Health, Social Care and Sport Committee

Meeting date: Tuesday, May 23, 2023

Official Report 759KB pdf

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Scrutiny of NHS Boards (NHS Shetland, NHS Eileanan Siar and NHS Orkney)

The second item on the agenda is a further session in our periodic scrutiny of front-line national health service boards. I welcome to the meeting Michael Dickson, chief executive of NHS Shetland; Gordon Jamieson, chief executive of NHS Eileanan Siar, who is joining us remotely; and Laura Skaife-Knight, chief executive of NHS Orkney. I welcome everyone on the panel and thank them for joining us.

We will move straight to questions.

I know from my time as a health minister that island boards frequently raised the challenge and associated cost of recruiting and retaining staff on the islands. How have your health boards met that challenge and what other challenges do you still face? Who wants to start off on that?

I would be happy to kick off, if that would be useful.

Thanks, Michael.

The principal challenge remains the same. We are faced with a workforce shortage that is felt across the whole of the United Kingdom and we as island communities have to be innovative in the extreme to be able to ensure that we attract and secure the right people. Some challenges relate to political decisions taken outwith us—obviously, the impact of leaving the European Union is felt not just in the NHS but across other sectors. Equally important, however, is the way in which the tax system works. If people are willing to come and spend time working in the island communities but have a home elsewhere, they are penalised if they are provided with accommodation as a benefit in kind. It is an interesting quirk of the tax system that people are penalised for wanting to come and work in different places.

Flexibility is key. We are seeing more and more people who are interested in a mixed career. They will have reached a certain point in their career or they will have had a pandemic wake-up moment and they want to give something back to society, perhaps from a global health platform or by teaching, or they want to travel. Offering people spaces where they can come to work and where they know that they will be employed for a time and then be able to go off and do innovative and exciting work before coming back to us, is an important way in which we recruit staff.

The islands still have challenges around housing, which is in huge demand. Suitable housing is also an issue. We may choose to try to recruit people who have families and who want to come and build a life in Shetland. We are having on-going discussions at the local authority level to see what we can do. NHS Shetland recently secured funding from the Scottish Government to purchase a former guest house, which we can use to provide good-quality accommodation for some of our peripatetic staff. Understandably, if a person is travelling up to do work on behalf of NHS Shetland, they will want somewhere nice to stay. They cannot be expected to stay in a run-down location.

We do and we will continue to face challenges. That is felt in the long-term use of high-cost locums. We are doing a huge amount of work to try to mitigate and ameliorate that but, fundamentally, that is likely to remain a consistent feature for now and in the future.

My observations are consistent with those of Michael Dickson. We face real challenges in the fragility of our medical workforce. As members can see in the submission that we sent in in advance of the meeting, last year alone we spent in excess of £6 million across agencies and locums. Our task this year is to try to reduce that wherever possible and convert that arrangement into substantive arrangements, notwithstanding the challenges that come with that.

I am pleased that your question put an equal focus on recruitment and retention. Recruitment tends to dominate conversations, but the focus must absolutely be on both. From an NHS Orkney perspective, we face additional challenges on top of the medical workforce challenges. Notably, some 22 per cent of our workforce are over the age of 56. We have a conundrum—a ticking time bomb, if you like—in that we need to address that retirement question now, rather than walking into it in the years to come.

In addition to the challenges in the acute setting, we have particular challenges in the community. As of today, we have 27 vacancies in our care-at-home team and some vacancies in social work and community nursing.

That said, as Michael Dickson said, that makes us think differently, creatively and innovatively. That is one of the many benefits of working for an island board. We have some success stories, in addition to those that Michael Dickson mentioned from an NHS Shetland perspective and which I will not repeat. We have seen real success in general practitioner recruitment. From a board perspective, we are up to full complement. Post-Covid, GPs have told us that they want to come back and really feel part of a community in an island setting, so that is a success story. From a child and adolescent mental health service perspective, we have moved from two members of staff to 10. We hope to get to 15 and are optimistic that we can do that. Building on the observation in my submission, I am pleased to let colleagues know that, yesterday, we recruited a GP with a special interest in dementia. Again, that bolsters the support that we have. I am sure that we will mention fragile services quite a lot this morning, but those are the kind of solutions that we need to put in place.

Finally, convener, you asked about some of the other challenges that we face. Fragile services go hand in hand with workforce challenges. Michael Dickson also referred to the chronic housing shortage. I am sure that Gordon Jamieson will mention this, but from an NHS Orkney perspective, we are forecasting a significant demographic shift over the next decade. We need to plan for that now; if we look at our clinical strategy, we think that we have done that. We are forecasting a 35 per cent increase, between 2020 and 2035, in those over the age of 65. The number of people over the age of 85 will double, which is significant. We need to start not just solving the issues that we face now but planning for the future.

Our experience over the years has been that although we want to attract and retain specific individuals, when people come to live, work and—we hope—stay in the Western Isles, it is really important to provide support for the whole family. A lot of people who have come for a job for one member of the family find that their partner cannot get a job, or that they do not have housing and or access to things like childcare. A complete package makes a difference to whether people live, work and stay—staying is the really important part. We try to support people with housing, and we have got a good relationship with the local housing partnership for accommodation prioritisation. We work with all our partners, and we help people with relocation and visas. At the moment, we are considering the local provision of childcare for 0 to 5-year-olds because, again, it is critical for our staff that they have access to childcare.

We try to bring about a whole package for each person who comes to work with us. It is really important that we are as flexible as we can be around working arrangements. Being carer friendly is also important, because people have broader responsibilities. As an employer, we find that the more receptive and supportive we are, the better chance we have of holding on to people for the longer term.

However, as you will have seen in my submission, the single biggest threat to health and social care services in the Western Isles is the alarming population decline. Our current vacancies, and the number of times that we have tried to recruit to different posts, mirror that population decline. As I said, though, we work with partners—it is a community effort—to get people here and keep people here. Similarly to Michael Dickson and Laura Skaife-Knight, we all work together.

What you are describing is how a whole-system approach of ensuring that there is childcare, housing and so on could be a double whammy: you would get staffing and you would also help to bring families to increase the population of the Western Isles and the sustainability of your communities.

Yes, we have people who come up to experience the working environment before they sign up to a permanent job—anaesthetic staff did that recently. We have a try-before-you-buy approach and we are flexible about bringing people up for a few weeks or months and letting them see the environment, the facilities, the community and access to childcare and so on. We think that that is the only approach. If we go out to recruit a single individual and we focus only on the success of that, we will fail on a much wider basis.

I read through the submissions and I was particularly interested in Laura Skaife-Knight’s, which says:

“NHS Orkney remains at 0.8% from NRAC parity”.

Why?

That is a construct of the way in which national funding works; I am sure that Michael Dickson and Gordon Jamieson will support me in that. It is one of the areas in which we, as an island board, remain at something of a disadvantage in terms of how the funding is allocated. I am oversimplifying this, but just to labour the point, we get funding in dribs and drabs and as one-off allocations that make it difficult to spend that funding meaningfully, given the size of the board and the infrastructure that we have.

For example, when the national funding is allocated and money comes down the line, we are allocated part of a post, such as 0.8 per cent of a whole-time equivalent. That does not help us to be agile, given the size of our boards, and it does not allow us to spend that money to best effect in a way that is best for our patients and local communities.

You therefore feel that you are £500,000 short of where you should be.

That is correct.

I turn to Gordon Jamieson. In your submission, you say that innovation in medicine is a challenge facing your health boards. Will you expand on that a little bit, please? Are clinical trials not also part of where you need to be?

I apologise if I have misrepresented what I meant. We certainly approach innovation enthusiastically and we have had some excellent successes. For example, the HeartFlow example that I gave in our submission is probably one of the best examples of innovation using digital technology and artificial intelligence.

The reference that I was trying to make was that the costs of some of the new medicines that are coming along put pressure on healthcare systems. We are , however, entirely wedded to the idea of innovation in many areas. We can sustain the service only if we get the right balance between our staff and the use of innovation, digital or otherwise, and that links back to workforce and population decline. We are proactive in developing different methods of innovation, whether that be in diabetes, heart failure, cardiac or anywhere. The cost of new medicines, however, puts us under the most pressure. We participate mainly in national research and occasionally in trials, but we are enthusiastic about innovation across the board.

09:00  

Thank you. I will stay with you, Gordon, for my final question.

Population decline is a serious issue, as is housing. If you are earning £100,000-plus, you will probably be able to find accommodation, but not everyone is fortunate enough to be earning that type of money and many of the jobs that are you are looking to recruit for are not in that bracket. One of the jobs that I saw advertised was a consultant post—which is, admittedly, a very well-paid job—and there was an annual £1,279 “distant islands allowance”. That does not seem to be a huge amount to attract people to the Western Isles. What measures need to be taken to make it more attractive for people to come to work where you are?

Again, we approach it in partnership and try to support people with housing. We have a growing supply of houses in the Western Isles that come through the local housing partnership. We have an agreement with it that health staff will be prioritised. To use the isle of Barra as an example, we rent a house on Barra on a continuous basis to allow us to put senior medical staff and general practice staff into accommodation. In areas such as Barra, where there are only 1,150 or so people and limited housing, we have had to take measures to provide houses.

The health board has houses that are under its endowment infrastructure—again, those can be used to support people in the short term. Some people ask, “Why would you come to the Western Isles and not have a house by the sea?”, so we try to support people when they come up to be around for a little while, by giving them supported accommodation, letting them choose whether they are going to stay and then supporting them in that decision about where they want to live.

The distant islands allowance is there as an additional incentive to people, but we look more at working flexibility, annualised hours and support with childcare, visas and relocation. Not everybody comes with a family, but we are trying to attract individuals and families, and we look at everybody to see how we can support them.

It is very much a bespoke, individual approach that involves picking out of the range of support measures that we have what best suits that individual or family.

Good morning to the witnesses in the room, and good morning to Gordon Jamieson online, who was a senior nurse when I was an NHS nurse employee in Dumfries and Galloway.

My question is about the innovation that Gordon Jamieson was talking about. Does that include enhancing the roles of allied health professionals and nursing staff? For instance, that could involve enhancing the role of registered nurse first assistants in the operating theatre, or enabling nurses to give midazolam in endoscopy, or expanding the role of allied health professionals in other areas, albeit within the scope of their role and by using competency-based training and assessment. Is that part of the innovation that you will take forward?

Yes—we are very active in that regard. In relation to allied health professionals, we have first-contact practitioners and advanced practitioners, and we have stand-alone consultant physiotherapists, who basically manage our musculoskeletal workload and do everything associated with the patient pathway.

We have a growing number of advanced nurse practitioners—we have just appointed three in Barra, and we have them in Western Isles hospital—and we have emergency nurse practitioners, all of whom are trained up to level 9 in acute assessment skills. They very much work hand in hand with junior and senior medical staff.

With that multidisciplinary multiprofessional approach, I get quite excited about how far we can take practice. I am not a person who is constrained by conventional or historical boundaries. I look for the opportunity to do things safely and effectively while broadening out as much as possible. When you get proper team working to look after patients, I find that it is an excellent environment to work in for medical staff and all the other staff. That ties back to the point about it being a good experience for the patients and for the staff.

It is about pushing the boundaries of practice. An example of that is in relation to cardiology: we were the first in Scotland, if not the UK, to adopt HeartFlow technology, which is of course in partnership with the United States. That is led by a nurse consultant in cardiology.

I know that Michael Dickson wants to come in, but could Gordon first explain what level 9 nursing is?

It is, in essence, nurses who are trained up to the level of a doctor such that they can assess and clerk an acute presentation of a patient. It is common for a clinical support nurse or an advanced nurse practitioner to make that initial assessment. When patients present, it is important that whoever immediately meets them is capable of making a comprehensive and very quick assessment. The advanced nurses are trained up to that level.

Thank you, Gordon. That was for lay people so that they are aware of what you are talking about.

As a nurse myself, I am hugely proud of the workforce that we have and the enormous steps that they have taken to embrace new and innovative roles. The future of remote and rural healthcare hangs around the principle of advanced practice of different professionals.

I mentioned nurse eye injectors in my submission. That is about people not having to travel because they have age-related macular degeneration. People were choosing not to travel because it would be so frequent and because, as I am sure that we are all aware, travel from the islands can be somewhat challenging at times. People were choosing to let their sight deteriorate or even to lose their sight for want of services in Shetland. We now have a trained nurse injector who can undertake that procedure, and nurse endoscopists.

Gordon stole all my thunder—thank you, Gordon—but it is about advanced practitioners leading services from the front and developing new and innovative pathways. It is interesting that NHS Forth Valley has led the way in nurse surgeons undertaking breast work and vasectomy—routine procedures that can be carried out in a very straightforward manner. From my perspective, advanced practitioners are a critical part of our future for remote and rural healthcare.

Michael, my question is on the theme of the nurse injectors that you have talked about. What do they do and how beneficial is it? Are there other areas that you are interested in making sure stay in the islands so that people do not have to travel? If so, will you tell us about them and what support you might need in that respect?

The scope and range of activities that advanced practitioners can do are pretty much endless, whether it be working in a fly-in, fly-out specialist environment in the remote communities in the Shetland Islands or in Macmillan specialist support to extend prehabilitation—which is an important part of the future of cancer care—and post-care after chemotherapy. Surgery is another good example of where we can train practitioners.

The default is always nurse practitioners, but I stress that the huge range of professionals that we have in the NHS is phenomenal. Pharmacists, for example, are an excellent resource and can provide care in a different way to patients, who might well have been prescribed multiple drugs. A pharmacist can provide expert advice through the pharmacy-first principle that we are introducing, which is also really important. The scope is huge. Moreover, cardiac technicians are using our recently refurbished computed tomography scanner to review cardiac scans, and that, again, reduces the need for people to travel.

To come back to Laura Skaife-Knight’s point, I think that the challenge relates to the NHS Scotland resource allocation committee. A common refrain in the islands is that people wear many hats, but it means that structuring a role can be quite difficult, because, if a person leaves, we lose not one but three jobs. NRAC parity creates a challenge in that regard, but the issue is not just that; it is that we might receive only a portion of funding for a role, and that affects sustainability. It means that, the next time that we recruit, we need to replace somebody whose job, as a whole, was made up of two or three parts.

As I have said, the range is boundless. We believe that a significant portion of our future workforce—our current estimate is about 30 per cent—will undertake an advanced role.

In your submission, you mention your work with LGBT young people. Can you tell us more about that?

I was approached by LGBT Youth Scotland, which recently published a report on the experience of Scotland’s LGBT+ youth. Those in remote and rural areas are at a significant disadvantage, because they feel more isolated, they do not have the same peer network and there is not necessarily the same group of people who can reach out to them.

At the time, I was working between Shetland and Orkney, and I took the opportunity to connect with school nurses who engaged with that group of young people to find out what was going on in the schools. Absolutely astonishing work was being done on Shetland—a youth worker had been leading that work from the front—but innovation had taken place across all three island boards. This is not a criticism, but all three islands were working in slightly different ways to reflect their communities, and we connected those school nurses and youth workers so that they had the opportunity to learn from one another.

Most recently, the LGBT youth workers in Anderson high school on Shetland received, quite rightly, an award for what they have done, and I am really proud that NHS Shetland participated in the first Shetland Pride, which took place last year. We are talking about an important group of young people who are particularly vulnerable, particularly in rural communities, so it is important to have that presence and visibility and to recognise that their voices and experiences matter. They should know that they can, without fear of prejudice, access all our health services, not just those located in education, and that they will be cared for. That is an important NHS value of which I am proud.

NHS Orkney’s submission mentions “IT system frailty”. Laura Skaife-Knight, can you expand on that? Does that apply only to your area or does it apply nationwide, too?

It is fair to say that, from a digital perspective, we are somewhat immature, but we have an ambitious but suitably realistic digital road map to ensure that we can see the progress that is needed in that area.

I will share some examples of the work that is under way, which Michael Dickson and his team have led superbly over the past few years. For a start, the intra-island network—the connectivity with our isles—is really important. There is a feeling in the community that, if there is not that connectivity, the isles will be literally cut off, so we have done a lot of work to improve that. It helps from a clinical perspective to be able to use, for example, portable scanners on the isles or the same telephony system. That might sound like we are going back to basics, but it has been absolutely necessary to ensure that the mainland and the isles remain connected.

We are also making good progress on our single sign-on system. As you can imagine, it is hugely frustrating for clinicians to have to log in and out of different clinical systems and remember multiple passwords, so we have moved to a single sign-on system, which is an important step forward. More recently, we have introduced e-prescribing.

I know that we all want to get to the end of the line, which will mean an electronic patient record. We have started those conversations. Clearly, such a system will be dependent on securing funding, but that is our ambition.

We have a road map that will allow us—incrementally, year on year, through our capital funding—to see the digital shift that is needed. We have made some good inroads in that regard.

I thank the witnesses for coming along.

I am interested in the key performance standards. To what extent do they drive service delivery?

09:15  

There is a two-fold answer to that question. We are not entirely in control of our own destiny with performance standards. One of the key measures is our accident and emergency performance, which has been sustained at a level that I am very comfortable with. Every time someone has to wait for more than four hours, that case is reviewed and there is a root-cause analysis. Those cases often relate to off-island transport, for example, for people who require intensive care. People sometimes have to wait for an extended period: we had a patient who was delayed on-island for 36 hours, because Shetland was fogbound and nothing was getting in or out. That is just the nature of providing healthcare in a remote setting such as Shetland.

For the services that we are able to provide on-island, waiting times are way below the 18 weeks treatment time guarantee. When we look at CAMHS performance, or at adult mental health services, we see that a small number of people wait for more than 18 weeks, but we do all that we can to ensure that waiting times are absolutely as short as possible. However, we have extended delays when a patient’s pathway leads them to the mainland health boards. Our performance is tied to their performance and we face the same pressures that you will have heard about from colleagues working for mainland boards.

We have a very tight grip on this. I do not mean to dismiss performance targets, but this is not about targets: it is about people from our community having to wait longer than they should for a procedure that is really important to them.

I suppose my question ties in with what was said earlier about innovation. We hear a lot about how critical early intervention and preventative care are and how performance targets and priority targets can drive providers away from that. Could early intervention and prevention be made higher priorities?

They could be. With support from the Scottish Government, NHS Shetland brought in the Vanguard operating theatre to allow us to do hip and knee replacements. That was truly transformational for the community—it was absolutely phenomenal.

I came from England, where public health is very separate. We do not see that in Shetland. Our public health director is phenomenal and the public health team is absolutely integrated into our work. We are talking about returns that will be felt in decades’ time. If we can get weight management right, or if we can get people’s diabetes under control—or even avoid it—those things will prevent people needing more support from the health service further down the road. NHS Shetland has a very strong public health focus, which I am hugely proud of, and we saw that throughout the pandemic.

The challenge is that you have to measure something. The measures we use are not bad ones, but there might be more that we could look at. For example, one of the interesting things about knee replacement is the regret rate, which sits at about 17 per cent. National work on elective waiting times is reviewing that with patients to find out if they understand the consequence of that surgery and what it means to have a knee replacement and, once they know all that, whether they still want to go ahead. We are trying to reduce the number of people having a procedure that they would rather not have had.

That was really helpful. I am keen to hear from Laura Skaife-Knight or Gordon Jamieson on this, too.

I am happy to come in and build on Michael Dickson’s observations. From an operational performance perspective, there is a real risk that we hit the target but miss the point. Fundamentally, this is about delivering high-quality, safe and timely care across our elective and emergency pathways and for our cancer patients.

As Michael Dickson said about Shetland, NHS Orkney, in the main, does well at meeting the standards that are within our gift. We were a little short of the standard of 95 per cent of people having access to emergency care within four hours, finishing last year on 86 per cent. We perform well in meeting the standard that people should start cancer treatment within 31 days and we consistently perform well in meeting the standard that people should begin treatment for non-urgent conditions within 18 weeks.

The areas where we need to do better—and this is not to deflect attention away from NHS Orkney in any way—are the areas where we rely on support from other centres. The situation has been different in the past year or two, compared with what it was perhaps just three to five years ago. Other centres are running at—or very close to—100 per cent bed occupancy most of the time, and we rely on those centres through our service level agreements. For example, the number of our patients to whom the 62-day cancer treatment time target applies is small, but the fact is that one delay for a cancer patient is one too many, and we are reliant on other centres to deliver on that target. In those areas in which the waits are longer than we would like, such as rheumatology—and ophthalmology, which is perhaps the best example of this happening—we have conversations with, for instance, the Golden Jubilee national hospital to see whether we can use some of the capacity that is allocated to us in a different way in order to address some of our longest waits.

Having worked in the NHS in England for 20-plus years, I absolutely back up Michael Dickson’s comments. It might not feel like it at times, but trust me: integrated care is significantly more advanced here than it is in England. NHS Orkney has very close relationships with its public health colleagues and its local authority colleagues in Orkney Islands Council, and there are huge opportunities there. One example is how we are addressing delayed discharges. We are a small island board, but I can tell you that, as of today, 19 per cent of our beds are taken up with what are called delayed discharges.

There are things that we can do differently by working with our local authorities in a different way, and we are looking at that ahead of next winter. For instance, we can use some community capacity differently and have a step-down bed facility in the community so that we can run at the 88 per cent bed occupancy that we know is the optimal level for us.

In summary, there is room for improvement, but relationships are really strong.

That is good to hear.

There is a similar picture in the Western Isles. Local waiting times are short. In the past number of years, we have expanded our orthopaedic service and we are very pleased with what we can deliver to the local population in that regard.

Some targets are reviewed daily and some weekly. For example, our performance on the cancer target is similar to the situations in Orkney and Shetland. Our 31-day performance, which involves more local diagnostic work, is very good, but the 62-day target is a bit more challenging. We are currently at 53 per cent in relation to that, compared with 93 per cent for the 31-day target, so we have some improvement to make there. However, as we work in partnership with others in the NHS Scotland system, some of that is due to system pressures, clinical prioritisation and the availability of generalists elsewhere.

On the emergency department target, we would all want people to be seen, diagnosed and so on as quickly as possible after appropriate presentation at such a department.

The targets drive our performance but, alongside the targets, we are carrying out a population health needs assessment to revisit the five-year and 10-year predictions for the population of the Western Isles. That does not bring us into conflict with the targets, but it tells us where we need to flex and change and develop services as well as giving us a refreshed view of the population health needs. When we last carried out such a review, it led us to redesign and enlarge our orthopaedic service, which now delivers very well for the population.

We are focused on recovery. In some areas, we are focusing on continuous improvement to get waiting times down. Alongside that, the population health needs assessment will allow us to understand where we need to prioritise and flex local services while achieving the targets that are set.

Thank you. Sandesh Gulhane will lead on our next theme, which is mental health performance.

I have some general questions based on my experience as a doctor working in University hospital Ayr, which covers a rural community, in part, along with an urban community. I know that your populations are very different, in that they are all rural. I remember that, whenever I was asked to see a patient who I was told was a farmer, I would drop everything, because farmers do not come to hospital unless something catastrophic has happened. For example, one person amputated their finger while lambing and only came to see me a couple of weeks later.

Bearing that in mind, and how people in rural committees—especially farmers—tend to be, what different approaches do you need to take to look after the mental health of your community compared with how the majority of the population in urban areas are treated?

I am happy to kick off and tell you about our very Shetland approach to that. As I have mentioned in my submission, we have an incredibly strong third sector; the default position is that the NHS is where you go if you have mental health conditions or concerns, but research has proved time and again that having multiple points of entry is the best approach. People need to be able to access services that are available not just 9 to 5, Monday to Friday, and an NHS practitioner does not always need to be your best first point of contact.

We have promoted the reliable connections available through NHS Inform. We have also provided some sustainability through Mind Your Head, so that it can help build its service; the organisation is a strong component of our approach, and the work that it does is well known in Shetland.

When people require further support that cannot be provided through third-sector first contact or they require on-going support, we use a variety of methods from web chats to apps on phones, which some people are more comfortable using. There is still a significant amount of stigma around mental health, particularly in the communities that you have referenced.

When people have reached the point at which they require an NHS level of service, we offer a range of approaches from face-to-face appointments to digital appointments, to try to flex round individuals’ needs. Our approach acknowledges that one of our biggest challenges is distance. Our mental health services are based predominantly on Lerwick; if you have a mental health concern and you need to talk to a practitioner, travelling from Unst to Lerwick will take at least a couple of hours and require two ferries. Being able to access the secure NHS Near Me facility so that you can have a conversation that you know is confidential and is in the same space as if you were walking into an NHS building can be really reassuring for people.

We also have a secure messaging facility, so people know that they can talk to someone. A conversation does not have to be face to face or through an appointment; asynchronous consultations are another part of our approach.

However, the big thing—and this ties back to the earlier point—is that the more we can do in relation to prevention and awareness, the better. I am very proud of the Up Helly Aa and the fire festivals that take place in Shetland every year. Those communities have really promoted the importance of talking about mental health, particularly to men, who are really reluctant to come forward. Full credit goes to the Up Helly Aa squads for their commitment to that and for being open about people’s struggle with and experience of mental health.

You have made some interesting points about the importance of talking, but my concern about rural and island areas is that people seek help when they are at crisis point rather than when something is becoming an issue. Things are much more easily and probably more quickly sorted at that earlier stage rather than when someone hits crisis.

Social isolation is a huge issue in your rural communities, but it is also something that your health board does not particularly have control over. Do you feel that, with all the methods that you use, you are able to help people with their social isolation?

09:30  

One of the very special things, as Laura Skaide-Knight referenced in relation to Orkney, is how we work together as a system. With regard to the barriers that routinely exist between, for example, the police, social work, the NHS and the third sector, there will, of course, be barriers—we are different organisations, after all—but they are not the same constructs that you will see in other places. Yes, we collaborate and work together; we know vulnerable individuals and seek to find the right support for them. That collaboration and that community are at the heart of all that we do.

Do we think that it is all perfect and that everyone has access to all the services that they need 24/7? I am afraid not, but that is a reflection of the constraint on what our services are able to offer. What is important is that the community is able to access the services easily and, again, that is why longer-term investment in Mind Your Head is so important.

I turn to Gordon Jamieson. I was on Uist and talked to someone who told me that there are around 1,200 people on his island and that he knows them all. In that type of small community—its size is probably one of the reasons a lot of people move out—do you think that the stigma of mental health might be a hindrance to people seeking help?

I am not sure, although that is a possibility. In relation to the interaction that we see, particularly in Uist and Barra, due to the work that has been done to strengthen our community services and put much more support, signposting, awareness and resource into the community, whether that is face to face or digital, I think that the communities are strong enough. There is definitely a chance that that stigma may be there, but the community spirit in most, if not all, of the Western Isles is incredibly supportive, and is probably more helpful to the community and the individuals within it.

Most of our effort is in creating stronger community services and having many more mental health workers. We have been very well supported over the past couple of years in terms of being able to strengthen our community services. We are able to see people in CAMHS very quickly, and our psychology services have been strengthened considerably over the past five to 10 years. There has been a lot of training around psychological first aid and suicide prevention.

Loneliness is a huge problem up here, without a shadow of a doubt. It is more of a threat than most illnesses, so we need to tackle loneliness, but the communities are incredibly strong and incredibly supportive. As Michael Dickson said, there is a very strong third sector presence, which is very supportive.

On your third sector, I heard of the great work that Penumbra has been doing in the Western Isles. What additional support do you give Penumbra to do the great work that it is already doing?

In relation to Penumbra, we have the Catch 23 drop-in centre in Stornoway and a range of providers across the islands. We are certainly in regular contact with the third sector through the community-based network. Those providers have more to offer than anybody else. Again, it is a balance with them, but they come forward with proposals, they are very much a part of our integrated planning and we work with them.

We still have quite a distance to go in reducing the acute mental health provision in order to strengthen the community provision. When our mental health strategy was agreed, it was quite clear that we would need significant additional investment over time, including in the third sector. I do not have any specific proposals just now that relate directly to Penumbra, but in general, the third sector is central when we plan to change services.

Perhaps you could write to us with that.

I want to pick up on what Sandesh Gulhane said about social prescribing and third sector and independent organisations. In our social prescribing inquiry, we heard about some great work that is being done in Shetland on engaging people. It is about tackling isolation and loneliness and recognising that those issues are a problem. In turn, that supports mental health. My question is for Michael Dickson. How does each local authority and NHS board interface and engage to support all of that? We know how important our third sector organisations are. I am looking at an RSPB link with nature prescriptions that can help to support people to get outside and tackle isolation and loneliness, and to join groups or whatever. Do you see that happening on the ground?

To be honest, I have never worked in a place that is like Shetland. It is not about organisations and what name is on a person’s badge; it is about doing the right thing for the people of Shetland.

“Anchor for families” is a piece of work about working with vulnerable families. That could sit in a social work world or a health world, but it did not sit in either. It was about somebody without any of those statutory organisation badges working with really vulnerable families to ensure that they got the widest possible support that they needed. They would not be families that would normally access support. By doing that, problems are prevented. That ties back to the key issue of prevention for decades and potentially generations down the line. At no point did anyone say, “Actually, I want to own that. That should be a social work thing.” It was about what was right for Shetland. That guides all that we do across all the organisations.

Way before my time—I think that it was around 10 to 12 years ago—the council and the NHS produced the statement that, whatever happens, the council, the NHS and their key partners will work together regardless of what is going on. I apologise for the statement politically. That guides what we do, and that means that we develop services that are about meeting the needs of our individual communities.

Shetland is not just one community; it is a community and communities. I apologise—I took that from Laura Skaife-Knight. It is about how we do things locally. We support activities that take place in Yell, Unst and Fair Isle, and acknowledge that it might not be us who are doing those. We have put a healthcare assistant in the Out Skerries, which are small islands, to support the small community out there. That is linked to the way in which the council works in maintaining the islands. That is a really innovative project, and it required both statutory partners to step aside from our organisational boundaries and say, “What’s the right thing to do here?”

Shetland, Orkney and the Western Isles are remote and rural. I am thinking about Stranraer in the south-west of Scotland, which is pretty rural and remote from the rest of NHS Dumfries and Galloway—its headquarters and everything. Is one of the strengths of remote and rural areas that it is not just about everybody owning areas as if they are their wee fiefdom; rather, it is about partnership working?

Without a shadow of a doubt.

I endorse that completely. Michael Dickson has already touched on two aspects. I have been in post for eight weeks, and I can share with members my raw experience.

Our relationship with our local communities is like nothing that I have experienced in my career to date, and the collaboration and partnership working are very strong. I see a triangle of the local authority, the health board and the third sector. For me, the unique aspect is that it is not just about the formal relationships and the formal set pieces that we go to; it is also about informal relationships. At the end of the day, we do not let the governance and the structures get in the way of doing what is right for our patients and local communities. That is the start of every conversation that we have. It is very different.

Okay. Thanks.

I am looking at the performance tables that all three health boards have submitted to us. We did not get any figures from NHS Orkney on the percentages of CAMHS patients who are seen within 18 weeks or 53 weeks or more. Could you write to us with those figures?

Of course; I would be more than happy to do so.

Tess White has questions on theme 4.

I have two questions on consultants and a supplementary. My first question is for Michael Dickson.

At the end of last year, NHS Shetland had a vacancy rate of 39 per cent for medical and dental consultants, which is against a backdrop of 6.5 per cent for the whole of Scotland. In your submission, you stated that it is

“difficult to recruit consultants with the breadth of skills needed”

for a remote and rural location

“because the NHS no longer trains staff in that way.”

Can you say a bit more about that and can you give your view on how to overcome it?

That vacancy percentage seems disproportionately high, but our consultant workforce is disproportionately small versus the overall size of the board. An increase in our consultant vacancy will have a significant impact on that.

However, the point is well made. Our consultant vacancy is higher than we would like to see. I am, sadly, old enough to remember when general surgeons would be able to turn their hands to most things. Thankfully, that has changed and we do not see surgeons having a go any more, but that has a disadvantage.

We are fortunate that we still have surgeons who can turn their hand to most emergency procedures. I am talking about the kind of situation where a major accident happens in Shetland, there is a life-threatening issue and a surgeon needs to intervene to, for example, remove a kidney, which is not a procedure that they would do routinely. We happen to have a stalwart group of general surgeons who can still do that, although they have their own sub-specialties.

Fundamentally, in Scotland—and more so in England—there is a degree of superspecialty in the surgical training that is undertaken now. You now have surgeons who specialise specifically in breast surgery, for example, who would not be able to undertake a emergency procedure such as a blocked bowel. They would be able to undertake more general stuff, but not deal with those kinds of life-threatening critical issues.

Our surgeons, as fantastic as they are, are reaching a point in their life where they are going to look to retire. We already know that and we are starting to have conversations about that. So what do we do? We have put in place some of the foundations to deal with that. We have taken on a new consultant who will be trained for the wider and more frequent events that could require getting out of bed at 2 in the morning and being able to provide that intervention.

There have been comments about advanced practitioners, and they have a part to play. There also has to be consideration of what the future will look like. We may well have to recruit outwith the United Kingdom, to ensure sustainability. Outside the UK, there is still a more generalist approach to training surgeons, for example. That may form part of what we see over the next few years as surgeons retire and other people are brought on. In the longer term, I would hope that the majority of the work will be taken up by advanced practitioners under the supervision of a broadly skilled general surgeon.

Rather than take recruitment outside the UK, is there work that could be done to revisit the issue, so that you could say, “We need to have modified training.”?

It is a challenge. In my former life, I worked in England, and there was a programme called “Getting it right first time”, which looked at how surgical specialties operated. There is a really good reason for why surgeons are now more specialist. The more you do something, the better the outcomes are—it is as simple as that.

There was a great model in Brighton and Worthing involving surgeons who worked in a particular specialty and would not routinely carry out surgery on children, but would have to if there was a major event at 3 o’clock in the morning. A franchise was created so that surgeons would go and experience paediatric surgery. Surgeons would not consider themselves to be specialists in that and they would not do it all the time, but they would do it enough to keep their skills up.

There is a remote and rural component of surgeons’ training, and we are building on that, to try to make the training Shetland proof, as it were. We still come back to the issue that, if you are a surgeon, you are, on the whole, expected to specialise in a particular area rather than hold general skills.

There may be good reasons for this, but I do not think that we will ever go back to having true general surgeons, the likes of whom can turn their hand to a range of activities. That creates problems for the future, and if we are to continue with a consultant-led model, that is likely to become more expensive for remote and rural communities to sustain.

09:45  

On the theme of consultants, Gordon Jamieson said in his submission that the board has a number of consultant roles that can take years to fill, so they are covered by agency staff. That has a huge cost. How many years would you say it is taking to recruit consultants, and do you have a view on the cost implications of that?

We have about 32 visiting specialties, so you need to bear in mind that a lot of the consultants fly in to the Western Isles, as they do on the other islands, to provide excellent care from other health boards. However, from our core of 16 permanent consultants, about half are locum staff just now. Some of them have been locum staff for three or four years. It is very difficult to recruit permanent substantive consultants. Medicine and surgery are specific examples and mental health is another, if I could mention three specialties that are particularly challenging at the moment.

An observation that I have shared recently is that we seem to have locums in the health service who want to work with us continuously but do not want to convert to a substantive post. They want to continue indefinitely on locum terms and conditions and, therefore, we have locums who are with us for a very long time. We have been unable to get them to take up or apply for substantive posts, which is a challenge. The flipside of that is that you get the continuity of a long-term locum and all the benefits for patients and the patient experience, but it comes at a significant increased cost.

When we are out to recruit new locums just now, we go to the on-framework agencies first, where there is already an agreement, but sometimes we have to go off framework and some eye-wateringly high locum rates come back. I can give you an example of a specialty where we went out to the market in the past two months. We were looking for locum costs to take someone on for a year and the lowest cost that I got back was £313,000; the highest was just over £1 million. I have never come across that before. It is alarming.

Therefore, the costs are very significant. We secured someone at the lower end rather than the higher end of that range, but the costs are an on-going pressure. For me, there is something about the people who want to continue to work but as locums. It is difficult to get them to convert to being full-time permanent members of staff.

The Scottish Government put in place multiple schemes to bolster rural GP numbers. We got positive feedback from Laura Skaife-Knight on that, so I will not ask her my question; I will ask Michael Dickson. There was the golden hello scheme and the bursary scheme. Have those been helpful in Shetland and is there anything else, in addition to those, that you think could be useful?

Any initiatives such as those are always really welcome. I must recognise that the majority of practices that are operating in Shetland are board-run, so we do not deal with GP practices in the same way as elsewhere. However, we have a number of single-handed GP practices. In particular, one in Hillswick has a very committed long-standing independent GP, who has been trying to recruit her successor for the past six months.

Moving to a place such as Shetland is not something that you do lightly, although people think, “It’s just an island”. I was talking to some American tourists, who thought that they would be able to catch a train somewhere—there are no trains.

You have to understand the quantum of moving; you have to want to go there. That is part of it. No golden hello will necessarily do that for you—it has to be about the desire to live and work as part of a committed community, knowing that there are trade-offs. It is incredibly safe, but it is really isolated; it is beautiful, but you might not be able to fly out for a number of days due to fog or fragilities around the airline that is providing the services, or you might have a really rough ferry crossing. Those are all factors that people consider.

I do not think that it is just about throwing money at the problem; we have to sell the proposition. I think that Shetland, Orkney and the Western Isles sell the beauty of where we work; however, fundamentally, you must have the right mindset and know what you are getting into. That is part of it—it is a choice.

Great; thank you. If I may, can I bring in Gordon Jamieson, or should we move on?

We just need to be very brief.

Gordon Jamieson, will you give your view on that topic, please?

We are about to go out—either today or tomorrow—to recruit for two GP posts for Barra, and the golden hello is part of that. Michael Dickson’s point is really important—we are selling Barra, where we happen to have two rural GP practitioner posts. The important thing is that we can sell the location so that people want to come to live there.

We have nine practices, including one 2C practice. Some of our GPs are retiring and returning. As Michael Dickson said, in many communities, there are very long-serving GPs. However, it is increasingly becoming a bit more challenging to get GPs in the Outer Hebrides. The next test will be in the next few weeks, when we go out for those two very different posts in Barra, which will cover the GP practice, out of hours and the inpatient beds in the hospital there.

Thank you.

Our next theme is Covid recovery and progress of the recovery plan. We are getting a bit tighter for time, so if we can have concise questions and answers, please, I would be very grateful.

I was going to mention the Scottish graduate entry medicine programme as a success for us in the recruitment of GPs.

As far as Covid recovery goes, I know that there is not an overnight fix, and the NHS recovery plan progress update says that recovery from the pandemic will take place not in weeks or even months but in years. Therefore, I am interested in hearing your perspectives on Covid recovery. Innovation is being used—for example, NHS Near Me and digital appointments have been part of the recovery—but how do you feel that recovery from the pandemic is affecting remote and island areas specifically? Michael Dickson is nodding, so I will go to him first.

I will keep it brief, because I am aware of the time. Our performance reduced slightly during Covid—I am thinking about the performance measures that we go against—but it did not dip significantly. From a performance metric perspective, I would argue that we are one of the best-performing boards, but the impact of the longer-term consequences of Covid on social aspects and our workforce will continue to play through for many years. We will continue to wrap our support around that.

We are using trauma-informed support for our staff. It was a very difficult period of time for the whole of Shetland, but trauma-informed support is a key plank in continuing support for our workforce.

I will build on Michael Dickson’s observations.

Covid recovery remains one of our top priorities as an organisation. We are back to pre-pandemic levels of activity, as you can see if you look at our elective and out-patient activity. As I mentioned earlier, we have particular pressure points in certain specialties, where we have particularly long waits. However, from a line-of-sight perspective, we know which specialties those are, both from an acute and a community perspective. We have plans in place to address those areas; notably, from an acute perspective, for us, those are pain services, rheumatology and ophthalmology.

Michael Dickson touched on the importance of staff health and wellbeing, which we should not lose sight of. There has been a lot of burn-out. Staff are tired. As health boards, we invested strongly in health and wellbeing through Covid, and we absolutely must maintain that. In fact, we must redouble our efforts in the future—we are determined to do that.

As has already been touched on, many good things came out of Covid that we need to keep, not least the acceleration of digitisation and the use of things such as virtual appointments, where that is appropriate for patients. We must also keep the increased speed of decision making, because we can take far too long in the NHS to get on and do things. We can have good governance and still work at speed. We must keep hold of those positives and build on them.

I am not sure whether Gordon Jamieson wants to come in. I am interested in what I read in the recovery plan about the mobile operating theatre that was introduced in Orkney and Shetland. I think that the Scottish Government invested £2.3 million to enable 350 elective surgeries to go ahead. Has that been beneficial in addressing elective surgeries?

That was in Shetland; we hosted it. I am so sorry, Laura. The Balfour hospital is fortunate to have a truly fantastic and first-rate set of theatres, whereas the Gilbert Bain hospital does not, due to its ageing—indeed, very elderly—infrastructure and building. A Vanguard theatre was supported, and it was absolutely transformational. It showed what we are able to do by using the innovative approach of layering on top of that the mobile magnetic resonance imaging scanner and routine diagnostic facilities that visit us. More than 400 operations had been completed by the time the Vanguard theatre went away.

There is an opportunity for the whole of Scotland in that. We used a private company, Vanguard, to provide the theatre, but we could do that within the NHS. A lot of Vanguard’s staff members were NHS staff members working through a different route.

That is interesting. On Covid recovery, do you agree that it will not be an overnight fix and that it will take a long time? I fully endorse supporting the mental health of all the workforce—that is critical—but it must be part of a long-term plan to address Covid recovery. Is that correct?

I agree entirely. We mentioned the pressures on the mainland boards, and our pathways lead to those boards. Even if we are doing the best that we can do, we are tied to what is happening throughout the rest of the system. You are absolutely right: we will feel the effects of Covid for many years to come.

I agree, and I will build on that. We have short, medium and long-term plans for the specialities that I mentioned in which we have particularly long waits. The plans recognise that, in many cases, the fix is changing the model of care in the service, which is why there needs to be longevity to it. It will take several years to get these things fixed and working in a different way—a way that is sustainable for the future.

I think that Gordon Jamieson wanted to come in on the previous question.

I want to say just a couple of things. As the NHS in Scotland, we must ensure that we do not slip back at all from using digital technology such as Attend Anywhere and Near Me. That will take a whole-NHS-Scotland approach. It would be very easy to slip back. We saw huge benefits from and want to push ahead with the appropriate and safe use of Attend Anywhere and Near Me. I want that to happen.

For us as a very small system, Covid is still around and—do not get me wrong—it is still causing us operational interruption problems. If it got a bit busy down in Dumfries and Galloway when I worked there, I could redirect patients to South Ayrshire, across to the Borders or even south to Carlisle, but if the hospital in Stornoway gets paralysed because of an outbreak of Covid, there is no other place for people to go, so risk and recovery have to be very carefully balanced. However, our recovery is going well; our patients are not waiting for long periods of time. Protecting scheduled care is really important.

One of the good things that came out of Covid was the renewed emphasis on staff wellbeing. We will keep that and hold on to it for ever; we will never slip back on that. As we move forward, many benefits will come from the focus on staff health and wellbeing, as well as full recovery and improvement for patients.

10:00  

I am conscious of the time, so I will stop there.

Thank you. Our next theme is culture and governance but, first, we have a supplementary question from Evelyn Tweed.

I was interested to hear Gordon Jamieson’s positive comments about the health board working with the local housing partnership to prioritise housing for staff. I would like to know whether Michael Dickson and Laura Skaife-Knight’s boards also have positive relationships with local housing providers. I am a housing professional, so I am really interested in that.

Very recently, in the past month or so, NHS Orkney set up a new strategic housing forum. We can make a proactive submission to the Scottish Government and can be very clear about what the gap will be for Orkney in the next five to 10 years. Those relationships are there. In fact, the partnership is even bigger than that, given the strategic contributions around the housing agenda.

We have strong working relationships and are using the experience of Western Isles as an example. We are starting to engage with our local housing association to see how we can use Gordon Jamieson’s experiences and those of the Western Isles as an example for Shetland.

The next theme is culture and governance, on which Gillian Mackay has some questions.

As well as being small health boards, there are small teams within the boards that you oversee. When there are complaints within those small teams, how are those managed? Given that people might be working in teams with single-digit numbers of staff, how are they encouraged to speak up when there are issues?

Complaints are really personal. I have worked in Northern Ireland, where people feel the same way. There is a direct connection with the community, which people who work in a larger board might not feel. We have had some quite difficult complaints about times when clinical care has not gone as we wanted it to and the consultant has been beside themselves because the care did not go the way that they wanted it to. Staff are part of a community and are incredibly visible, which makes a difference to how they feel.

You asked how complaints are handled. When a complaint is made, we engage to see whether we can resolve it. We do that exactly as you would expect, by following the Scottish pathway for complaints that has been set out. We try to resolve complaints as quickly as we can, but we know that some complaints will reach a certain threshold. I am involved in a number of complaints that have reached that point. Visibility makes that more visceral: a complaint is not just a number or a name somewhere.

Are you asking whether both staff and patients are encouraged to speak up?

Yes, absolutely.

We offer patients a range of ways to engage with the health board. Social media play a significant part in that. On the whole, locals are comfortable that, whether they raise an issue anonymously or with their name attached to it, they will always get a response and will always be truly heard. Of course, we can link back to the external process, if need be.

Regarding staff speaking up, our internal processes allow people to use the Datix system to raise concerns. We also use GREAT-ix, which enables people to recognise good practice, so it is a two-way process. We also have an independent whistleblowing champion, who sits on the board and frequently checks how people are feeling, and we have our iMatter survey, which is just being completed.

I will try not to repeat too much, because some of these things are national constructs.

You are right: in health boards, there is one big team that is made up of lots of small teams, and, at times, that can lead to silo working. In my experience, staff will speak up in multiple ways if they have confidence that their concerns will be listened to, heard, taken seriously and followed through on. It is important to close the loop so that there is trust in the system.

One thing that I have already started to do is to promote to staff the many formal and informal ways in which they can speak up, all the way through to the whistleblowing end of the spectrum that Michael Dickson talked about. However, we still have some way to go in order to build that trust and credibility. We are working really hard on that.

From a patient complaint perspective, I insist on seeing every complaint that comes into the organisation and there is a response from me, personally, before it goes out. Wherever possible, I will meet complainants at a venue of their choice. Being cognisant of those complaint themes, so that when there are red flags, you can nip those things in the bud and act on them in real time, is really important.

One thing that we have not mentioned is the importance of learning from complaints. Complaints are a gift. It is important to learn from feedback—no matter how small it may be—and demonstrate that something has truly changed in response to it.

Finally, whichever way you look at it, you cannot disentangle staff and patient experiences—one impacts on the other. For example, when I look at complaints trends, I often see that there is something going on in terms of staff sickness or absence, or staff experience. It is an experience package and it is really important that those things are taken together.

It is a hugely important area. I spent a lot of time in the world of patient safety before I came up to the Western Isles, and one of the things that I have always been alert to is the danger of hierarchy and how it can impact on clinical and multidisciplinary teams. It is critical to constantly develop a culture of openness and speaking up.

We do a range of things in that respect. We have everything from an informal sounding board where staff can raise concerns, through to the formal route. I regularly host open meetings with staff where there is no agenda and they can raise issues with me, personally. I carry out exit interviews alongside the employee director to try to learn from people who move on and see whether there is anything that we can play back into the system.

We have a real focus on early resolution where there is an issue—we try to resolve people’s issues informally before going down the formal route. The formal route always becomes quite elongated and it is stressful for everyone involved. It is really important for us to get an early resolution if we can.

We have a patient participation forum that feeds back to us. The point that Laura Skaife-Knight made is really important. We now have a lot more direct contact with patients—face-to-face or, at least, telephone conversations—and the exchange of letters or correspondence is now the end of the process. It is really important to get to know people and to be personal about understanding their experience. We get a much fuller understanding of someone’s experience through direct contact with them.

It is a central, mission-critical issue for us. Behaviour is everything, and we try to ensure that everyone feels that they can speak up at any time about any issue. Likewise, we have the whistleblowing system, which is there for when the business-as-usual methods do not work.

How do the boards monitor bullying and harassment in your workforces? I am reflecting on the nature of small teams and where that can cause issues, particularly if someone is on a small island in Orkney or Shetland, where they know the whole community and could be raising an issue with their next-door neighbour or someone across the road.

We have a staff governance committee, which is the key body for monitoring that. That is a separate governance pathway—bullying and harassment does not come to the management or the executive, but is routed through that route. We have a strong human resources department that is present and available. We also have spaces for listening for people to be able to engage on an informal basis in order to raise concerns at a lower level.

There is of course a link to occupational health, which ties back to what Laura Skaife-Knight said about staff sickness. That is all reviewed through the staff governance committee, which ultimately feeds through to the board.

Do you want to add to that, Gordon?

It is a really important issue. I welcome the introduction of the iMatter system, where staff can fill in questionnaires and we can get right down to a team level. That means that, where behavioural issues start to come up in the way in which teams interact, there is an opportunity to fix that locally.

We do on-going reviews of any cases of alleged bullying and harassment that come up. Quite simply, we take a zero-tolerance approach to it—there is absolutely no room for that kind of behaviour in any of our organisations.

There is a very clear focus on that, but the more important work is around developing teams, staff wellbeing, being alert, early resolution and using tools such as iMatter to pick up on themes that might be developing in the organisation. As Michael Dickson said, that goes through the area partnership forum, which is where we meet our trade union colleagues. That is a very open forum where we have very strong partnership working. Ultimately, the board’s statutory committee—the staff governance committee—will monitor issues that come up as well.

I have a question for Laura Skaife-Knight. Laura, I appreciate that you have only been in post for eight weeks, but you will be aware that NHS Orkney had the lowest overall experience score on the employee engagement index. The committee is keen to hear what steps NHS Orkney has taken or is taking to address that.

When I commenced in post, I published a 100-day plan, and front and centre of that was how I would spend time—not only during my first three months but beyond—listening very carefully to the views of staff. I recognise that our staff engagement and experience scores are not where we want them to be.

I am already very clear that there are some clear themes being fed back from staff. They do not consistently feel heard and listened to, and they do not feel that our internal communication is what it should be. They also find it really difficult to navigate through the organisation and understand how decisions are made, how the feedback loop works and who to go to for help and support, so we are going back to basics to reset that with staff.

I continue to hold listening sessions during the week, in the evenings and over weekends, because I want to ensure that I am as accessible as I can be. That will continue beyond my first three months.

At the end of my first three months, I will publish a report to be clear, open and transparent—both internally with staff and externally with partners and the local community. The report will say: “These are the themes that I have heard, and this is what we are going to do about that.” Fundamentally, it is about leading with kindness and visible leadership, and about truly listening and acting on a rolling basis; it is not just a one-off exercise.

Gordon Jamieson mentioned the importance of iMatter. As important as that is to give us a moment-in-time view from staff, and as a benchmark and comparison of how we are doing year on year, staff engagement and experience have to happen every day of the year. At the moment, those are not embedded in NHS Orkney. We are in the process of putting in place regular listening sessions with the executive team and me. We will also start doing quarterly pulse surveys in addition to the annual surveys that we have talked about today, so that they become part and parcel of what we do throughout the year and we can play that back, consistently, into the organisation.

As part of my 100-day plan, I was very clear that there were five top priorities, one of which was organisational culture. I knew that there was work to do. I am now getting underneath the bonnet of it, and I am clear about where we need to focus our efforts during the next six to 12 months and beyond.

I am heartened to hear that you mentioned the staff partnership forum. I declare an interest, as I am a member of Unison. Where do you see the role of staff side in assisting you with that?

It is absolutely central to moving us forward. We have really strong relationships with the area partnership forum, and we are resetting the agenda so that we can ensure that the staff experience, engagement and culture programme are front and centre of that, and that they are consistent with our annual plan, which the board has just agreed to and published for this year.

We have a really healthy relationship with our employee director, but I want the area partnership forum to do what it says in the title: work in partnership and move forward on some of the big issues. I have not held back. We need to move beyond tick-box exercises and towards meaningful engagement and partnership working, and we have some great ideas as to how we can do that together.

10:15  

Thank you. We are going to move on to our final theme, which is future work.

Thank you for all the detailed information. My question might give you a chance to give us some homework. The Scottish Government has committed to the development of a national centre for remote and rural healthcare for Scotland. What might your aspirations for such a centre be?

The committee has also committed to trying to undertake an inquiry into remote and rural healthcare. Do you have anything that we should specifically direct it to? Please give us some work to do.

I am happy to kick off on that one. We have touched on a lot of issues that would be pertinent to that inquiry. Front and centre has to be the workforce. Having worked in a remote setting, I see it as a badge of honour. You get a huge amount of experience. People often look at the islands and think that it will be easy and that, because it is 22,500 to 26,000 people, it will not be a problem, but there is not the breadth of workforce that there is in other organisations, so you have to be more agile and adept.

At the heart of that is our community and workforce. The committee has heard from colleagues about the importance of that package and the valuable offer that people can make. We have done some work through the rediscover the joy GP recruitment process in Shetland, whereby people come for a period of time. Allowing flexible ways of working that recognise that working in a place such as Shetland might not be for everybody for ever, but it might be for some people for a period of time, means that we can build up a profile. However, we are not talking about traditional models because current funding arrangements do not particularly support anything that goes beyond those models, and that remains a challenge for NRAC.

The workforce of the future is going to look different, and I question whether the biggest challenge that faces the remote and rural centre has to be about working many years in advance because we are facing challenges today. Separating the two is useful for ensuring that we have a broad focus rather than traditional models that have been defined by what happens on the mainland. For example, lifting a Glasgow model and applying it to Shetland just does not work. What happens through our experience will be the same as what happens in the rural areas of Dumfries and Galloway and the Highlands.

The Australian flying doctors is a brand. Everyone knows that. It is a real thing. I think that we could replicate something like that in Scotland and not just for doctors, I hasten to add. It could be a badge of honour that people embrace as part of their lifelong careers.

Thank you. Laura Skaife-Knight, you are quite new in but does anything spring to mind?

As Michael Dickson said, workforce has been the dominant theme throughout the meeting. Perhaps we should return to the theme of innovation, which was mentioned earlier. Gordon Jamieson and I have an ambition that our board should be the best remote and rural care provider in some way. What would that look like from the perspective of a remote and rural healthcare provider? If we could bottle all the pockets of innovation from remote and rural settings, how would we get all that into one laboratory, if you like, so that we can truly learn from it? We have pockets of innovation between ourselves, but if we could truly bring them together, it would be hugely powerful.

Gordon Jamieson, is there anything that you would like to add?

There are three things, really, the first of which is on the point that Laura Skaife-Knight and Michael Dickson made about the breadth of practitioners that are needed for remote and rural healthcare. I worked in Dumfries and Galloway, which is remote and rural, but island healthcare provision is unique. I will give you an example. A couple of years ago, I was on Barra with a chief executive from the NHS in Scotland and a GP who worked in Edinburgh. They were talking to me about the GP facilities and service on Barra, and we told them about the range of work that was involved, particularly the acute work, hospital work and retrieval work.

The GP said to me, “There is no way on this earth that I could even contemplate working in a rural location like that, because of the acuity of patient presentations. I work in the centre of Edinburgh, and I can refer into the Edinburgh hospital half a mile away. This is a completely different world.”

The message of that is that there is something about the type of practitioner that is needed for island and remote healthcare. Recruiting the GPs for Barra will be a real test, because GPs will look after general medical services, hospital in-patients and out-of-hours unscheduled care. I do not know how many such people are around just now, but we are about to test that.

Secondly, I would like a revisiting of the obligate networks in remote and rural healthcare. All our island systems depend on very strong and good working relationships with other health boards. We in the Western Isles have relationships with at least eight other health boards for a range of clinical services and service delivery, but I would like a revisiting of the obligation to keep that service up when the going gets tough. Sometimes, we see a bit of a pull-back: “Oh, we’re very, very busy, so we can’t come up”. In rural healthcare, sustaining that relationship is important.

Finally for remote and rural healthcare is the taking forward of single-system working across health and social care, in order to develop the right type of practitioners in remote, rural and island systems to provide services. The only way in the islands is to have one system. The area is too small to have multiple bodies trying to do the same or different things. Anything that a remote or rural system could do to produce the right type of care provider and practitioner would be helpful.

Have any of you had information about when we might get some movement on the set-up of the system? Have you had anything through the health boards? You indicate that you have not.

We have not had anything formally.

That is helpful. Thank you very much.

I have a final question. When I was in Shetland a few years ago, one of the ambitions of the people there was to grow their own workforce, so that people were already embedded in those communities and, if they left to go to university on the mainland, they were more likely to return. I am keen to hear whether that has developed, whether you have had any success with it and what the challenges have been. I go to Gordon Jamieson first, as his hand is up.

That is such an important issue for us. We know that 54 per cent of people who leave school leave the island, that very few return until they are in their 50s or 60s, and that they return only if they have very strong family connections. Once we lose that 54 per cent, they are really lost—to the mainland and other places.

We are therefore very active in the schools just now. We have a summer programme that involves offering multiple student posts to schools and communities, to bring people in and give them experience. We have also had a significant increase and movement forward in apprenticeships. That is critical to us because, all the time, we compete with the offshore energy sector—the wind farms—the commercial sector and the hospitality sector. We have therefore put a big push into apprenticeships.

Generally, we seek to give folk experience and exposure. We engage with schools to try to reduce that 54 per cent who go off island. We are as flexible as we can be with the workforce—when they work, when they start and when they finish—and we need to be carer friendly and family friendly. We cannot just focus on our task; we have to look at the person. In that way, I hope that we will increase the number of people who stay in work, and decrease that 54 per cent.

I am happy to build on that. First, I cannot believe that we have got to this stage in the meeting without mentioning grow your own. It is hugely important and central to the conundrum that we have talked about of addressing the workforce challenges that we all face.

Similar to what Gordon Jamieson said, the trend in Orkney is that more younger people are leaving the island. At the moment, we are bolstering our programme of work on growing our own, which includes, as Gordon Jamieson mentioned, offering work experience and ensuring that those who come to us on placement have the best possible experience. One of my first meetings in my first couple of weeks in my role was with all the students on placement. It is, largely, a good experience, but there are things that would make it even better. We know that we need to invest more in that area.

I am clear that we already have some true stars of the future in front of us at NHS Orkney. We need a proper programme to invest in, grow and nurture those colleagues, and the organisation needs to have a proper succession-planning programme wrapped around that. That needs to be done in a systematic way, starting with the executive team and going down through the organisation. That is locked into our plans, starting from this year.

We have strong pathways that allow healthcare support workers to access nurse training through Robert Gordon University and the Open University. The advantage with the Open University is that people do not need to leave Shetland to undertake their training. We support them by giving them at least one placement on the mainland, so that they get wider exposure and there is not just a student focus. However, it has been flagged up to me that trainee GPs struggle to select their home board if they want to come back home after they have done their key training.

I am envious of Laura Skaife-Knight’s strong apprenticeship scheme. NHS Orkney and NHS Shetland currently share human resources services, and I am shamelessly trying to steal that scheme, because it involves great work in supporting people to reach graduate level.

We get really positive feedback from our junior doctors and student nurses. That was highlighted in our recent board paper. We see growing our own as an ideal opportunity—I know that it is not the traditional approach, but if people have that experience, it is more likely that they will come back. Growing our own is about people who are seeking to have a career anywhere in the NHS; it is not just about health professionals. Given the breadth of experience that people get by coming to Shetland, they could easily be turned into one of our own and have future pathways. For example, we brought on two consultants at a very early stage and worked with NHS Grampian to provide their on-going support and development, because we know that they will be our consultants of the future.

I thank Laura Skaife-Knight, Michael Dickson and Gordon Jamieson for their participation, which is very much appreciated. You have certainly given us some food for thought in relation to not just the work that we are doing today but the future inquiry. Once we are ready to progress that work, I am sure that we will be in touch with you.

There will be a brief suspension.

10:27 Meeting suspended.  

10:35 On resuming—