very different from what people imagine—it all depends on what you think constitutes a hospital.

In short, the reality of what is being offered is a Stracathro that is a shadow of its former self. It would be a diagnostic centre with ambulatory patients, with an enhanced community hospital elsewhere in Angus—an enhanced infirmary, if you like.

Would you be opposed to that?

It would be a severe reduction in services. Ronald has just read out all the services that would be removed from Angus.

My point relates to Mr Macdonald's submission in particular. He mentions the report "Acute Care Futures in Angus" and talks about the poor condition of Stracathro hospital and the lack of capital investment in it. He points out in his submission that the report noted that the hospital

"had a life span of five to ten years."

The report further noted:

"Backlog maintenance was estimated at £4.5 million."

Given those conclusions in the report, are you certain that patient services would not be served better by change? Are you confident that patients will be better served by continuing to plough money into a building that the report tells us has a lifespan of five to 10 years?

We are coming to the end of these witnesses' time, so it would be helpful if we could speed up our questions and answers.

I have a copy of the report here, which I will make available to the committee. The latest board documentation follows on from that report.

Agenda Consulting was commissioned by the former Angus NHS Trust to do the report. Agenda Consulting is now playing an active part on Tayside Health Board. People do not spend a lot of money getting a report such as this done only to throw it in the dustbin. The report is still continuing, and if it were not for ferreting—I am nicknamed the ferret by the way, in connection with getting information from the health board—we would not know about it.

There must be openness and transparency, the public have a right to know and the board and the trust have a duty to ensure that the public get that information.

On consultation, Ronald Macdonald gave an example of a personal request for a copy of the report on assessing secondary care for patients in Angus, and you say in your submission that a copy of it was declined, on 11 June. Will you comment on that?

The AMASS submission gives an example of a patient who left Montrose at 9 o'clock in the morning and was seen by a doctor in Ninewells at 6 o'clock at night. How do you feel that the reduction in services at Stracathro has affected the provision of service and the waiting time for people in Dundee?

There has been mismanagement, a decline in morale, and lack of trust. Once this is all over and there has been a positive outcome—we hope— will it be possible for the trust and the health board to regain the trust of the patients and the people of Angus, so that there can be a working relationship that will be beneficial to all in future?

On the first question about 11 June, the reason given for my request for the Jones No 1 report being turned down was that it named names. I could not even have sight of what the general direction of the report was. I managed to get hold of the Jones No 2 report, which told me what Jones No 1 was about anyway.

I refer to the example given by my colleagues in AMASS, of people leaving Montrose at 9 o'clock and not being seen until 6 o'clock in the evening. If provision at Stracathro reduces, that problem will be magnified greatly. We are having problems with the ambulances. There will have to be a major investment in ambulance services to get people to the centre. Once they have been seen, there is a backlog of people waiting for the patient ambulance to take them back. Sometimes a detour is necessary. If people stay in Montrose, they can be lucky sometimes and go via Arbroath, or they might go up the glens. If it is a bonnie day, it is not bad.

That is where I come from—I know how bonnie it is.

I refer to the question about regaining trust in the health board. We will have to wait and see what its next review says. There will be a community services review now that the acute services review has finished. In June, there will be a combined acute services and community care review. By that time, I do not know whether there will be any trust left to regain.

Do you think that the trust and the health board have learned any lessons?

They have learned the importance of communication. Communication is an asset in any organisation. Having spent 30 years in the health service, and having worked at Vernonholme, communication has always been my maxim. If you do not communicate, nobody knows what you are doing. You cannot have a secret service.

Can I make a point about the ambulance? It is relevant.

Kay Ullrich can ask her question—it might include other issues.

In your answer to Mary Scanlon, you mentioned the ambulance service. I have to say that in the submission by AMASS, that was the issue that stood out for me. Given that 25 per cent of the population are elderly, I am concerned not only about future ambulance provision—is it adequate at present for people who currently have to go to Ninewells?

The answer is no. At the moment, between 6 o'clock at night and 8 o'clock in the morning, one ambulance serves both Brechin and Montrose, which are 8 miles apart. More and more GPs are telling patients—I could give you a list of cases—that it would be quicker to take the person to Ninewells themselves. Stracathro is 12 miles from any point in Angus and Mearns, so it is 10 minutes away. The difference between that and the distance to Ninewells is frightening, and it adds to stress for elderly people.

Elderly people tend not to be car owners or car drivers.

That is correct.

My concern is that there is currently a problem with ambulance provision, and I would like that to be registered.

I am intrigued by a submission from the Brechin Advertiser, which refers to Stewart Mowatt and Ronald Macdonald, who are here today. Would you say that you emerged from a meeting with the trust medical director, Dr Derek McLean,

"much more positive than before our meeting took place"?

That is a quotation from Derek McLean. Is that true?

No, we came out the same way as we went in—depressed.

Just a little bit older.

The Brechin Advertiser says that when it sought corroboration from the two members of the association,

"we were informed that this was, at best, an over exaggeration."

So you were not much more positive after meeting Dr McLean?

No, we were less positive, because he revealed that the coronary care unit survival rate at Stracathro was one of the lowest in Scotland, because it did not have clot-busting drugs. I wrote to him subsequently and asked what he was going to do about it. I do not see why people in Angus who are admitted to the coronary care unit should receive a second-class service. The service should be equal across the region.

So you did not emerge encouraged in any way from that meeting, but Dr McLean has represented you as such.

Sometimes it is on those small points that we get close to the truth.

You have read out a catalogue of cutbacks and closures. Will you give us an idea of the consequences for the local population, in terms of employment and facilities, if the closure goes ahead?

Has the ambulance problem been addressed by any of the authorities involved?

I will answer that question, as I am the local councillor for the area.

Stracathro is one of the major employers in the north of Angus. It provides direct employment for the staff working there and additional employment for services for those staff. If Stracathro hospital were to be closed, it would have a devastating effect on the north Angus population.

There could be an increase in ambulance services, but that is not happening. Social work and police services are all stretched to the limit—they have to go to Ninewells because of the removal of many of the services that were at Stracathro. Those services are all stretched and are finding it difficult to continue to give the support that is required.

I will go back to the issue of consultation, as it seems to be fundamental. Your group has been established since 1991. If I understand you correctly, you are saying that the local health council has not served your needs. Have you gone to the annual general meetings of the local health council? Have you attempted to get people on to the local health council? It should have been consulting you, but you should also have been involved with it. Will you tell me about that?

The relationship is not unfriendly. At one point, a member of our committee was a member of the health council. It has not been possible for us to attend those meetings. For a start, we have not known when they take place, and because the council covers the whole of Tayside, the meetings can be a significant distance away, for example, in Pitlochry. It has therefore not been possible for us to attend health council meetings to any great extent.

I have made it clear in the past that I do not in any way castigate the health council. It has an extremely difficult job because of the amount of work that it has to do and the few members that it has. It receives a huge amount of paperwork and submissions from the health authorities.

On consultation, on 1 April when the two new trusts were set up, contrary to the way in which Tayside University Hospitals NHS Trust has carried on, Tayside Primary Care NHS Trust almost immediately offered to meet us at the Brechin and District Patients Association. It did so, and we agreed to meet every six months. I spoke to the chairman's secretary the other day: she said that we would have to arrange a further meeting.

The primary care trust certainly seems to understand communication; I do not think that the acute trust does. I am much more cynical than Ronald Macdonald—I do not think that the acute trust has learned its lesson on communication; there is an arrogance in the health service, particularly in acute care. One thing that is not taken on board—apart from straightforward communication—is the fact that, whatever those people think as clinicians, they must, in a democracy, take on board what the public want. If the public say, "This is what we want," that must be given attention.

I have assurances—

Just to come back to consultation: very recently, Sir William Stewart openly reported through the newspapers that all board meetings are open to the public. I would like to know how many people have known that. That is another thing that has never been offered to the different organisations.

As Hugh Henry says, we will probably return to the whole issue of health boards in the health service—

Can I immediately correct—

Three other members want to make points and we are already five minutes over our time. I am sure that you understand that we want to talk to the health board and the health trust in the time that is available.

Ben Wallace and Brian Adam have assured me that they have short points, so I will ask them both to make those and then wait for them to be answered.

The Government has a strong strategy of access. Do you see a conflict between the health boards—on the closure of Stracathro—and that policy, as far as it affects Angus and the Mearns? Secondly, the last paragraph of page 2 of Mr Macdonald's report begins:

"Correspondence received by Brechin and District Patients' Association . . . advised that:-"

and a quotation is then given. Can you tell me what correspondence that was?

I will ask Brian Adam to put his question, and that will have to be it.

Given that there are problems already, and taking into account the new proposals, the ambulance service will have to be enhanced. Has the service indicated that it will attempt to recover any of its costs in any way?

I think that Mr Welsh could answer that.

It has given us no assurance about any more money to cover the increase in the ambulance service. Funding for all the extra costs will be expected to be found from—I do not know, there is nowhere.

There has been no provision for the increased cost of patients going to Ninewells hospital and back. I do not know where everybody is expected to find all the extra money from.

Access to Stracathro is excellent, from all directions. The service provided at the hospital in Aberdeen can be supplemented by taking cases from there to Stracathro just as easily as cases can be transferred from Dundee or Perth. With the new flyover on the A90, the access is second to none, and there are no traffic congestion problems.

The Jones No 1 report recommended the immediate planned closure of various departments and their integration into other trust buildings. That would cause immediate public uproar, but a gradual phasing-in should overcome that.

I asked Paul White the specific question about trusts at a meeting in Brechin City Hall. His response from the platform was that the document had no life—it was dead.

It would appear from what was originally thought that, until now, closure has almost been phased in, in a sense. I maintain that there is a hidden agenda.

I tried to get the Jones report, as you know.

I am afraid that I will have to close this part of the meeting. We could ask you a lot more questions, but time has caught up with us. I thank you, gentlemen, for your oral and advance written submissions to this meeting. We will examine this matter again at our next meeting on 1 December—we are simply taking evidence from witnesses this morning. Thank you for your time.

We will now hear witnesses from Tayside Health Board and Tayside University Hospitals NHS Trust.

I welcome you to the Health and Community Care Committee. You have asked to make a short submission each. We have time only for very short submissions, but I think that a couple of minutes each will be acceptable. We will then have a series of questions. In answering the questions, I ask you to be as concise as possible. I ask the representatives of the health board to kick off.

Thank you very much, convener. I will not introduce my colleagues now, as time is short, except to say that I am accompanied by Miss Jeanette McMillan, also from Tayside Health Board.

The health board has responsibility for assessing the health needs of the whole population of Tayside, which is 390,000 people. The Tayside University Hospitals NHS Trust provides services to an additional population from north Fife and south Grampian, covering a total population of 450,000. Tayside Health Board spends about £180 million a year on acute services, which is slightly above the Scottish average. As you may be aware, the board will be a loser under the Arbuthnott report's recommendations, if they are accepted.

Acute secondary services are provided in Tayside from three main sites: Perth royal infirmary, Ninewells hospital in Dundee and Stracathro hospital in Angus. The trust provides a comprehensive range of services from those sites, with the exception of cardiothoracic and specialist children's services. Most of the regional in-patient services are provided at Ninewells, but there is an extensive network of out-patient services across Tayside, for example in Pitlochry, Brechin, Crieff and all the Angus towns. Waiting times are close to the Scottish average and we have made good progress in meeting the Government's waiting list targets.

Tayside Health Board provides high quality services, but we have some of the highest rates of referral and treatment in many of our specialties, compared with the rest of Scotland. Tayside Health Board is one of a number of health boards that are currently undertaking an acute services review following the publication in 1998 of Sir David Carter's national acute services review.

The board decided that there was a need to undertake a local review of acute services and to examine our requirement for acute services over the next 10 years. In my submission to the committee I have set out the remit of the review, which will ensure that the people of Tayside and Fife are offered the highest quality of health care within the resources available to us. It will consider the nature and range of emergency and non-emergency care that will be delivered in various sites in Tayside, including the location and distribution of in-patient, day-case, out-patient and support services.

We need to consider the role and impact of new methods of care delivery, including information technologies and the emerging new medical technologies. We must also consider the provision, type and location of community services.

The review is about examining the nature of all the health services in Tayside, not just acute hospital services. We must consider the whole range, from referral from general practitioners into hospital and back into the community for rehabilitation and follow-up care. The review has been clinically led by Professor Roland Jung, and nearly 200 clinicians from both primary and secondary care have been involved in the process.

The results of the review will be presented to the health board in the middle of December. It will contain a number of strategic options. No decisions have been made on any aspect of the review at this time and the board will need to evaluate them. Those strategic options will then be the subject of formal public consultation next year. The health board's role is to ensure that we provide safe and effective services to the whole of the Tayside population.

Thank you. We shall now hear a short contribution from Paul White of the Tayside acute trust, before asking questions.

I want to stress that Tayside University Hospitals NHS Trust supports the clinical services at Stracathro hospital. It is our responsibility to provide acute hospital and outreach services for the whole population of Tayside, including the residents of Angus.

As the committee has heard this morning, there has been concern for many years among the population and the staff about the future of Stracathro hospital. There has been tension in Angus, caused by perceptions of how the health board might deal with Stracathro hospital. Over the years, the hospital has lost many services. In the past two years, further services have moved, mainly because of the loss of some consultants and the suspension of two of the surgeons, including the medical director of the trust. Those staff losses caused a shift of clinical services from Stracathro to Ninewells hospital for reasons of clinical safety.

That is the background against which Tayside University Hospitals NHS Trust came into being on 1 April, when it assumed responsibility for Stracathro hospital. We also inherited a significant funding shortfall from each of the three predecessor trusts, which has been exacerbated in the current year by the major increases in demand pressures to which I have referred in my written submission.

The status quo was therefore not an option for the trust board. For reasons of clinical safety, for reasons of sustainability of services and because of the resource constraints on the trust, we had to make decisions about Stracathro hospital. We could not await the outcome of the acute services review, as it is likely to be well into 2000 before decisions are made on it.

We are introducing changes to the ward configuration and to staffing levels, which have brought benefits to the way in which services are configured in Stracathro. The clinical services there are now part of a Tayside network and are being managed on a Tayside-wide basis, linking into other clinical services. Many of the consultants in Ninewells are going out to Stracathro to support the services. Earlier this week, the director of medicine confirmed that four of the physicians and a number of the surgeons will be going out to support services there.

We are committed to the services at Stracathro. We have communicated with our staff, with MSPs, with the local council and with the health council about the changes and the reasons for them. In the circumstances, we believe that we have done what we could in the short time the trust has been in existence to stabilise services. We are not trying to pre-empt the review. The changes are not irrevocable and we are interested in providing safe, sustainable and affordable services at Stracathro.

One of our main concerns is about consultation, so I want to put one question to the board and one to the trust. Representatives of Angus and Mearns Action to Save Stracathro said that they had been refused a consultation meeting in either Montrose or the Mearns about the review. I would like the health board to tell us why those meetings were refused and what consultation meetings have taken place.

Concerns were raised by staff, who said that there had been minimal consultation. It seemed that information had not been given except in response to articles in the media, so I would like the trust to comment on that.

We were keen to engage with the community and with the public of Tayside throughout the process, and we have done that in a number of ways. In September, we held five public meetings. Prior to that, at the invitation of the Brechin and District Patients Association, we also attended a public meeting. There have been other requests for public meetings in other parts of Tayside, but we felt that we could not continue with that process because the people who were involved with it were also the people who needed to get on with completing the review.

We have not been consulting on proposals. Unusually for the health service, we have gone out to explain to people what we are doing and why we are doing it, before getting together any proposals to put to them. The official public consultation will take place in the new year, once we receive the report.

A meeting was refused in Montrose and the Mearns. Were there any other areas that asked for a meeting and did not get one? Will they get one at the next stage of the consultation process?

We had requests from Montrose and from Crieff, in Perthshire. We felt that we were spending a lot of time and energy on meetings. We have issued 100,000 leaflets and invited people to write in, and we have involved the health council heavily in the whole process. We are also undertaking a survey of public opinion on health issues across the whole region. I expect that, in the new year, there will be meetings in Montrose and Crieff.

The consultation with staff took place over an extended period of about six weeks and resulted in a change in the proposed plans for the hospital. Alternative plans were put forward by the staff, and Mr Townell, the associate medical director, led staff in considering them. As a result of that consultation period, from August to the beginning of October, the plans were modified to those that we are now implementing.

Did you say that it was the associate medical director who led the human resources discussions?

No.

Were there HR discussions, and who led them?

There were, and they were led jointly by the director of HR, Peter Murphy, and the then general manager of Stracathro hospital, Ann Pearson. The role of the associate medical director, Mr Townell, was to consider from a clinical perspective the possibilities for reconfiguration in Stracathro hospital, as distinct from the implementation of those proposals, which is where the general manager and the HR director were involved in discussions with staff.

Do you believe that the HR strategy is central to the way in which you deliver your services so that the staff are fully aware of what is happening?

We do—very much so.

So why are you doing it separately?

We are not doing it separately. We spoke to staff when the initial ideas for changes in service were developed. It would not have been possible to speak to staff before that.

Why not?

We needed a plan to develop some idea of—

The HR strategy document on the NHS in Scotland called "Towards a New Way of Working" is emphatic that staff should be involved from the planning stage right through the process. You seem to be saying that your approach is to formulate the plans and then consult the staff.

That was not our approach. An initial idea about a change in configuration was developed by Stracathro hospital staff into the series of plans that are set out in the document before you: five options for surgery and three for medicine. Mr Townell will confirm that the staff consultation took account of the required changes and the possible impact on jobs for Stracathro staff.

What levels of staff are you talking about?

That information came out as part of the plans.

Are you talking about nurses, doctors or ancillary staff?

I would like to answer that question. I am primarily a urological surgeon, not a politician, and have been affected by this situation in Angus as well as the rest of the staff. We all feel great distress at the long-perceived continual threat of possible closures in Angus—where I have worked for 15 years—from all sorts of areas such as the Scottish Office and even the NHS in London. The threats have created paranoia about the closures, which has been spelt out in some of the submissions—for example in the phrase "death by a thousand cuts".

Let me make my position clear as a surgeon, not as a politician. I became associate medical director only in October, purely to co-ordinate and continue the changes, and I found that the wards were basically half full. Because medical staff had left and the two suspended surgeons had remained on the payroll, it was not possible to re-appoint consultants in a fixed capacity. That raises significant health care issues.

Patients admitted in acute surgical circumstances are being treated by locums whom GPs do not know—GPs usually refer patients to surgeons they know—and who may or may not be good. As a surgeon who stayed at Stracathro where two colleagues had been suspended, how could I look after a hospital that was regularly being staffed by people who were coming in from outside on a temporary basis? That is an issue for Government.

Staff morale has declined because of the history of the situation and the fact that services have been taken away from the hospital. Everyone can see that. Because the wards were partially full, the nurses said that they were being deskilled. As a result, the atmosphere was not good and nurses were leaving. That nasty background goes back before 1996. Even when I arrived at the hospital, someone said that I would be there only three years anyway.

I want to stop you there. We are really tight for time and I have eight or nine colleagues who want to ask specific questions.

I am pleased that Mr Brett wants to examine the whole range of health services in Tayside, because two areas of concern raised in the submissions suggest that such a review should happen. The first is the financial crisis over Tayside Health Board's £12 million deficit. The feeling is that Stracathro is paying more than its fair share for the deficit.

Furthermore, a submission from Stracathro staff action committee says:

"The Chairman and Chief Executive of Tayside Health Board have repeatedly stated that no decisions will be taken about the future of Stracathro until the acute services review is published. The Medical Director of Tayside University Hospital Trust has said that Stracathro will close within eighteen months".

Will you comment on both those areas of concern?

In answer to your second question, Tayside Health Board has not yet received any proposals about the future of acute services in Tayside, including Stracathro. Although I am aware that Dr Derek Maclean has made his personal views known in the past, the matter will be decided by the health board and the minister. I hope that that clarifies the point.

The Stracathro staff action committee submission also says:

"It is minuted that the Joint Consultative Committee of Tayside Health Board on 2/9/99 discussed the ‘proposed closure of Stracathro hospital'."

Those words were used by staff members of that group. We have made it clear in every meeting that no decision has been made.

Are you saying that the medical director of Tayside University Hospitals NHS Trust has been making personal statements that Stracathro will close within 18 months?

I am aware that Dr Maclean has made that statement. He has not taken any active part in the acute services review.

Will you now answer my first question about Stracathro bearing the burden of a deficit through no fault of its own?

Mr White has referred to the serious and severe financial pressure that the university hospital trusts are under. However, the primary care trusts in Tayside, like other trusts across Scotland, are also facing problems because the cost of drugs in the UK has increased. As Paul White has indicated, the trusts have inherited a number of well-publicised problems and difficulties, which we and the trusts are actively trying to resolve. A series of complex issues has arisen based not only on problems that the trusts have inherited and on difficulties of which we and the trusts were not aware, but on the severe pressure caused by the additional demand for high-cost emergency areas of service.

But can you answer my question about the death by a thousand cuts at Stracathro? Many submissions have suggested that the hospital is being asked to pay towards the £12 million deficit.

We expect both of our trusts, particularly the university hospitals trust, to provide safe and efficient services. However, if they can provide those services and still make savings, we expect them to do so, as long as there is no change to the location or volume of services. Tayside Health Board carefully examined the trusts' proposals. We asked them a number of questions and were satisfied that their actions would meet our requirements and would not compromise the acute services review.

So I am not going to get an answer to my specific question about Stracathro.

Stracathro hospital is not bearing the brunt of meeting the trust's £12 million deficit.

Have the changes at Stracathro hospital been financially or clinically driven?

The changes were clinically driven, but we also need to make financial reductions in the costs of services. We are responsible for living within the resources given by this Parliament and voted in the current year by Westminster. The trust board has a dual responsibility to provide safe clinical care, but within the resources that it has been given.

I want to turn to that point about safe clinical care. I call Dr Richard Simpson.

I am interested in clinical safety in relation to the specific closures at the end of August. The staff side representatives say that they were not consulted and that they first heard about the amalgamation of those wards—or whatever happened on 23 August—through the media. Their central complaint is that they were not consulted. From what you were saying, there appears to have been plenty of consultation from August—although you did not specify when—to October and Mr Townell has been conducting that consultation with staff. The staff are complaining about what happened prior to that. What consultation took place before the amalgamation of wards?

The amalgamation of wards has not yet taken place—we are in the implementation phase now. I think that 24 August was the day on which the executive directors said to staff, "These are proposals that we would like you to consider and we would like to hear your views on them."

On 23 August, The Courier and Advertiser ran an article—the story was picked up from someone—about the possibility that there might be changes at Stracathro hospital and reductions in bed numbers. That happened on the day before the executive directors had planned to go to Stracathro hospital. It was unfortunate and it is certainly not the way in which we would have liked it to happen. However, that is a fact of life in the service in which we work, which is a democracy, as the country is a democracy. We do not gag people to prevent them from speaking to the press. I assume that a member of staff spoke to the press, which ran a speculative story. Members who read the article will see that it was written in a speculative manner.

I understand the financial issues and I understand the bed occupancy problems, which have been graphically described. What were the safety issues that led you to make these closure proposals?

The safety issues go back to the previous year, when surgical staff were suspended and the clinical care of major surgery, cancer and intensive care patients, for example, was transferred to Ninewells hospital. The resources to care for those patients—the nurses at Stracathro hospital and some of the other costs associated with that care—did not transfer at that time. Ninewells hospital was left to provide care for the transferred Angus patients without resources transferring at the same time. We are belatedly switching those resources to where the patient care is now being delivered. That was the key safety issue.

Was that decided when the surgeons were suspended? That was the point at which things really started to go downhill. At that time, did the board and the trust determine a strategy to cope with the situation in the medium to long term? In other words, was there a plan that was discussed with the staff as to what was going to happen after the two surgeons had been suspended, in terms of locum replacements or whatever?

I was not in Tayside at that time—

I am asking the health board that question.

There was discussion around the short-term arrangements, to which Mr White has just alluded, for emergency surgical admissions to be transferred to Ninewells. As part of those discussions, the situation was taken into the acute services review, as we were well aware that there had to be a medium-term plan and a long-term plan for the delivery of services for Tayside residents, including the population of Angus. As Mr White said, these key issues will be progressed in the acute services review.

That does not really answer my question. The surgeons were suspended in August 1998 and that is the point at which the situation started to go badly wrong—no one could have foreseen that. At that point, what was the medium-term strategy? I understand the immediate strategy, as you had no choice but to transfer patients to Ninewells. However, the situation was then allowed to drift on into the acute services review, which Stracathro then perceives as the permanent removal of those services. What medium-term strategy—on which you had consulted—did you have for those services?

As Mr White indicated, the medium-term strategy was that consultants from Ninewells agreed to go up to provide services at Stracathro. We faced the difficulty that we had no idea how long it would take to carry out the review and to come to a conclusion about the two surgeons. At the time, everyone thought that those situations would be finalised much quicker than they were.

On the one hand, there has been a period of limbo, almost, because you decided to have short-life working groups that came up with suggestions and conclusions, including the proposal to maintain services for a three to five-year period, while long-term provision was considered; on the other hand, you have not maintained those services. Rather, you made changes to them while the acute services review was under way. By your own admission, the acute services review has extended beyond the period that you expected. Instead of waiting for the outcome of the review, you have been making changes.

At the time, changes were made in emergency surgery and major surgery in particular, which had to transferred—immediate decisions had to be taken. Consequently, some emergency medical care also had to be transferred into Dundee. The board and the trust have tried jointly to stabilise and maintain the situation at Stracathro until the acute services review produces its recommendations in a few weeks' time.

I wish to pursue that point. From my reading of these submissions, it appears that you have pursued negative issues, such as ward amalgamations or the closure of the stroke rehabilitation unit, merging the unit with other services. However, when the short-life working groups have proposed taking on staff or making a variety of changes, including changes to the water system, such proposals have not been followed through. While you are pursuing negative suggestions, you do not seem to be following through positive suggestions that might maintain, or even improve, services at Stracathro. You present a very negative picture.

I will try to correct that impression, as it is wrong. The positive side is that we have asked consultant staff from Ninewells hospital to go out and support services at Stracathro. As a trust, we were very concerned about the quality of care and the sustainability of services at Stracathro, where we were engaging a lot of locum staff to cover the senior medical posts. The trusts endeavoured unsuccessfully to attract permanent staff to radiologist posts—people were not attracted to those jobs. There is a scarcity of staff in many specialities around Scotland and therefore people can choose which job they want to go to. I would be concerned if the committee left the meeting with the view that we have done only negative things, as that is absolutely not the case.

Even if we had decided to install the computed tomography, or CT, scanner in April, we would have had to go to the European journals to advertise competitively, because of the scanner's cost, and that would be just to buy it. The installation costs would have been about £300,000 to £400,000. The running costs to keep the scanner going 24 hours a day—there is no point having it unless it covers emergencies—would have been in excess of £500,000 per annum. As I indicated, we are under severe pressure to maintain the existing service base, and cannot expand it.

The infrastructure at Stracathro, as the Angus GPs indicated, requires significant investment. The hospital has no piped sewage or water. I am aware that Andrew Welsh has asked many questions in the Parliament about the state of the infrastructure in Angus—the infrastructure is awful, terrible. Ward 8, where the stroke patients were being looked after, is an appalling environment in which to care for patients. The trust is concerned about these issues and is trying to do something about them. I do not want it to be said that we are not concerned and that we do not want to take positive measures to help the hospital.

There is an endowment fund of almost £1 million, which could have been spent on the stroke unit, but which was not.

That is correct, but I think that that was the right decision. It would have been crazy if we had spent almost £1 million of publicly donated money on a ward when the future of the hospital is still uncertain. [Members: "Aha".] I am not trying to make any secret about this—the future of Stracathro has been uncertain for 20 years. I am desperately anxious to get a decision about the hospital's future. If it is to have a future in Angus, we must invest in it. We cannot continue to provide patient care at Stracathro without investing in the infrastructure. That would not be acceptable.

I want to pick up on Richard Simpson's point about the medium-term strategy. I understand the logic of incorporating that into the acute services review. If you want to include in the review the recommendations for what you call service reconfiguration that were made on 28 October, which will mean a cut of something like £500,000, the closure of two wards, the loss of 30 staff and 50 beds, that is fine, but why would you make that pre-emptive strike in October?

As I indicated in the written report, the decisions on the acute services review are unlikely to be made until May next year at the earliest. If there is political scrutiny of the bill, the decisions will not be made before the latter half of next year. It is impossible for us to sustain safe clinical services without making some changes.

That gives the impression that you are making the cuts so that, when the review comes round, it will be too expensive to go back on what you have done. It looks like you are trying to run down the hospital.

I appreciate how that impression has arisen, but I repeat that none of the changes is irreversible. However, we need investment in the infrastructure if the hospital is to continue to serve the area.

Will starting up the services again not cost a disproportionately high amount? That will be a disincentive.

There would no more of a disincentive to invest in the hospital then than there is now. We are doing nothing to devalue the present infrastructure.

I want to establish the level of the competence of the management and the consultation programme. The trust's submission says:

"In the period, senior medical staff from both Ninewells and Stracathro made clear their grave concerns about the sustainability and safety of medical services in Stracathro hospital".

When I questioned staff, I found out that they had never been approached by members of their senior medical staff to say that they had concerns for Stracathro. Do you not find it odd that senior medical staff would not talk to other members of staff before going to the board? Who were the senior medical staff who came to you?

One of the physicians and one of the orthopaedic surgeons, as well as some of the senior consultants from Ninewells who had worked at Stracathro during the interim period that Mr Brett referred to. They were concerned about the quality of care at the hospital and the suggestion that major surgery might be reinstated despite the absence of CT scanning and intensive care, both of which the Royal College of Surgeons recommends as prerequisites for safe clinical practice for major surgery.

When did they come to you? Early this year?

Yes.

As Mr Townell said, Stracathro has had problems for 15 years. Good management is about consulting and creating trust. If it is felt that the hospital is on a knife edge, it is the management's responsibility to talk to staff, patients and patients' organisations—whom you failed to meet in Montrose—and reassure them. When the senior medical staff came to you, did it not occur to you to tell the staff what they had said?

We met the staff collectively and I have been through the wards many times to speak to the staff individually.

Did you do that after the senior medical staff had come to see you? Given that it was a major issue, did you not think to call a staff meeting?

I would like to bring in Lesley Summerhill, who is the director of nursing.

Many of the things that you have said that managers are responsible for are correct. When the consultants in Stracathro brought their concerns to the new trust, Paul White immediately set up a working group to look at how we could address those concerns and continue to sustain services.

Were members of staff on that working group?

Yes. There were also general practitioners from Angus and consultants from Dundee and Perth. We also had representatives from the local health council. The working party's remit was to consider ways of sustaining safe services in Stracathro. That cannot be done overnight. The fact is that activity in the wards was low. Nursing staff, particularly the nurses in the surgical unit, had small numbers of patients to deal with and were concerned about losing their skills. Many of them left the hospital because of that concern.

I am not saying that the working group can solve the problem overnight. My point is that consultation at all levels helps to remove the uncertainty. The morale in Stracathro is low and people are uncertain about their future. That is due to a failure of management. I have not questioned you on the acute services review because I believe that it is a matter for the board to deal with. However, the fact that the people on the ground in Stracathro are unhappy and insecure tells me that management has failed for the past 15 years. Do you accept that?

We have been responsible for Stracathro for eight months, not 15 years. We could only do the best that we could with the situation that we inherited on 1 April. Those of us in the trust have worked extremely hard to bring about stability. We inherited a situation that none of us would have chosen to start from, but we have tried to make the best of it. I recognise that there is uncertainty and mistrust, but that has built up over many years and cannot be changed overnight. I had never worked in Angus before and it was difficult to build up trust in a short period of time when the hospital was facing a crisis.

Communication is a major issue in a hospital with 7,500 staff. We can always work to improve it. I have a lot of empathy for the staff at Stracathro and I would like the committee to recognise that.

Given that you expressed those concerns, what effect do you think Dr Maclean's publicly proclaimed position on Stracathro has had on the credibility of your consultation?

I am delighted to accept Mr Brett's assurance that Dr Maclean is not taking part in the review, but will you further assure us that he will not take part in any decision-making process subsequent to the review?

Dr Maclean is the trust's medical director. The decision on the acute services review will be taken by the health board, of which Dr Maclean is not a member; he has no contribution to make.

Will he be involved in any way, such as in an advisory capacity?

He is not part of the review process.

Do you agree that his publicly expressed view on Stracathro will totally undermine the trust management's credibility in any consultation process with either patients or staff?

No. Dr Maclean is one of eleven members of the trust board and has expressed a personal view. He did so prior to the formation of the current trust. There are many more views around than his.

You said that Dr Maclean's was an individual view. However, he is part of the trust board and surely the organisation of the health service involves corporate objectives and responsibility. What action have you taken against that individual, given that he expressed a view—to the press, staff and patient organisations—that has destabilised your trust board?

I do not consider it as destabilising the trust board—

Undermining it?

I do not think so. As I said, Dr Maclean made those comments prior to the trust being formed—

No. The comments continue to be made.

I am not aware that Dr Maclean has made any such public statements. He is entitled to hold a personal view, in the same way as you or I—

Not as a member of the trust board, who receives his salary from public funds.

The trust board will not make the decision on the acute services review. We have a right—and a responsibility—to make decisions for operational issues within the trust. Dr Maclean, as a member of the trust board, will be party to information that we receive at board meetings and will participate in the process, using that evidence. He will help the board to make objective decisions.

Will he be bound by the board's decision, or will he continue to peddle his own views?

The board has a corporate responsibility, which binds all the individuals to corporate decisions about the trust.

We shall see.

You made the consultation process sound quite in-depth, but by missing out Montrose you missed out a major population centre related to Stracathro. That was a mistake, which I hope will not be repeated.

Will Tayside Health Board confirm that at a briefing meeting for all the Tayside MSPs—at which Professor Jung outlined his proposals for the future of Stracathro hospital—no mention was made of the cuts that were announced three days later? The health board and the trust knew about the cuts, but did not mention them to the MSPs. Is that consultation?

I described the consultation process earlier. We have had a number of briefings with MSPs to keep them informed. You are correct, in that no mention of cuts was made at that particular meeting. Mr White explained the circumstances behind that.

It was a private meeting, yet that crucial information was withheld from MSPs, who were there to be briefed. That is hardly the way to go about consultation.

In the past seven months, how many Tayside University Hospitals NHS Trust board meetings have been held in public?

All our health board meetings have been held in public. The trust board initially decided that it would alternate its board meetings, bimonthly, with the meetings of its policy and resources committee. Tomorrow, the trust board will consider an amendment to the standing orders to allow it to hold its board meetings monthly, except during periods of recess.

In the past few months, how many have been held in public?

Since the trust started, I think four meetings have been held.

So meetings have been held in private?

There are committee meetings of all trust boards that are not held in public. The trust has an obligation to hold its board meetings in public; it was at its public board meeting at Stracathro that the decision about the Stracathro wards was taken.

Was the Jones report on assessing secondary care services for the patients of Angus commissioned for the new Tayside University Hospitals NHS Trust?

No. It was not commissioned by the trust board. I established a working group, which I asked Dr Jones to chair, to try to give me some immediate feedback on the clinical concerns that Mr Wallace asked about.

So you commissioned it, and it was designed to inform the hospital trust as it approached problems such as Stracathro. Are you aware of the view, expressed in the Jones report, that

"there is no status quo option or an option that requires no investment of capital"?

You said that infrastructure is needed desperately at Stracathro, so why has the trust failed to invest in Stracathro's capital budget?

I referred to the report of the short-life working group, chaired by Dr Jones, in my written submission to the committee. The key points to come out of that report were investment and infrastructure, and the filling of the consultant posts. I have explained the difficulty we faced in attracting suitable candidates to those posts and I touched briefly on the amount of investment required for the CT scanner.

You said that investment was needed, but what have you actually invested? If I am correct, the trust's capital budget for 1999-2000, by project, does not even mention Stracathro hospital and the only investment that is outlined in the 1999 to 2004 implementation expenditure plan is £35,000 for a telephone exchange. You say that investment is needed desperately, but Tayside University Hospitals NHS Trust has not invested in Stracathro. Why not?

The trust faces a constraint on its capital budget as well as its revenue. However, it would not be a prudent use of public money for us to invest in Stracathro until we are clear which elements of the hospital will be used for the future provision of health care. The Stracathro site has significant unused elements; large parts of the hospital do not undertake patient care. We need to be clear about the nature of services that will continue to be provided following the acute services review, whether any enhancement will be made to those services and what building infrastructure will be required to support them. That is the correct sequence in which to make those decisions.

I put it to you that your failure to invest is pre-empting the decision of the acute services review.

If, as has been said, the buildings are in a bad state, why has Tayside Health Board allowed that to happen?

Responsibility for the buildings is a matter for the trust and its predecessor organisations. Only with the recent changes that came through with "Designed to Care" does the health board have to endorse capital projects formally. Of course, we are concerned to ensure that the fabric and sites at all health care establishments in Tayside are of the highest quality. However, as Mr White said, it is the case—in Angus in particular, but in other parts of Tayside as well—that some facilities need to be modernised.

Do you endorse the current plans, which are inadequate?

That will have to be your final question, Andrew.

Certainly, the capital is inadequate but, as I am sure you will appreciate, the trust—with our support—has to approach the Scottish Executive for capital funds. I cannot imagine that the Scottish Executive would approve the release of significant capital funds until we have resolved the future nature of acute services in Tayside.

So you have not invested in services—

Mary Scanlon will ask the next question.

May I ask one final question?

You have asked about four. I appreciate that you have a keen interest, but we have to move on.

If the trust cannot maintain the present hospital, what chance is there of getting capital to build a new one? Where will the capital come from?

Mary Scanlon.

The submission from the Stracathro staff action committee is a fairly damning indictment of your financial management. Can you confirm that Dr Maclean, the medical director, was given an 18 per cent salary increase to take his salary to £122,000? If he was given that increase in salary, on what basis was that given, bearing in mind the financial constraints that Stracathro is facing?

My second question is this: why was the Dundee royal infirmary, a prime site, sold for only £600,000?

Finally, the staff action committee says:

"High costs have been incurred as a result of suspensions and ‘gardening leave', and have required further expenditure . . . for example, a consultant in a badly-needed speciality . . . has been prevented from working for four years".

Have you utilised fully and managed appropriately the staff that you have, to retain the services at Stracathro, given that two surgeons left?

I think that you are straying with your first two questions, Mary.

They are about finance and management.

We could stray on to the general finance and management of the health boards and the acute trusts. That is not what we are here to do. We are focusing on Stracathro. Your second question, on staffing, is reasonable. You might want to add to that.

Yes. I shall add to that, but my questions reflect the concerns of the staff action committee, which has collected 25,000 signatures.

Tayside Health Board is to be wholly inclusive of stakeholders. Given that we are living in an open, honest, accountable, democratic society in which we work to forge partnerships—[Interruption.] Seriously, what we have seen this morning is the opposite of that. With the benefit of hindsight, would you do things differently? Given the strength of feeling that exists in the local community, looking back six or seven months down the line, what should you have done?

The two questions focus on staff relations and whether you would do anything differently.

It was always going to be extremely difficult to do what we have done, for all the reasons that you have heard this morning. The situation goes back 20 or 25 years. We will certainly reflect on the many messages, written and verbal, that we have received and we are considering how we should proceed with public consultation next year. It would be foolish of me to say that we are not going to learn from this. I am, in one sense, encouraged, as there is such interest in our health services. We are left in no doubt about how strongly communities in Tayside, not just the people of Angus, feel about their health service.

We are charged with the difficult task of trying to ensure that everybody in Tayside has access to high-quality, safe services. There are inevitably trade-offs between having local access and ensuring that all health providers have the expertise, as medicine becomes increasingly specialised. The difficulty is deciding how that can be achieved within the fixed budget that the health board receives.

So you would do things differently in future?

We would certainly want to review things. I have taken the point that some communities feel that we should have consulted them. We will certainly consider that.

Can you answer my question about the suspensions and the utilisation of staff?

We will make that the final question.

The suspension of which staff in particular?

The submission from the Stracathro staff action group says :

"High costs have been incurred as a result of suspensions and ‘gardening leave', and have required further expenditure on costly replacement locums."

Do you feel that you have adequately utilised the qualified staff that you have, to retain services at Stracathro?

Yes, I do. We have done so to the best of our ability. The two surgeons were suspended last year, during the time of the Angus trust. We were faced with a situation in which one of them had undergone retraining. In subsequent discussions with that individual, it was mutually agreed that he should take early retirement from the service. That happened last month. He was being paid his salary until last month, and has now taken early retirement.

I apologise, but we will have to leave it there. I am aware that we could have asked a lot more questions, but we have run out of time and must move on to our next agenda item.

I thank the representatives of the board and the trust for attending this morning, answering our questions and giving us their written submissions.

I suggest that we examine this evidence and consider a draft report in private session at our meeting on 1 December. Prior to that, I shall take some soundings and advice on what courses of action are open to the committee and to whom we should make representations on this matter. Is that agreed?

Members indicated agreement.

I also ask the committee to agree to hear item 2 on the draft Arbuthnott report in private today. We are still working on our draft report. I hope that our final draft report meeting will be on 1 December, but this should be the final substantive meeting. I suggest that the meeting on 1 December, on the Arbuthnott report, should be taken in private session. Is that agreed?

Members indicated agreement.

I suggest that we have a short suspension of business for a comfort break, and that we return in five minutes. We will then be on a tight time schedule.

Meeting continued in private until 12:53.