The next item of business is a statement by Shona Robison on NHS Grampian—Healthcare Improvement Scotland reports. As the cabinet secretary will take questions at the end of her statement, there should be no interventions or interruptions.
I call the cabinet secretary. You have 10 minutes, Ms Robison.
14:40
In March, the then Cabinet Secretary for Health and Wellbeing, Alex Neil, was made aware of concerns about quality of care and patient safety by a number of senior consultants at Aberdeen royal infirmary. The Scottish Government acted swiftly in response to that contact and within a week Healthcare Improvement Scotland had arranged to begin the first stage of the work that has culminated in the reports that were published on the HIS website yesterday morning: “Aberdeen Royal Infirmary: Short-Life Review of Quality and Safety” and the report on care for older people at Aberdeen royal infirmary and Woodend hospital.
A third report on NHS Grampian has also been produced by the Royal College of Surgeons of England. The board has published on its website the terms of reference and the recommendations arising from that review, but it has not yet published the full report because of legal action that has been initiated by individuals named in it. However, Healthcare Improvement Scotland has seen the report and has made its own recommendations to address many of the issues that the college raised.
The reports highlight significant failings in the management of NHS Grampian that, as the leader of the HIS review team has said, make sobering reading and which we take very seriously indeed. They also highlight the important role of the inspection regime that this Government has put in place to scrutinise safety and quality in the national health service in Scotland. This statement sets out the Scottish Government’s response to the findings of those reports and the action that we expect NHS Grampian to take both immediately and in the longer term.
It is important to make clear up front that HIS’s work did not identify consistent or widespread concerns about patient safety. Without minimising the importance of some of the concerns raised by the HIS reports, I note that the review highlighted that Aberdeen royal infirmary is not significantly different from the Scottish average for a range of indicators of quality and safety of patient care, including the hospital standardised mortality rate and infection rates. During the inspection of care for older people, patients and carers also provided very positive feedback on their experiences, with 89 per cent stating that the care that they had received was good and staff being described as “compassionate and considerate”.
However, the report highlights a number of issues relating to leadership, management and staffing that, if not addressed immediately and decisively, pose a clear risk to the quality of patient care. That they have not yet impacted adversely on the care of patients is, as the report makes quite clear, due to the hard work of dedicated and highly committed front-line staff who have gone above and beyond to compensate for weaknesses in NHS Grampian’s structures and processes. I put on record my sincere thanks to every member of staff in Grampian for their work in ensuring that their patients continue to get the best possible care, and I assure them that we will do everything possible to support them in making things better.
The review was a complex and thorough piece of work. Headed up by Angus Cameron, who is currently medical director at NHS Dumfries and Galloway, the HIS review team agreed with NHS Grampian that it would examine two main areas, the first of which was the culture, leadership, values and behaviours in operation in the board. Although such things can be difficult to pin down, they shape the day-to-day interactions in any organisation and are essential in supporting the on-going delivery of a safe and high-quality healthcare system. Secondly, the review team looked in detail at the actual quality and safety of care in a focused number of specialties and services, including the emergency department, general surgery and care of the elderly, with a clear focus on outcomes and the experiences of patients using those services.
The review team worked with NHS Grampian for more than five months and gathered information from a wide range of sources. In addition to analysing nationally available data, the team spoke to around 530 members of staff; received feedback from 362 patients and carers; reviewed 49 case files; looked at 32 complaints; and analysed 13 adverse events. Its work has created a rich picture of healthcare provision in Grampian.
The picture that Dr Cameron’s team has painted is a worrying one. The review describes a climate of mistrust between clinicians and senior managers in several specialties; unprofessional behaviour by a number of consultants that impacted on morale and the effectiveness of the service and which went largely unchallenged; and a failure to respond effectively to concerns about staffing pressures and vacancies. There is also evidence that managers were distant, trainees were inadequately supported, complaints were poorly handled and systems of governance and performance management were weak, muddled or, indeed, absent.
Make no mistake: those things are unacceptable in the NHS in Scotland, and they will be resolved. Let me send the clear message that, no matter who a person is or at what level they work in the NHS, the behaviours that are highlighted in the HIS review will not be tolerated in our national health service.
The key issue now must be how those findings are responded to. The report on quality and safety contains 13 recommendations, which are grouped under the headings of “Patient outcome”; “Leadership and culture”; “Governance and accountability”; “Staff governance”; and “Complaints management”. They are accompanied by 22 more detailed areas for improvement in the report on care for older people.
I visited Aberdeen royal infirmary yesterday and spoke to staff and the board to emphasise how much importance we attach to seeing real improvements being made. I was given assurances that NHS Grampian accepts every single one of the recommendations and that, under the leadership of its new interim chief executive, Malcolm Wright, it has already begun work to address many of those areas. The board has apologised for those instances in which its patient care did not meet the required standard and has committed to improving leadership, management and engagement at the ARI and across NHS Grampian.
The report highlights some particular concerns around nursing staffing levels and vacancy rates. The board is continuing to experience challenges around recruitment, with factors such as the high cost of living and the competitive job market contributing to the challenge. However, the board invested in the creation of 100 additional nursing posts in the year to March 2014 in priority areas such as theatre, the emergency care centre and mental health services. A further almost 100 posts have been added to the nursing establishment since March, and funding has been allocated for up to 40 posts in 2015-16.
NHS Grampian is also actively recruiting to vacant medical and nursing posts using every means at its disposal, including social media and executive search as well as more traditional means, such as medical careers events and graduate nurse recruitment, which resulted in 88 graduate nurses from Robert Gordon University being placed in 2014.
The HIS reports on NHS Grampian are challenging to read, but they must be seen as a vindication of our unflinching resolve to shine a light on poor practice through the systematic use of independent inspection processes, and to hold to account healthcare providers that fail to provide the quality of care that the people of Scotland deserve and the support that those who work in the NHS in Scotland have the right to expect.
We recognise that we have a role to play in supporting the board to improve, and that improvement will not happen overnight. The Scottish Government is providing record levels of funding to NHS Grampian to support its recruitment efforts. In 2015-16, NHS Grampian’s resource budget is planned to increase by 4.4 per cent, to £812.6 million—the increase is above inflation and is the largest increase of any board—and it previously increased by 4.6 per cent in 2014-15. Those increases include sums of £15.5 million this year and £17.5 million next year to move the board closer to its target share under the NHS Scotland resource allocation committee funding formula. The intention is that, by 2016-17, NHS Grampian, along with all the other territorial boards, will be no more than 1 per cent away from NRAC parity.
In addition to the financial support that we are continuing to provide, we have put in place a comprehensive support team to advise and work alongside the new interim chief executive and his executive team in implementing the improvements that are needed to strengthen key systems, structures and processes. That vital organisational development will be supported by an additional allocation of £100,000 to help to develop and strengthen leadership at all levels within NHS Grampian.
We are also fast-tracking the identification of a new chair for the board. Interviews are taking place today, and there is an expectation that the new chair will take up post very early in the new year.
The report of the quality and safety review makes it clear that the board is expected to develop a detailed and considered improvement plan that sets out exactly how it intends to implement the report’s recommendations, along with timescales for action and clear accountability. The plan will also be expected to set out clearly what success will look like. However, these are serious issues and although we expect immediate action to be taken in relation to several of the key findings, we cannot expect changes to culture and leadership to happen overnight.
The changes must be taken forward in partnership with clinical and staff-side representatives from the very beginning if they are to be woven through the fabric of the organisation—as we expect them to be—and we must accept that that will take some time. The Scottish Government will monitor the implementation of the plan very closely in the coming months, and I will receive regular updates on progress as work goes forward.
This has been, and will continue to be, a difficult and challenging time for NHS Grampian. However, by putting patient outcomes and patient experiences at the heart of its services—and with the involvement of the committed and dedicated staff who we know work in NHS Grampian—I am confident that NHS Grampian can turn the situation round and begin to live up to its ambition of providing top-class healthcare services for all the people of north-east Scotland.
Thank you. The cabinet secretary will now take questions on the issues raised in her statement. I intend to allow around 20 minutes for questions, after which we will move to the next item of business.
I thank the cabinet secretary for the advance copy of her statement. This week’s three reports into NHS Grampian and Aberdeen royal infirmary paint a grim picture of the NHS in the north-east: weaknesses at board level; poor management; low morale; bullying; lack of accountability; concerns ignored by managers; a staffing crisis; a system of cover that staff felt was unsafe; a surgical unit described as dysfunctional; patient flow and capacity at Aberdeen royal infirmary and Woodend hospital not fit for purpose and putting patient safety at risk; inappropriate boarding; ineffective discharge systems; and wards continually short-staffed—just some of the problems that were experienced.
Many of those issues are common across the Scottish NHS and not unique to NHS Grampian, but it is evident that there is a small group of consultants at Aberdeen royal infirmary who appear to think that they are above the rules that apply to everyone else. What will the cabinet secretary do to ensure that we have a culture in which systematic failings are evident early and a nurse, support worker or cleaner can raise concerns without fearing for their job, with action being taken to address those concerns; and which does not rely on a powerful group of consultants with a hotline to a friendly minister to expose failings that have an impact on the wellbeing of staff and patients? How does the cabinet secretary intend keeping not only the Parliament but, more important, the patients and taxpayers of Grampian informed of progress?
I reiterate the point that is made clearly in the report, which is that patient safety was not adversely affected by the circumstances in Grampian. It is important to reiterate that because we do not want patients to be afraid of using the services in NHS Grampian. The services that it provides and the results and outcomes for patients are as good as those in other parts of the health system in Scotland. It is clear that certain behaviours did not help to improve patient care, but the efforts of front-line staff who went the extra mile ensured that some of the management and clinician challenges that could have adversely affected patient safety were overcome.
On the small group of clinicians whom Neil Findlay described as thinking that they were above the rules, I said very clearly in my statement that no one working in the NHS—no matter who they are—is above the rules. That type of behaviour would not be accepted in any other workplace and it should not be accepted in the NHS. We will absolutely ensure that those issues are addressed. Neil Findlay will understand, though, that a number of processes are emerging from the report, including the General Medical Council looking at the issues and the internal processes of NHS Grampian, which will have to take their course in addressing the behaviours of individuals as the investigations go forward. However, I can assure him that that is exactly what will happen.
On whistleblowing, we already have processes that encourage anyone working in the NHS who has concerns, no matter who they are, to raise those concerns, and that is exactly what people should do.
On keeping the Parliament and, importantly, patients and the public informed, I certainly expect NHS Grampian, as it takes forward its implementation plan for change, to be very good at communicating the changes to staff, patients and the public, and I am happy to keep the Parliament informed, whether that is through the Health and Sport Committee or through an update to the Parliament on the progress that is being made in NHS Grampian.
I thank the cabinet secretary for the advance copy of her statement. For those of us who represent the north-east, the on-going problems facing NHS Grampian are both concerning and upsetting. The reports clearly point to a number of areas for improvements to be made.
NHS Grampian is, like health boards across Scotland, facing significant pressures from the increasing demand on health services and difficulty in recruiting and retaining key specialist and nursing staff, especially given the added pressures of the oil and gas industry.
Patients want to be reassured that, when they go into hospital, they will receive both first-class care and a well-managed service. It is reassuring that the reports about NHS Grampian are clear that, to date, patient safety has not been compromised, and that is due to the hard work of its loyal staff. However, a number of failures in strategic leadership have been clearly articulated. I know that that is being urgently addressed and I am pleased that NHS Grampian has already undertaken to act on all the recommendations that have been made to it.
However, Scottish National Party ministers are ultimately responsible for the NHS in Scotland and they must work to address the increasing problems that we are facing within our health service. Will the Scottish Government undertake a review of all current vacancies in the NHS Grampian area and look to publish an action plan to address staffing problems with the minimum of delay?
It is important that we are clear that NHS Grampian accepts all the recommendations without reservation and is going to act on them.
Nanette Milne highlights the increased demand for NHS services, which is absolutely a pressure on NHS Grampian in the same way that it is a pressure on other parts of the health service. Recruitment challenges, though, are a particular issue for NHS Grampian because of the issues that she cited in her question. We are looking at the use of the medical workforce bank. The nurse bank has operated successfully in other parts of the country and the medical bank has worked well in Lothian, and I know that NHS Grampian is looking at that as well.
On the management of vacancies, there are some specialties in which, for a variety of reasons, it is much harder to fill vacancies because of their challenging nature, 24/7 availability and the pressures, therefore, within those posts. Again, we are looking at how we can make those posts more attractive and potentially more flexible. We are working closely not just with NHS Grampian but with other boards to look at how we can address those difficult-to-fill posts.
The member can be absolutely assured that we are not just sending the new interim chief executive, who started in his job on Monday, to sort out these problems himself. He has a team behind him and he has a lot of support from the Scottish Government in taking forward all these issues.
I appreciate the interim chief executive of NHS Grampian meeting MSPs on Monday and the comprehensive briefing that we received there. I recognise that resources are in place to recruit for clinical and nursing vacancies and that there are funded plans to expand the nursing workforce even further. However, key workers often have difficulties in getting affordable housing in the area. How many houses will be allocated to health service staff on the Craiginches site and what further plans does the Government have to increase the number of affordable homes that are available to NHS staff in Aberdeen?
Kevin Stewart raises a really important issue. We have to look at how we can tackle some of the underlying recruitment problems, which are an issue not just for the health board but for the local authority as well. The cost of living in Aberdeen is without a doubt a critical issue.
I reassure the member that I have asked for an update on the plans and the discussions between the NHS and the council about the affordable housing solution. I will be very happy to share that update with the member and I will be happy to keep other members up to date on how the matter progresses. That is absolutely the type of innovative solution that we need if we are to be able to overcome some of the recruitment challenges in the public sector in Aberdeen and Aberdeenshire.
The cabinet secretary will be aware of the statutory duty of candour that applies in the NHS elsewhere in the United Kingdom, which would require publication of a report such as that of the Royal College of Surgeons, which she mentioned. Although such a duty does not exist in the same form in Scotland, will she, in the spirit of candour, urge NHS Grampian to publish the conclusions as well as the recommendations of the report as soon as possible?
How does the cabinet secretary intend to reassure individual patients that they will be told at the earliest possible date whether their care has been affected by the unacceptable behaviour of a small number of consultants, which was identified by Healthcare Improvement Scotland?
On the effect on individual patients, in its inspection the HIS team looked carefully at the issue to ensure that individual patients had not been adversely affected. There was a degree of follow-up on patients. I hope that I can reassure the member in that regard and I am happy to provide him with additional information, if he would find that helpful.
On the conclusions in the Royal College of Surgeons report, the member will understand that there is a legal process around the report, in that certain individuals who were named in it have taken legal action to stop it being published. NHS Grampian has to work through the legal issues to get to a position in which the report can be published at some point.
However, the main findings on the dysfunctional relationship between some clinicians and management and other clinicians are pretty much laid bare in the HIS report, because the HIS team had a copy of the RCS report and reflected that in its findings. I do not think that anything is preventing us or NHS Grampian from getting on and resolving the issues. People certainly do not have to wait for the publication of the report, and they are getting on with resolving the issues.
The member will be aware that a duty of candour is being considered in the context of the forthcoming public health bill. I think that we should be taking such a measure. Our whistleblowing procedures are good, but there is something about an explicit duty of candour that sends a clear message to the NHS. We will take the matter forward in the bill.
As we think about the serious problems of NHS Grampian and compare them with the tragedy in the Vale of Leven hospital, was not the essential lesson of the Vale of Leven tragedy that the health service must develop systems that enable problems to be identified before they impact on patient care and safety? Surely that has happened in this case, through Healthcare Improvement Scotland. For example, accident and emergency rates are vastly better in NHS Grampian today than they were in 2006.
The cabinet secretary put that down to the excellence and hard work of the staff of NHS Grampian, and she was right to do so. Is it not incumbent on every member of this Parliament to rally behind the staff and the new leadership of NHS Grampian as they take matters forward?
I absolutely agree with the member. Although a report can make uncomfortable reading, I, as the health secretary, would rather know where problems lie in our health service—warts and all—because only then can we take steps to address them. Before we set up systems of independent inspection we had no ability to look in detail at problems in the health system. The huge lessons that have been learned from the Vale of Leven are a case in point.
I absolutely agree that we should rally behind the staff. I got the sense yesterday, when I met staff at Aberdeen royal infirmary, that we have a group of very dedicated staff who were clearly under a lot of pressure regarding the reports, which make difficult reading. However, they had a resolve to go forward and to ensure that NHS Grampian can become one of the top-performing health boards in Scotland.
I met the board, and many of the non-executives were very keen to step up to the leadership plate and to help NHS Grampian become the top-performing health board that we all know it can become.
The cabinet secretary mentioned 100 additional nursing posts. The HIS reports are not the first to warn that wards must have not only sufficient numbers of nurses, but the right skills mix. What planning is the Scottish Government doing with NHS boards to ensure that the right people are in the right place at the right time, so as to maintain quality of care?
Does the cabinet secretary believe that, in these circumstances, NHS Grampian has the capacity to move at the pace that is required in order effectively to achieve the integration of health and social care?
I set out in my statement the nurse numbers and the additional investment in nurses. The investment is significant. However, the member is right with regard to the skills mix. I found it heartening yesterday that one of the care-of-the-elderly wards that I visited had absolutely looked into the skills mix. Not just nurses but allied health professionals and healthcare assistants were helping with some of the issues around food and fluids that had been highlighted in the reports, and were ensuring that those personal care tasks were in place. I am sure that I am not the only member who regularly sees that issue coming up in our mailbags. It is important to get the right skills mix, and we are helping boards to do that.
It is important for NHS Grampian and all the other boards to make progress on health and social care. Only by integrating health and social care, by preventing people who do not need to be there from turning up at the front door of the hospital, and by discharging people from hospital in a timely fashion if they no longer need to be there can we reduce some of the pressures on our acute sector, while giving patients a better experience. As we know, an acute hospital ward is often the last place where a vulnerable elderly person should be.
From what I saw yesterday, I can say that NHS Grampian is doing a lot of work to deal with delayed discharge. I have every confidence that the board will be able to take forward the integration plans.
We are extremely short for time this afternoon, and I will not fit in everyone who wants to ask a question. I urge short questions and answers.
Message received and understood, Presiding Officer.
Part of the responsibility of leadership at local level rests with the board. Does the cabinet secretary share my concern that the board appears not to have had a grip or sufficient proactive oversight of many aspects of the performance of the NHS in Grampian, and that it has contributed to some of the leadership vacuum that existed? How will she make clear to the new board chairman or chairwoman the expectations on the board to provide effective scrutiny of the issues and to challenge the executive of NHS Grampian?
Mark McDonald must have been a fly on the wall when I met the board yesterday. One of the things that I was asked by one of the non-executive members was what more those members could do around the board table. My answer was for them to ask questions, to scrutinise and to question anything that comes before them. As far as I am concerned, that is a key role of the non-executive members around the board table.
As I said in my statement, there is a fast track to get a new chair in place. That chair will have a key leadership role in ensuring that the board goes forward with renewed vigour, while supporting the interim chief executive.
I can reassure members that the view that I got from the board was that every person around the table wanted to take the opportunity to reset relationships in NHS Grampian, to reset the way in which they go about their business, and to get NHS Grampian back on track to where it should be.
The cabinet secretary’s predecessor said that NHS Grampian would be brought more quickly towards parity of funding under the NRAC formula if more funds were made available for the NHS by the UK Government. Is that still the Government’s policy?
As I laid out in my statement, with the significant additional investment—I must remind the member that such investment was not seen previously—by 2016-17, we will move to within 1 per cent of NRAC parity. That is a great deal more progress than was made in previous years. I would have hoped that the member would welcome that.
Patient feedback is important. I want the cabinet secretary to understand that many comments on the patient opinion website tell us about patients’ good experiences in Grampian. However, the Healthcare Improvement Scotland report highlighted the poor response rate to complaints made to NHS Grampian. How does the Government expect the board to respond to complaints and to positive patient feedback, such as through the patient opinion website?
The Government has provided updated guidance and training to all boards on responding to feedback and complaints. Yesterday, I made it very clear that that area needs to be addressed.
I reassure the member that the Government has provided support and worked with NHS Grampian to ensure that it not only responds timeously to complaints, but addresses them as fully as they should be addressed. That is a key priority. I will keep the member updated on progress.
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